An observant reader of this column asked me the other day when I would comment on the June 28 Supreme Court decision regarding the Affordable Care Act (ACA), as I had promised to do in an earlier column.  With the settling of some dust on the matter, now seems to be an appropriate time.

First, the decision did not bring the clarity that many had expected. In fact, it may be years before we know whether it will work or not. The primary reason being that the major portion of ACA, the expansion of Medicaid, has been left to the determination of the individual states. One has to go back to junior high civics to consider the matter of states’ rights vs. federal rights.

However, here is the issue — provisions of the ACA would greatly expand the number of people eligible for Medicaid by increasing eligibility up to 133% of federal poverty guidelines. If states do this, they would get a lot of federal money to help offset the cost for all the newly covered people.  As proposed, if states did not expand Medicaid, they put at risk ALL of their state Medicaid dollars. The Supreme Court said that is not allowable nor fair. A state can expand or not expand Medicaid, but the federal government cannot withhold ALL Medicaid funding.  The court said that looks too much like coercion.

The other big issue is the individual mandate itself, which is the concept that most Americans would be required to have insurance coverage. Without getting too wordy, it came down to an interpretation of the commerce clause of the Constitution and whether Congress has the power to pass a requirement that most Americans have to have health coverage or pay a fine. The Supreme Court said no, Congress could not use the commerce clause to justify a mandate — BUT, the penalty for non-compliance with the mandate was actually a “tax” and therefore it would stand. In other words, the justices said new penalties for those who ignore the insurance mandate are within the taxing powers of Congress

So, what does this mean for Texas Tech Physicians? Medicare and Medicaid payments in the future will almost certainly go down.  Even before the ruling, Medicare and Medicaid were scheduled to go down $200 billion over the next 10 years because of the ACA and Budget Control Act. Hospitals, nursing homes and other providers will feel the pinch once these cuts start happening. Barring a political intervention, that has huge ramifications for us.  Second, purchases of health care (and yes, this is an old song) will be looking to pay for value, (meaning outcomes), rather than volume. We will need to focus on those things that really help people obtain a better measure of health and that means “evidence based” medicine and achieving measurable quality outcomes.