26 Healthcare Leaders React to the Supreme Court's Decision to Uphold the PPACA

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It finally happened. The Supreme Court has ruled on the healthcare reform, and has decided to uphold the Patient Protection and Affordable Care Act, with the distinction that the individual mandate can stay, so long as it is deemed a tax and that the federal government cannot withhold Medicaid funds if states do not follow PPACA expansion guidelines.

Now that the waiting game has ended, here are reactions from healthcare leaders, executives, lawyers and consultants weighing in on the impact of the Supreme Court's historic decision.

Mike Abrams, CEO and President of the Ohio Hospital Association: This ruling provides clarity to allow welcome and much-needed health reform efforts already underway to move forward. Ohio hospitals are committed to leading the evolution to value-based health care delivery. While the ruling is expected to increase demand for medical care, Ohio's hospitals are pleased it will allow nearly one million uninsured Ohioans to obtain better access to essential care in the most appropriate setting. While some provisions of the ACA merit further debate and amendment, Ohio hospitals believe leaving such refinement to future legislative action is a wise decision.

Maureen Bisognano, President and CEO of the Institute for Healthcare Improvement: This is a hugely important decision, because it brings clarity to one of the most contentious policy issues of recent years. The Affordable Care Act, when fully implemented, has the potential to expand access for tens of millions of Americans to vital preventive services and care for chronic conditions. Both are crucial to improving care in America at a time when all of the metrics for chronic conditions are going the wrong way.

But increased access to care alone is not the answer. What America should now pursue is the triple aim: better health, better healthcare and lower per capita cost. The Institute for Healthcare Improvement conceived of this framework several years ago and has growing evidence that organizations and communities can achieve all three aims simultaneously. IHI has been working with innovative healthcare providers across the country who are eager to share what they're learning and what's possible. With this court decision now behind us, our nation's attention should shift to the triple aim and its extraordinary potential to make our healthcare system sustainable.

David Burik, Managing Director of Navigant Healthcare: Healthcare reform has been and is being driven by market dynamics and economic change. The Affordable Care Act simply crystalized a need to overhaul the industry. Healthcare increasingly was too expensive, unaffordable and poor in quality — a terrible trifecta. Additionally, the unstable economy heightened the need for immediate change.

John Chessare, MD, CEO and President of GBMC HealthCare System: Our healthcare system is not meeting the needs of the American people, it is too costly, and it is placing unacceptable burdens on our industries, especially on small businesses, where most of our jobs are created. The Affordable Care Act sets in motion many necessary changes to get us to better health, better care, and lower cost.

Sara Collins, PhD, Vice President, and Karen Davis, PhD, President of the Commonwealth Fund: Today, the Supreme Court upheld the constitutionality of the Affordable Care Act. This decision allows state and federal policymakers across the country to move forward in their work to implement the health reform law's provisions. Over the next decade, as many as 32 million previously uninsured people will gain affordable and comprehensive health insurance coverage because of the law.

Susan Feigin Harris, Partner in the Baker Hostetler Healthcare Practice Group: While the Supreme Court upheld the individual mandate and in fact left a large portion of the ACA intact, a close reading of the decision conveys the complexity of the ruling and some real concerns for the provider community.

Seven of the Supreme Court justices found the Medicaid expansion unconstitutional holding that the penalty imposed for failing to comply with the expansion — the loss of all Medicaid payments — was overreaching.  

"The Court today limits the financial pressure the Secretary may apply to induce states to accept the terms of the Medicaid expansion." (page 57 of the Court's ruling).

The Court leaves to each state's discretion whether to accept 100 percent federal support for the Medicaid expansion.  

For providers, this calls into question the potential success of the ACA's intent to eliminate a large chunk of the uninsured — some 16 million Americans. If a provider's state chooses to forgo the expansion, a provider could still be faced with significant numbers of uninsured patients and experience Medicaid payment shortfalls.
As part of the ACA, providers agreed to $155 billion in cuts, including significant cuts to disproportionate share hospital supplemental payments intended to compensate for the number of uninsured patients treated by a facility. In the case of DSH, the supplemental payments would not have been required, theoretically, if the number of uninsured was eliminated.  

With this ruling, there is absolutely no guarantee that a state will participate in the Medicaid expansion and that the number of uninsured will be reduced, yet DSH cuts remain.  The near universal coverage intent of the statute remains ambiguous. While state exchanges appear to be sanctioned, it is unclear what this ruling's impact on the Medicaid maintenance of effort provisions will be.  Providers will likely raise these issues to Congress for action in a year in which Congress has many other fiscal priorities.

