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The Supreme Court has ruled that it is constitutional to require that all Americans obtain health insurance coverage or pay a penalty.
Chief Justice John Roberts cast the deciding vote in the 5-4 decision to uphold the controversial health reform law. His support for the so-called individual mandate was that it was constitutional based on Congress’ taxing authority and not on the Commerce clause and regulation of interstate commerce.
“The mandate can be regarded as establishing a condition – not owning health insurance – that triggers a tax – the required payment to IRS,” He said in the opinion http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf.
The remaining parts of the Patient Protection and Affordable Care Act also remain intact, resulting in a clean sweep for the healthcare reform overhaul advanced by President Barack Obama and a majority in Congress in 2010.
The justices, however, took a narrower view of the Medicaid expansion by limiting the potential penalty to states if they did not participate in the program.
mHealth advocates hailed the ruling as well. While not specifically mentioning mobile healthcare, the ACA is seen by many as a driver in the adoption of new tolls and technology to improve clinical outcomes, reduce wasteful spending and advance wellness and preventive health programs.
"The Supreme Court decision solidifies an already strong opportunity for the mHealth sector to contribute to healthcare delivery, working with consumers, practitioners and insurers to improve quality and lower costs." Said Joseph C. Kvedar, MD, founder and director of the Center for Connected Health, a division of Boston-based Partners HealthCare.
Chuck Parker, of the Continua Health Alliance, issued a statement prior to the court's decision.
"I think the simple answer, at this point, is that mHealth is going to be an important tool for controlling costs either way," he wrote. "High-risk individuals – patients with more than one chronic disease, for example – account for nearly 75 percent of expenditures and create an enormous burden on the healthcare system. mHealth has proven to be an inexpensive, simple and effective solution to educate and improve quality of life for these patients while gaining control of costs."
"With or without Obama's healthcare plan, we will still need to reduce costs, and that means identifying and targeting the "frequent flyers" in our healthcare system through mHealth," he added. "Furthermore, the mHealth ship has already sailed with the move toward an accountable care system which is not directly tied to the Accountable Care Act (ACA). Hospitals, providers and health systems need mHealth's tracking, reporting and clinical support capabilities to manage their populations. Another factor is the shift toward preventive care forced by the accountable care model, for which mHealth is ideally suited. So overall, I'd have to say that I see mHealth growing and thriving in either scenario."
"The Supreme Court’s decision is a historic moment for this country, but regardless of what the court had decided, healthcare in this country is already changing and must keep evolving, because it’s broken," said Chris Van Gorder, president and CEO of San Diego-based Scripps Health and former chairman of the American College of Healthcare Executives, in a press release. "This crisis presents a challenge and an incredible opportunity for physicians and hospitals to fundamentally reshape the future of healthcare."
"Today, healthcare is a sick business, one that’s in business to care for the sick," Van Gorder said. "We must shift to become a wellness business, one that’s focused and financially rewarded for keeping patients well. At Scripps, we're knitting together what has been a fragmented delivery system through a focus on streamlined management in the hospital and ambulatory setting, And we’re making the most of the new tools we have in genomics and innovative wireless technologies to allow us to monitor populations at risk or with chronic illnesses and to deliver individualized medicine."
The American Telemedicine Association also weighed in on the decision.
“Now that the Supreme Court has ruled, we can move forward with the modernization of our healthcare delivery system, integrating telemedicine to improve care, reduce costs and increase access for everyone in America,” said Jonathan Linkous, the ATA's Chief Executive Officer. “ATA will continue to work with Federal and state legislators from both parties, as well as all public and private payers, to adopt these proven, valued technologies into our healthcare system.”
The Healthcare Information and Management Systems Society, of which mHIMSS is a part, issued its own comments following the ruling. HIMSS has also scheduled a July 12 webinar to discuss the decision.
"HIMSS, like the rest of the country, is relieved that questions about the healthcare reform law have now been settled and the nation can move forward with the essential work of transforming healthcare in America," HIMSS President and CEO H. Stephen Lieber said. "Health information technology is critical to the ongoing transformation in our nation.”
"Now that the uncertainty around ACA has been settled, it is critical that we continue the momentum to transform healthcare, including the use of information technology," added Dave Roberts, MPA, FHIMSS, HIMSS vice president of government relations. "We are pleased that congressional support for nationwide adoption of health IT on both sides of the aisle remains strong, and has been unaffected by the debate on the healthcare reform law."
