Welcome to the Sioux City Journal's live blog about health care reform. Joining us are Dr. Thomas Benzoni from Mercy Medical Center and Cynthia Moser, a lawyer with Heidman Law Firm, who will discuss the Supreme Court's decision on health care reform. If you have medical or legal questions about how the Supreme Court's decision will affect you please ask them in the comments section of this blog and our experts will help answer them.
Discussion of the Supreme Court decision will start at 10 a.m. If you have any questions, please ask them in the comments section and our experts will help answer them.
All: We will be getting started in two minutes. Please leave your questions as you have them. We will approve questions one by one, giving our experts time to answer before moving on to the next query. Thanks for reading!
Here is the AP summary of today's historic decision:
WASHINGTON (AP) — The Supreme Court on Thursday upheld the individual insurance requirement at the heart of President Barack Obama's historic health care overhaul.
The decision means the huge overhaul, still only partly in effect, will proceed and pick up momentum over the next several years, affecting the way that countless Americans receive and pay for their personal medical care. The ruling also hands Obama a campaign-season victory in rejecting arguments that Congress went too far in requiring most Americans to have health insurance or pay a penalty.
Breaking with the court's other conservative justices, Chief Justice John Roberts announced the judgment that allows the law to go forward with its aim of covering more than 30 million uninsured Americans.
We will start our live Q&A with a question for our legal expert, Cynthia Moser. Ms. Moser: The justices rejected two of the administration's three arguments in support of the individual mandate. But the court said the mandate can be construed as a tax. "Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness," Roberts said.
Can you tell our readers why weighing in on the tax issue -- at this point -- is not the Supreme Court’s role?
Moser: In plain English, a majority of the Court agreed that the penalty that someone must pay if he or she refuses to buy health insurance is a kind of tax that Congress can impose using its taxing powers. Because the mandate does not take effect until 2014, no one has yet been subject to the penalty or "tax".
Ms. Moser: Legally, what is the difference between using the commerce clause to support the mandate and using taxing authority to support the mandate? Or is that understanding of the decision inaccurate? Thank you.
Moser: There were not 5 votes on the Court to uphold the Accountable Care Act on the ground that Congress could use its power under the Commerce Clause of the Constitution to regulate commerce between the states to require everyone to buy health insurance. However, they did uphold the constitutionality of the Act under Congress' taxing authority.'\
Ms. Moser: Can you, as you said earlier in plain English, describe for our readers what the Commerce Clause of the Constitution is and how the Obama administration was trying to apply it in this case?
The Commerce Clause regulates commerce -- the buying and selling of goods and services -- across state lines, otherwise known as interstate commerce. The Obama administration's position was that requiring individuals to buy health insurance was not an impermissible burden on interstate commerce.
Dr. Benzoni: Obviously those in the health care field were watching this case closely. Does today’s decision at all clarify the future of health care in America?
Benzoni: Somewhat. It ensures there will (or may be) a mechanism to fund healthcare. The devil will be in the details. Reminds me of Ben
Franklin's remark to the lady who asked what they had done in there (after drafting the Constitution). "We've given you a republic, ma'am. If you can keep it."
Dr. Benzoni, how will this affect my visits to the doctor’s office or hospital?
Readers of this blog: If you have questions, please post them now. We will approve questions one by one, giving our experts time to respond thoughtfully to each query. Thanks for reading!
Benzoni: Knowing little about you personally, this will (or should) assure your doctor that he/she will be paid for the work they want to do for you. This should increase their willingness to see you. (To state the obvious, getting paid for your work increases the likelihood you will do that work.) In short, access should increase. We have seen that already in states that have piloted this idea.
Moser: Today's ruling also keeps in place a number of initiatives aimed at hospitals and other provider groups that will impact health care delivery in the future -- things like accountable care organizations that allow provider groups to share in cost savings if they reach certain quality of care outcomes and value-based purchasing programs that provide incentives to hospitals tht meet quality targets.
Dr. Benzoni: What are the biggest challenges and opportunities for the health care industry moving forward, assuming the law stands as is?
Benzoni: This idea as expressed by Ms. Moser is vitally important. This enables the study of interventions that actually work instead of "Mikey liked it." And I don't know a competent physician who doesn't want to know what will work best for this patient.