Donald W. Fisher, PhD, CAE, CEO and President of the American Medical Group Association: For decades, AMGA members have been leaders in the use of care coordination and evidence-based, team-based medicine, which are the core elements of accountable care. Our members are distinguished for being innovative and providing patient-centered medical care. AMGA and its members will continue to focus on efforts to deliver the right care at the right time for patients, in the most cost-effective manner currently available.

AMGA accepts today’s ruling, and we would encourage federal policymakers to remember that delivery system reform is not dependent on any single piece of legislation, but rather the continuing efforts of patient-centered organizations beyond the Beltway that are making healthcare advancements day-in and day-out. We need to support and foster them, and we remain hopeful that the dialogue can now shift to this necessary debate.

Bill Frack, Vice President, Head of the Healthcare practice for LEK Consulting: As articulated in our white paper "Will ACOs Keep Hospital's and Insurers Out of Critical Care?" we expect the representative hospital to see a 5 percent decline in margin including the positive impact of less uncompensated care.  This is because reform accelerates the shift in payor mix from more profitable commercial business to less profitable Medicare and Medicaid programs. This effect drowns out the benefit of coverage for previously uninsured individuals.

Relief from some or all provisions of healthcare reform will reduce margin pressure and perhaps reduce the distraction of rapid provider system alignment initiatives ignited by ACO implementation. However, margin pressure will not go away, and with or without reform the priorities remain the same: align services to market needs, create and administer new care models, institute incentives focused on holistic care, integrate clinical data, ensure seamless transitions of care, and measure performance.

The only difference is that without or with less ACA, providers will have more time to achieve this dramatic transition.

Robin Gelburd, President of FAIR Health: The Supreme Court's affirmation of the Affordable Care Act does not put an end to our national conversation on health reform. Issues related to cost, quality and the value of healthcare continue — particularly for fiscally-challenged states now grappling with the expansion of their Medicaid programs. The stakeholders in our healthcare system will need to continue to work together to advance new approaches to control costs and maximize quality. Reliable, robust data on how Americans receive care and what it costs will be a critical element in the reforms to come.

Bruce Johnson, CEO of GHX: The ruling today by the U.S. Supreme Court reminds us that healthcare continues to be in a state of change. For GHX and its customers, the providers and suppliers of healthcare services and products, it's about creating a sustainable healthcare industry.  

Unlike most industries, healthcare is two-dimensional: delivering high-quality care to save lives while running efficient businesses. At the core, healthcare reform is driven by the need to reduce costs while delivering care of the highest quality. The business of healthcare needs to change in order to deliver cost efficient and effective business processes — toward the goal we all share of reducing the overall cost of care.  It's all about quality and access — and quality can be improved by healthcare businesses working together to standardize and streamline their processes.

I've had the pleasure of working with healthcare suppliers and providers, who by driving standard business processes and implementing new technologies for better information sharing, are reducing operational costs and investing in the highest quality healthcare. But there is still a lot of work left to be done and many healthcare organizations have to change the way they do business if they want to survive in the new age of healthcare.

Paula A. Johnson, MD, MPH, Executive Director of Connors Center for Women's Health and Gender Biology and Chief of the Division of Women's Health at Brigham and Women's Hospital: Today's Supreme Court decision is a significant step forward for the health and equality of our nation's women and their families.  This ruling assures that women will have access to all those provisions of the Affordable Care Act that speak directly to their lives. Women will now be secure in knowing that they will be able to find insurance despite having a preexisting condition. They now know that they will have coverage for prevention services like mammograms and birth control at no additional cost. And now women know once and for all, that they cannot be charged more than men for the same insurance or lose their coverage when they get sick.

As a member of the Institute of Medicine's panel that recommended the preventive services that are central to women's health, I am particularly pleased that women's access to essential no-cost preventive services including mammograms and screenings for cervical cancer are secure and will go into effect as planned on August 1. Expanding preventive care for women allows doctors to detect illnesses early before they get more expensive to treat resulting in a huge cost savings four our country. Given that chronic illness among women costs our nation's health care system over $460 billion each year, these cost savings will be substantial. From allowing young women access to health insurance through their parents' plans to assisting older women with prescription drug affordability by closing the Medicare "donut hole", the ACA is historic in its ability to provide women with access to comprehensive health care across the lifespan.

