The Supreme Court Decision on Health Reform: Takeaways for Ordinary Americans
Editor's Note: with this overview by veteran health journalist Trudy Lieberman, Reporting on Health kicks off coverage of the historic U.S. Supreme Court decision on the Affordable Care Act, expected by the end of June. Check back with us in the coming days for more perspectives on what the decision means for your work and your audience.
As news outlets of all sizes wait anxiously for the Supreme Court’s decision on the Affordable Care Act, CNN’s legal analyst Jeffrey Toobin nailed it about right.
“What most interests me is the fallout for the court and the law,” Toobin told the Washington journal Politico. “But with the way the news media operates, the overwhelming question people are going to address will be, what does this mean for Obama and Romney.”
In other words, the Supreme Court’s decision will be reduced to a political horse race story about whether Obama or Romney emerges as the winner.
In recent days, the media has overflowed with stories about the impact of the court decision—how it will affect insurance companies, how it will affect non-profit hospitals, how it will affect state insurance exchanges, how it will affect small businesses.
There has been plenty of coverage that handicaps the outcome and details the possible what-ifs. When you consider that huge numbers of Americans don’t even know about the health reform law, including those who might benefit from it, stories about law’s fallout on hospitals mean very little.
The question the media need to address is what the decision--either for or against the law--will mean for ordinary people.While we don’t know exactly how any decision ultimately will play out, it’s critical to consider it in the context of why Congress passed the law in the first place.
Here's how the following groups might fare:
1. The uninsured. The individual mandate with its subsidies for buying coverage and penalties for not buying is the crux of the Supreme Court case. Conventional wisdom in the U.S. holds that the only acceptable way to cover more people is through private insurance, and for that to happen, profit-making carriers must be assured of a large mix of healthy and unhealthy customers. That’s unlikely if people are not forced to carry insurance. In return for requiring virtually all Americans to have coverage, health insurers agreed to issue policies to people buying on their own in the so-called individual market.
If the Court okays the law, people now obtaining coverage in that market and those currently uninsured will be able to buy a policy even if they are sick. The policy's generosity will depend on the amount of subsidies they will receive. People with smaller subsidies may select the “bronze” policies that are the cheapest and offer less coverage. That’s what people do in Massachusetts, which requires its residents to buy coverage.
People who earn more than 400 percent of the federal poverty level ($44,680 for a single person and $92,200 for a family of four) won't qualify for subsidies. They will have to pay the full premiums, which are not cheap.
Journalists, advocates and other storytellers looking for ideas might want to investigate prices for individual market coverage in their states and talk to people about how they will afford them and what kind of coverage they can actually buy for the money they have to spend. Who is likely to take the penalty instead of buying insurance? That was never quite discussed during the long debate on the law.
If the Court strikes down the Act, the health system reverts to square one. All people looking for insurance except those with government or employer coverage will have the option they’ve always have had--the individual market. Those who have preexisting health conditions will continue to have a tough time buying coverage.
2. Working class families. A major reason for the Affordable Care Act was expand insurance coverage under Medicaid, the joint federal and state program for people with very low incomes. The law expands coverage to people with incomes above 133 percent of the federal poverty level, or about $29,965 for a family of four. If the law prevails, between 16 and 17 million people will be eligible for insurance they don’t have now.
That doesn’t mean, however, that new access to insurance will actually result in more people getting health care. In many states, health providers aren’t keen to treat Medicaid patients and often turn them away. There’s nothing in the Affordable Care Act that says they have to give them care. The influx of new Medicaid customers is expected to put additional burdens on primary care docs, who are in short supply anyway. What’s likely to happen in your state as these newly insured patients seek care? Who may be left out?
The Court is also deciding whether the federal government can force the states to actually make such a large expansion of Medicaid. That’s key to whether more people will be added to the state Medicaid rolls. States are already grumbling about having to pay for the expansion in the future years when the feds stop paying the full costs in the next few years. That was part of a deal struck during debate. Many states are having trouble now covering the cost of care for residents currently eligible. The financial story about Medicaid remains a good one.
If the court strikes down the law and its Medicaid provisions, those who would be helped will be in the same position they are now--seeking care from community health clinics and paying fees according to the sliding scales some clinics impose. Or they will use free clinics or hospital ERs possibly encountering the often-aggressive efforts hospitals use to collect their debts. What does your local hospital do to collect from the uninsured? Lindy Washburn of the Bergen Recordhad a smashing piece on this earlier in the year.
3. People with (or who want) individual insurance policies. As the Affordable Care Act moved through Congress, its raison d’etre became making the individual insurance market work better. Requiring insurance companies to insure everyone even those who have serious illnesses certainly makes it work better for many consumers. There were other changes, too, like letting young adults up to age 26 remain insured under their parents’ policies.
This has been perhaps the most successful achievement of the law so far, with some 6.6 million young adults getting coverage. Under a scenario that upholds the law, they will continue to have coverage. If the law disappears, they will have coverage. Insurers are unlikely to kick these newly insured young people off the policies. Even though no law will require them to continue insuring these people, many companies, including United Healthcare, Aetna, and Humana, view that as good business and will let young adults stay on mom and dad’s insurance. It’s not clear yet what carriers will do about other consumer protections the act provides such as the elimination of lifetime caps on coverage. Continuing that one might be tougher, and is fair game for reporters to look into.
4. The Elderly. Seniors on Medicare got some goodies courtesy of the Affordable Care Act. The government sent those with large drug expenses a check for $250 soon after the law took effect, and they now get a 50 percent discount on brand drugs they must pay for when their prescription drug coverage hits the donut hole where they have no benefits. By the end of the decade, the law calls for elimination of the donut hole and its coverage gap. If the law is upheld, coverage continues as planned. It’s not clear what will happen to the coverage if it isn’t. Drug companies may decide to continue the discounts since they help increase market share, the name of the game in the drug business, or Congress may find a way to continue a popular benefit. Medicare will probably continue paying for some screening tests without requiring a copayment or coinsurance, which is now the case.
What happens to Medicare Advantage plans may be more problematic. This is what those who follow Medicare should focus on. The Affordable Care Act called for cuts in government payments to Medicare Advantage plans, and the full effect of those cuts won’t be felt for a few years. At that time, seniors in some markets will see increases in premiums and more cost sharing as well as fewer extra benefits these plans now provide. If the entire law is struck down, those cuts may not take effect. If only the mandate goes but the rest of the law stays, cuts probably will move forward. What’s happening to Medicare Advantage plans this coming enrollment season is a good story, no matter what.
A study out this week from the Pew Research Center’s Project for Excellence in Journalism finds that most of the coverage of health reform has focused on its politics, not its substance. If we’re to be relevant, good, clear journalism on what this law and the Supreme Court decision mean for our audiences is a must, or Jeffrey Toobin may just be right.
Photo credit: Elvert Barnes via Flickr