Moser: one of the major challenges I see is how our health care system will be able accomodate what is likely to be a huge influx of patients who, once they have health coverage, will seek health care sooner. The Act also requires more preventative and wellness services be covered, so I think we will see an increased emphasis on those types of programs.
Benzoni: This presents an opportunity for healthcare to, bluntly stated, put up or shut up. We, as an industry, are consuming more and more of the finances (GDP) of the country without a discernible effect and, in fact, somewhat of the opposite. Restrained spending, using better techniques and interventions, may simultaneously increase the health (well-being, actually) of the population and permit working folks to use more of their earnings to buy other stuff (cars and couches, anyone?)
Ms. Moser: Are Supreme Court decisions typically this complex and, frankly, dense? Or is this decision more of a reflection of the complexity of the issue itself?
Benzoni: We have studied the question of influx, and there appears to be none. The demand was and is there; now the met-demand can be paid for at the point of use rather than being spread to other sites (this is called cost-shifting, another discussion.) Preventive care is interesting; it increases costs (and must do so, by definition). It also appears to increase the sense of well-being of the affected population, a very important effect.
Moser: The answer to both your questions is "yes". The United States Supreme Court is very selective in the cases it chooses to hear and decide and those cases, by their nature, typically involve very complicated and contentious issues. That said, the opinion rendered today (which runs 193 pages) is particularly complicated because of the number of concurring and dissenting opinions issued by the justices.
Can you explain what the court’s move to limit the states’ power to terminate Medicaid funds means? Does this allow states that oppose the law to opt out?
Benzoni: This question of the effect on health care costs is a great one. I am going to argue both sides because, as Yogi Bera said, it's awful difficult to make accurate predictions, especially about the future.
Moser: One of the key provisions of the Accountable Care Act is the provision that requires insurance companies to provide coverage, regardless of any pre-existing conditions. Because the Act has been upheld, pre-existing conditions will be covered.
Benzoni: Increase costs: There is now a method to fund heath care. This can, if not properly controlled, result in non-rational spending. (Spending on stuff I don't need and that won't help because someone else is paying for it. Like me going to Menards...) This is not unlike our present situation, only with the potential to be worse.
Benzoni: Decrease costs: If the mechanisms to cover only the things that work operate as advertised (clinical effectiveness research), this could have great potential. If you can be reasonably sure that what your doctor wants you to do will help, and your doctor shares that confidence, the upside is great. Spending your money, to say nothing of your life, on something that doesn't help and might hurt is a concept that needs exposure.
Reader Jill's question about cost is one we hear a lot. What more can be done to better control health care costs in this country? And this question is for either Dr. Benzoni or Ms. Moser or both.
Moser: This is only my personal opinion, but the reasons behind escalating health care costs are multi-faceted and health care reform via federal legislation probably can't be held responsible for fixing everything. Medical advances and new technology are expensive, but we want and demand them. The notion of health care rationing is distasteful to all of us, but at some point, we may need to face the difficult question whether we can afford to do everything possible for everyone.
Benzoni: Jill: You raise a very interesting concept: Will costs continue to rise? See our current state: we're spending, as an industry, more and more of your paycheck (notice how it hasn't gone up? guess why...) We have not been returning to you value for money received. (Please. I recognize I am over generalizing. You in Iowa re really badly spoiled. REally bad. I just got back from National Disaster Life Support.) What if I could make for you a system that helped you improve your own health and that of your family, and you could have confidence it wouldn't hurt you? That is the future we can create.
Dr. Benzoni: If Mitt Romney is elected in November and this law is repealed in early 2013, what would that mean for the health care industry?
Benzoni: The thought/concept of rationing is one worth addressing. I prefer the word Rationalizing. Currently, there is very little rational thought in interventions. Take, for example, someone with a terminal disease within 2 years (except life, which is terminal). Why, oh why, do we have that person taking a cholesterol drug that won't give benefit for 5 years (and then only to 1 out of 10 who take it) but will give harm fro the first week to 1 of 20? That is a human and financial cost currently routine but ineffective.
Benzoni: (You really don't want to ask me a political question because I'll rise to it like trout to a fly.) It would likely mean that Congress would go Democratic in a NY minute. See, while people state they don't like the law, they like its provisions. That means they don't know the law, just its effects. And take away the effects...well, that's a mad electorate. As the lady said, "Keep the Government out of my Medicare!"