"Despite differences of opinion on the healthcare reform law, members of both parties in Congress recognize the need to transform healthcare in this country, and the important role health IT will play in that transformation," he added. "We anticipate that the benefits of health IT will continue to receive bipartisan support as our nation establishes the infrastructure necessary for improving patient care and take strides to enhance the cost effectiveness of care delivery in the U.S."
The historic decision by the Supreme Court in a lawsuit brought by 26 states (led by Florida and the National Federation of Independent Business) against the federal government offers some certainty in how healthcare reform will proceed and how Americans will obtain and pay for health coverage.
Two of the most far-reaching consumer breakthroughs of the ACA that rely on the individual mandate also remain: guaranteed issue, which requires payers to insure all applicants regardless of their health status; and community rating, which prohibits insurers from charging customers more based on pre-existing conditions and demographics.
During oral arguments in March, the government had asked the justices that if they overturned the individual mandate, they should also strike the two consumer protections because premiums would skyrocket. An individual mandate would produce a broad pool of both high-and low-risk customers for insurers. Without the mandate, insurers would be stuck with the sickest and most expensive patients, so they would hike premiums to pay for escalating costs.
The health reform law was designed to provide for the biggest increase in the number of insured individuals since the creation of the Medicaid and Medicare programs in the 1960s.
The justices upheld the expansion of the Medicaid program for low-income individuals and families for which the federal government and states share costs. But the justices held that the provision is constitutional as long as states would only lose new funds if they didn't comply with the new requirements, rather than all of their Medicaid funding as originally put forth.
The Medicaid expansion was expected to survive the challenge because the lower courts had upheld it, said Timothy Jost, law professor at Washington and Lee University in Lexington, Va.
“No federal court has ever held a federal law to be unconstitutional based on this theory,” he said at a recent Medicaid conference.
Medicaid will widen its safety net to those earning up to 133 percent of the poverty level from 100 percent, accounting for about 15 million individuals. Under the ACA, the federal government will pay for the cost of the expansion through 2016 and phase down to 90 percent by 2020. Currently, states pay 40 percent to 50 percent of Medicaid costs. Many states had already begun to increase coverage on their own, especially for children.
The ACA will also increase payments to primary providers who treat Medicaid patients to that of Medicare rates.
Because the Supreme Court justices upheld the mandate, the rest of the law stands, including federal tax credits that will help consumers within a certain income range afford to purchase health coverage on the individual insurance market and the creation of health insurance exchanges, which will be state-based online marketplaces.
The justices offer more specific rulings on four questions:
• Whether Congress has the power under the Constitution to require all Americans to obtain health insurance or pay a penalty;
• If the court strikes the individual mandate, whether the rest of the contested law remains intact or should be struck down;
• Whether the Anti-Injunction Act, which prohibits a challenge to a tax until the tax or penalty has been imposed, can block the lawsuit; and
• Whether Congress can require states to significantly expand their Medicaid programs or risk losing all their federal funding for Medicaid if they don’t comply.
Some health and economic policy experts believe that experimentation around changes in the way healthcare is delivered and eventually paid for are already beginning to take root regardless of the outcome of the health reform lawsuit. The ACA has already provided momentum, tools and a framework to accelerate it.
Healthcare organizations and public and private payers are testing different payment models for improved quality of care, according to Peter Orszag, economist and vice chairman of global banking at Citigroup and former director of the Office of Management and Budget.
“Regardless of the decision, 10 years from now providers will be bearing much more risk for care than today, whether it’s through bundled payments or ACOs, independent of what happens in the Supreme Court,” he said at a recent World Health Care Congress conference.
“More intensive health IT and computerized decision support will be a big growth area no matter what happens in the Supreme Court or in the presidential elections,” he said, adding that “a lot of the important things are happening regardless of what happens in the Supreme Court.”
While the Supreme Court ruling will bring some certainty in the immediate term, the future of healthcare and how it will change is still in the distance, with elections in November sure to shape how it is rolled out, slowed, or possibly beat back and with most of the visible reforms, like health insurance exchanges, not taking effect until 2014.
The federal government has put into effect some provisions that have proven popular, such as allowing young adults under 26 to stay on their parents’ insurance; rebates from insurance companies to customers when they spend too much of their premium on administrative costs; and payments to seniors to bridge the gap in drug coverage known as the “doughnut hole.”
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