Today is a day to celebrate but it is also a call to action for our states. As national health reform implementation moves forward, states will likely encounter many of the same women's health challenges experienced in Massachusetts, the model for national reform. Massachusetts women have the highest rates of health insurance coverage in the nation and access to care among women has improved across all demographic groups.  Challenges persist. But today is the day we get the green light to move forward, meet these challenges and implement a robust system of care that works for women who are 51 percent of the U.S. population.

Stephen K. Jones, FACHE, President and Chief Executive Officer of Robert Wood Johnson University Hospital and Robert Wood Johnson Health System: RWJ is very pleased that 32 million more Americans will have access to healthcare coverage as the result of the Supreme Court's decision. That's welcome news for the nearly one million New Jersey residents who will enjoy the promise of health insurance.

RWJ, in partnership with Robert Wood Johnson Medical School and our medical staff, has already taken proactive steps to improve the value of our healthcare delivery system in preparation for reform. They include efforts such as quality improvement initiatives, increased integration among different types of healthcare providers and working with our physicians as well as members of our entire healthcare team to improve care coordination and efficiency efforts.

It is clear that the new model of healthcare delivery is driven by value, specifically the quality of services provided, not the quantity of tests completed or patients admitted. In the new environment, hospitals, physicians and all healthcare providers must remain focused on improving patient safety measures, reducing readmission rates and effectively managing our patients care from time of admission through their hospital stay and eventual return home. This means taking aggressive steps to reduce hospital-acquired infections, preventing both medical and medication errors and enhancing the discharge planning process to ensure that at-risk populations continue to receive essential services after they leave the hospital.

Darrell G. Kirch, MD, CEO and President of the Association of American Medical Colleges: The AAMC is extremely pleased that the Supreme Court has upheld virtually all of the Affordable Care Act. This law is an important step toward an improved healthcare system that gives all Americans access to the care they need when they need it. However, we are closely examining the court’s ruling as it relates to the Medicaid expansion.

America's medical schools and teaching hospitals are committed to improving the nation's healthcare and have been leading the transformation of healthcare delivery through innovations in medical education, clinical care, and research. The court’s decision to uphold the PPACA allows the important work of the Center for Medicare and Medicaid Innovation, the Patient-Centered Outcomes Research Institute and the programs supported by the Prevention and Public Health Fund to continue.

With 32 million newly insured Americans entering the healthcare system, addressing the nation’s physician shortage — projected to climb to more than 90,000 by 2020 — is now more critical than ever. Medical schools have done their part, increasing enrollments during the last six years in response to these shortage projections. But the overall supply of U.S. physicians cannot expand unless Congress increases the number of federally funded residency training positions, a number that has been frozen since 1997.

We urge Congress to move quickly to provide more federal support for additional doctor training to ensure that Americans have access to care — not just an insurance card.

Jeremy Lazarus, MD, President of the American Medical Association: This decision protects important improvements, such as ending coverage denials due to pre-existing conditions and lifetime caps on insurance, and allowing the 2.5 million young adults up to age 26 who gained coverage under the law to stay on their parents' health insurance policies. The expanded health care coverage upheld by the Supreme Court will allow patients to see their doctors earlier rather than waiting for treatment until they are sicker and care is more expensive. The decision upholds funding for important research on the effectiveness of drugs and treatments and protects expanded coverage for prevention and wellness care, which has already benefited about 54 million Americans.

The health reform law upheld by the Supreme Court simplifies administrative burdens, including streamlining insurance claims, so physicians and their staff can spend more time with patients and less time on paperwork. It protects those in the Medicare 'donut hole,' including the 5.1 million Medicare patients who saved significantly on prescription drugs in 2010 and 2011. These important changes have been made while maintaining our American system with both private and public insurers.

Bill Leaver, CEO and President of Iowa Health System: There's no doubt about it.  The healthcare industry has anxiously awaited the Supreme Court opinion upholding or striking down the Affordable Care Act. Since its passage, our health system, the largest group of health care providers in Iowa, also serving regions in Illinois, has invested millions of dollars in carrying out provisions of the ACA — provisions that have nothing to do with the individual mandate, co-ops or Medicaid coverage expansion. Accountable care organizations, bundled payment projects and electronic health records are just a few of the health care delivery provisions of the law in which we've invested. The best kept secret about these provisions is that they embody concepts supported by Democrats and Republicans.
Now that the court has upheld these portions of the law, we breathe a momentary sigh of relief.  

Our next reaction is an appeal — to the public, policy makers and political campaign staff:  Can we move on? Let's not have the upcoming election, lame duck session and 2013 Congress focus on ripping apart healthcare delivery provisions of the ACA that will lower the cost, increase the quality, and improve the patient experience in the healthcare setting.