For both: The court found problems with the law's expansion of Medicaid, but even there said the expansion could proceed as long as the federal government does not threaten to withhold states' entire Medicaid allotment if they don't take part in the law's extension. What could this mean for states who do not want to participate and could it eventually undermine the entire law?
Benzoni: If this is repealed, frankly, many in the healthcare industry, especially those who peddle things that don't work or that don't help the population much, will be overjoyed. To have to admit that what you are selling doesn't work is a very tough thing to do. But, by math and definition, half of all people (and interventions) are below average.
Moser: If I can weigh in on the question about what the repeal of the Act would mean under a Romney administration, I think it would have a significant impact on hospitals. The hospital industry reluctantly agreed to sign on in support of the Act and accept a reduction in Medicare payments, based on the assurance that hospitals would be providing care to a fully-insured population. Right now the amount of totally unfunded care (that is, charity care for patients who do not qualify for Medicare, Medicaid or other government programs) is a huge financial burden for many hospitals.
Moser: In answer to BretH's question: the Supreme Court
Benzoni: The medicaid question is very difficult and has complex applications. Medicaid, remember, is a way for the poor to ensure that someone doesn't have to give them charity care. However, that is a very small part of Medicaid. Much of Medicaid is spent for nursing home care. And if the nursing home is not going to get paid for taking for taking care of Grandma, what is your plan?
Moser: Today's ruling is now the law. Whether a future court could reconsider the ruling depends upon whether another case makes its way through the federal court system and is accepted by the Court for consideration. But yes, it could happen.
Benzoni: State exchanges have several sides. One is permitting purchase from another state. Now, if you live in Iowa and move to Missouri, your insurance agent in Iowa has to send you to an agent licensed by and in Missouri, who can only sell you insurance approved for Missouri.
Benzoni: Exchanges continued. Another facet of exchanges is the ability to assemble the coverage you need. I don't need OB coverage but I need old knee coverage. So I can assemble a coverage for me and my family and pe priced accordingly.
Benzoni: The question of the uninsured and the ER is important. Currently, folks use the ER for a number of reasons, nearly all very rational from their standpoint. The uninsured can't access the systems available to the rest of us, like a doctor's office. So they come to the ER; what do you expect them to do? People with insurance also use the ER because they are getting value for their policy dollar. (Think this through; ER use is rising, but out of proportion to the increase in uninsured. It's because people with options are following the consumer model: 24/7/365 access, be it ER or QuikTrip.) Oh, and the ER is VERY efficient. Know what % of the US healthcare dollar goes to ER (including ambulances)? 2%. And we see nearly 30% of acute care visits using 4% of the healthcare workforce. (All figures from sources without a dog in the fight, like the CDC. No industry generated figures here!
Moser: The Act expands Medicaid eligibility for a significant number of Americans. The question raised in the lawsuit was whether Congress could require the states to comply with the law's requirements for Medicaid eligibility or risk losing all of their Medicaid funding. The Court held that it would be unconstitutional for the federal government to withhold a state's Medicaid funds for noncompliance with the Act, but it can offer additional funding or incentives to expand the availability of health care services to Medicaid-eligible patients and require states that accept this additional funding to comply with the conditions imposed by the Act.
Benzoni: It is a common and convenient misunderstanding that care is cheaper elsewhere. Effective care is cheaper elsewhere, but ineffective care is expensive everywhere. Take, for example, antibiotics for uncomplicated sinusitis. Most of the visits take place in primary care offices, most result in an antibiotic prescription, and there is no positive value in this transaction. However, there are a lot of negatives!! Cost, effect on the microbial community, patient perception of illness and thus drive to repeat care-seeking with subsequent self limited illnesses, etc.-
A big thank you to Cynthia Moser and Dr. Thomas Benzoni for helping us all understand today's decision and its impact. We will be wrapping up shortly. One final question before we finish: Could each of you share with us what you think the most important or interesting takeaway is from today's decision?
Benzoni: Increasing the population on Medicaid has an interesting effect. Medicaid usually pays the physician well below the cost to provide the care. The business loss, though, can't be used as a deduction against taxes.
Moser: For me, the most interesting takeaway from today's decision is that, even though the Supreme Court has settled the question from a legal perspective, the debate is far from over. It will continue to dominate the national debate for a long time to come.