The media and political pundits were having a field day with predictions and countdowns. No matter what your politics were, opinions resonated all around you: What would the Supreme Court do? What would it mean?
Then the decision came down. With a 5 to 4 vote, the Affordable Care Act (ACA) was largely upheld and justified as a “tax.” States would retain the right to decide whether to participate in the Medicaid expansion portion of the bill and not risk federal expulsion from Medicaid if they refuse to enact the portion of the ACA related to Medicaid eligibility expansion.
Immediately after, Republicans and Democrats found ways to present the ruling as a victory. People who have not read much, if any, of this controversial healthcare reform bill in its entirety voiced strong opinions about the findings of the Supreme Court.
Yes, there are aspects of the ACA bill that provide for deeper coverage for many people, including those with cancer, buried in the ACA law. These include coverage of preventive screenings for cancer and for other diseases, without copayments or coinsurance charges to individuals; continued coverage of young people through age 26 under their parents’ insurance plan; elimination of lifetime caps on insurance coverage; coverage protections on the basis of preexisting conditions; and patient access to clinical trials expanded to private insurance. Like motherhood and apple pie, it is difficult to argue against most of those provisions, and, indeed, some major private insurers had already announced that they intended to continue many of those provisions even if the Supreme Court ruled against the ACA law.
The issue that we are having difficulty facing is that we are still left with a lengthy bill that few people have fully read, let alone understood, and a virtual battle of the politicos looming to play tug of war over the specifics of the ACA provisions. We are left with even more questions unanswered, such as:
- Who will be insured under the health insurance exchanges once they are implemented?
- Will health insurance exchanges be implemented as set forth under the law? Several states are still not yet engaged in development efforts, and there will come a time when it is just too late to get started to meet the 2014 deadline—what happens then?
- Will commercial insurance be turned off by employers in droves, sending formerly commercially insured patients into the streets, seeking health insurance exchange coverage that is not yet defined, priced, or known if it will be available?
- Even if the health insurance exchanges materialize as planned under the ACA law, what rates of reimbursement will they offer to physicians and hospitals, and which physicians and hospitals will agree to participate?
- What will the evolving answers to these questions do to access to healthcare in the United States, and at what levels of quality?
- What will happen to the existing delivery models of healthcare if suddenly the majority of insured patients in the United States become insured as Medicaid or Medicare populations?
Currently, Medicare represents approximately 50% of patients with cancer, with Medicaid running close to 5%, and commercial and other insurance picking up roughly the other 45%. If suddenly the percentage mix of Medicaid and commercial were to come close to reversing over the next 5 years, there would be a significant impact (as yet undetermined, but probably very painful) on the current healthcare delivery system.
Practices and hospital centers already are embroiled in a variety of proactive and reactive discussions about new relationships. Strategic planning in these organizations will now need to consider these potential ramifications of the ACA law, in addition to the myriad other challenges facing cancer programs today. We may have received a ruling, but we have not yet received the answers we need to face the future of oncology.