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SCOTUS on health reform – the bloggers respond

Health Wonk Review is hosting a special edition today compiling the views of the health bloggers on the Supreme Court’s decision on PPACA.
By now all know the Court upheld the Affordable Care Act by the narrowest of margins, with Chief Justice John Roberts the swing vote and author of the majority opinion. The quick synopsis from MCM (that’s me). Everything stands except the Feds’ ability to require states to expand Medicaid coverage or lose all their Medicaid dollars.
While there will still be a significant expansion of coverage, if some states opt out the number of uninsureds will not drop below 18 million as originally forecast. I don’t see a lot of states standing on principle and rejecting the money – which covers up to 90% of the cost for the first few years, and 50% thereafter. Then again, stranger things have happened. The basis for Justice Roberts’ opinion lay not with the Commerce Clause but rather the Constitutional power of taxation. We’re going to start with the legalities.
Which are much more than just “legalities.”
Several contributors explore the issue albeit from different perspectives.
David Harlow of Healthblawg fame finds the dissenting opinions rich in content and entertainment value, especially Justice Ginsburg’s statement “no one would offer the hypothetical and unreal possibility of a vegetarian state as a credible reason to deny Congress the authority ever to ban the possession and sale of goods. The Chief Justice accepts just such specious logic when he cites the broccoli horrible as a reason to deny Congress the power to pass the individual mandate.”
At Health Affairs, Tim Jost digs into the Roberts opinion, citing this key statement: “proper respect for a co-ordinate branch of government requires that we strike down an Act of Congress only if the lack of constitutional authority to pass [the] act in question is clearly demonstrated.” Clearly Roberts felt the “demonstration”, to the extent there was one, was not clear enough.
We welcome back HWR co-founder Matthew Holt to these digital pages. Matthew sees the tie to taxation as a watershed moment; “In any rational society health care ought to be a public good financed through taxation and distributed in some manner that makes rational sense. America has never officially believed that. [emphasis added] Now it at least has affirmed the concept.”
Jason Shafrin sees this from his economist’s perspective; saying the mandate-as-tax logic “is one that economists would support (whether economists support the mandate is a separate issue). All regulation is a form of a tax in that it restricts one’s choices and imposes a cost on consumers and/or producers.”
And Ezra Klein thinks Roberts toed the conservative line; “The 5-4 language suggests that Roberts agreed with the liberals. But for the most part, he didn’t. If you read the opinions, he sided with the conservative bloc on every major legal question before the court…Roberts’s coup in writing an opinion that has found support on both sides must inspire some grudging respect.”
Maggie Mahar – and we are happy to see her back at her signature Health Beat blog – was not only unsurprised by today’s ruling – she called it. Read why she was sure the law would not be overturned in her post, Today, the Supremes sang
At Workers’ Comp Insider, Julie Ferguson did a little live blogging of the Supreme Court ruling, catching some of the major media in “Dewey wins” moment. CEO Tom Lynch weighed in with some analysis of the impact today’s decision.
Jay at Colorado Health Insurance Insider sees Roberts’ decision as not inconsistent with the government activism of the Bush administration. Jay opines “While the individual mandate and wire tapping seem on the surface to be completely different topics, they’re both on the spectrum of government involvement in our lives, and government utilizing its powers to promote an agenda that it views as good for society at large…”
The only part of the ACA seriously affected by the decision was the expansion of Medicaid, which, according to Sara Rosenbaum, was to “reshape Medicaid from a program covering certain categories of the poor into one that offers universal public insurance for all non-elderly low income citizens and long-term legal residents living in poverty.” Rosenbaum believes Roberts was able to convince other Justices to split Medicaid into “two spending programs,” thereby preserving the existing programs while placating the states’ rights advocates.
The implications for Medicaid are succinctly summarized by David Williams in his podcast interview with Avalere Health CEO Dan Mendelson.
While David’s got the high level view, Liz Borkowski sees a lot of uncertainty at the Pump Handle; “If some states decide not to go along with the now-optional Medicaid expansion, their poorest residents who don’t already qualify for Medicaid will have neither Medicaid coverage nor subsidies to help them get private coverage.”
Hank Stern’s had it with all this reform and Obama-stuff; he’s ready to pack up and leave, and suggests the medical tourism folks may be big beneficiaries of the Roberts decision
Roy Poses notes the decision – and the PPACA – suffer from a lamentable lack of attention on the concentration and abuse of power that still pervades our health care system; without addressing those issues, we’re unlikely to see any real and lasting improvement.
And of course, there’s the internet’s ability to quickly give us the reaction of the public, Jon Stewart,
and, of course, President Obama…

2 thoughts on “SCOTUS on health reform – the bloggers respond”

  1. Joe,
    Thanks for the post. Just wanted to point out, the Medicaid Expansion covers 100% of the cost for the States for the first few years, then works its way down to 90% for 2020 and thereafter. From the bill itself:
    ‘‘(A) 100 percent for calendar quarters in 2014, 2015, and 2016;
    ‘‘(B) 95 percent for calendar quarters in 2017;
    ‘‘(C) 94 percent for calendar quarters in 2018;
    ‘‘(D) 93 percent for calendar quarters in 2019; and
    ‘‘(E) 90 percent for calendar quarters in 2020 and each year thereafter.

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Joe Paduda is the principal of Health Strategy Associates



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