As a country we face two incredible challenges: one, to balance the budget and reduce our federal debt; second, to ensure that our private sector companies and their employees can be competitive in a global economy. Part of the answer to meeting these challenges is figuring out how to make our health care system deliver better outcomes for our patients and be more affordable for all Americans. To do this, we must pay for care differently and clinicians must deliver the care differently.

Laurie Liles, CEO and President of Arizona Hopsital and Healthcare Association: While no legislation is perfect, more people will now have access to affordable health insurance, and that is a good development for patients and the hospitals that serve them. This is a pivotal time in our history, and hospitals are transforming the way healthcare is delivered, making care safer and more affordable for patients. Arizona hospital leaders look forward to partnering with policymakers to achieve the goals of better care, better health and lower costs.

Dan Mendelson, CEO and founder of Avalere Health: The Supreme Court found common ground in the fact that the requirement to purchase insurance was really framed as a tax. So while the conservatives don't like the mandate and liberals aren’t bothered by it, the center of the court agreed that it is permissible to penalize consumers who don’t purchase insurance with financial penalties.  

What this means for healthcare companies is that they can re-focus strategically on the business of preparing for the implementation of the law. Most have already gone well down that road strategically, investing in Medicaid, individual insurance lines, and regional consolidation.  

Going forward, there will be further threats to the law from the Congress, and we will know in November how serious those threats will be.

Martin Merrit, JD, MartinMerritt PLLC: As a health lawyer, the 193-page Supreme Court opinion upholding PPACA was job one on the day it became available. Just for the sake of completing the puzzle, I then watched members of Congress and the President discuss the ruling. Informed by hot-off-the-press points of view from all three branches of the federal government, I began to wonder if the case shouldn't have been dubbed, "welfare state" vs. "state of denial."  

First, to those who say healthy Americans don't use healthcare, and should not have to pay for other's needs, I have to respond, "Yes, healthy uninsured Americans do use the system." They use the system every time they aren't forced to take in, and care for elderly relatives in their final years — which doesn't happen because of Medicare. The uninsured use the system every time a Careflight helicopter is purchased and the crew shows up for work, just in case they wrap their car around a tree…The reality is, we have a system which knocks the harsh edges off of a pure free-market health system; but in doing so, we ran up a bill we simply can't afford to pay... and we aren't paying for it. In the case of federal and state-run programs, we are actually putting much of Medicare and Medicaid on a credit card, called the "national debt."

President Obama's remarks on the day of the Court ruling were aided by the fact the provisions of PPACA do actually bear some logical relation to the problems we face. The premise seems to be: reduce the number of uninsured people, eliminate pre-existing conditions as a basis for denying insurance, keep young adults on their parents' plans longer and force everyone who doesn't have insurance to buy some. If we just do this, the problem will be solved.  

But this logic still requires scrutiny. How does making uninsured people buy coverage help in any way federal deficit spending on Medicare and Medicaid? There will still be just as many seniors, disabled and poor children receiving government benefits. For the answer, we don't need a crystal ball. A rear-view mirror works just fine. Based upon past experience, one might surmise the federal government has every intention of using the new money from all these private-sector insured patients to justify cuts in Medicare reimbursement rates. While many administrators hope the newly insured will ease financial strain, it may be more like moving five dollars from your back pocket to the front pocket and thinking you have five more dollars.

Republicans, in their remarks following the ruling don't get a free pass either. Plenty was promised about repealing PPACA, but when pressed for an answer to the question, "What would Republicans do to address the problem?" Texas Senator John Cornyn reminded me of a first- grade child performing in a school play. It was painful to watch, but I did have to admire his courage for trying to answer with so little to offer. Sen. Cornyn said he was confident the problem could be solved with medical savings accounts. He also offered the idea that high-deductible insurance would help those for whom premiums are out of reach. But we already have medical savings accounts and high-deductible insurance plans. Ask any hospital administrator how many people affected by PPACA (who don't have employer provided  or government plans)  show up in an emergency room with either one of these. It is not really clear how the Republican response changes anything.

If there is to be true reform of our healthcare system, there must be a sea change in our psychology. People don't like being forced to buy health insurance — and for good reason. This country once was populated by working poor who would never have dreamed of accepting medical help without paying for it. The growth of employer provided health plans in WWII, together with the passage of Medicare in 1965, fundamentally re-wired our brains. We began to think of healthcare costs as something "other people" provided for us.

Slowly, the global economy led to an even more difficult pill to swallow. As fewer employers provided insurance, the population began to notice that having health insurance had little to do with how hard a person worked, or how good he or she might be at their job. Much like standing in a long line at the bank, while others are served quickly, nothing makes Americans more rebellious than disparate treatment, for no obvious reason.

These are some of the conclusions I have as I read and listen in the wake of the Court's ruling.  I think the President's plan is not perfect, (and may do no good at all) but do applaud the fact that it does something to address the alarming number of uninsured Americans and the crisis this has caused. If Republicans are able to unseat the president in November, I would certainly be more comfortable supporting them if they presented more concrete solutions of their own.

Dennis Morabito, Senior Manager and Marketing Communications Director for Teletracking Technologies:
The U.S. Supreme Court decision on the Affordable Care Act leaves the doors to America's hospitals open to the largest onslaught of potential patients in the nation's history, an estimated 30-40 million people who currently do not have coverage plus the leading edge of the 70-million-strong Baby Boom Generation.

The ruling is good news for suppliers of the type of medical information technology which helps hospitals maximize the use of existing capacity. Resource optimization will be crucial to the success of hospitals which must deal with a large influx of new patients without benefit of adding new capacity. Hospitals needing to do more with less now have access to operational tools, such as real-time capacity management, which can optimize space, staff and equipment resources while easing overcrowding, reducing waste and increasing revenue.

Reimbursement changes and a shift to disease prevention and more primary care may shift volume but capacity problems in hospitals are more complex than that. Fewer emergency departments, changing reimbursement models, lack of access to capital and the aging population coupled with ongoing challenges with community access to primary care, which may take years or even decades to fix, means it will continue to be increasingly important to the financial well-being of all hospitals to make the best use of existing capacity and resources.

Ronald A. Paulus, MD, CEO and President of Mission Health: Regardless of the Supreme Court decision, hospitals need to manage for what's ahead without bleeding more red ink. The real-time enterprise of the industrial world may now experience a higher adoption rate in America's hospitals because it achieves a key objective of Affordable care organizations, to stabilize or reduce costs while improving patient care.  

Today's ruling from the Supreme Court to uphold the law now gives us direction in moving forward with healthcare reform. We are pleased that there is now clarity on the constitutionality of the law. That said, it's important to note that with or without reform, the overarching issues are the same:

  • Care quality is not where we need it to be nationally, and it must be improved;
  • Healthcare costs are high and growing too rapidly, and we must become more efficient;
  • Even with the current law, far too many individuals are and will remain uninsured or underinsured, and as a result, they frequently don’t receive the care that they need to prevent and manage illness in an optimal manner;
  • Inappropriate incentives hard-wired into our system reward "more" rather than best outcomes.

Raj Rao, MD, Spine Surgeon and Professor at the Medical College of Wisconsin: Given that the bulk of PPACA was upheld, preparation for enforcement of the various provisions along the timescale previously established by law will continue. Healthcare is likely to become a bigger issue in the presidential election.

In the short term, the ruling reduces any anxiety that may be associated with having to make changes again.

Carolyn F. Scanlan, CEO and President of the Hospital & Healthsystem Association of Pennsylvania: Increasing the numbers of individuals and families with health insurance has always been a priority for Pennsylvania's hospitals. Higher rates of coverage improve access to primary and preventive care, and therefore contribute to better health; assure that more who are hospitalized or need other health care services are covered; and reduce the uncompensated care burden on hospitals. We have supported, and will continue to support, state and federal healthcare policies aimed at reducing the number of uninsured individuals.

Bruce Siegel, MD, MPH, CEO and President of the National Association of Public Hospitals and Health Systems: We are pleased by the Court's decision today to uphold the Affordable Care Act's individual mandate, which will broadly expand healthcare coverage. We also are pleased that the decision retains other positive elements of the ACA, including initiatives to promote innovation, preventive care, and community-based collaborations.

But our initial assessment of the decision leaves us concerned by its potential to limit Medicaid expansion, which could strand millions of our most disadvantaged people without access to basic health care coverage.

The decision could allow states to opt out of the ACA's expansion of Medicaid coverage to people below 133 percent of the federal poverty level. While the ACA provides substantial support to states to expand Medicaid, we are concerned many states will choose not to expand coverage. Indeed, in the 26 states that participated in the federal lawsuit, more than 27 million people have no insurance and many who would have been eligible for Medicaid in 2014 might no longer have that option.

We hope states choose to do the right thing. But we cannot base federal policy on hope alone. NAPH urges Congress to avert a potentially disastrous outcome for vulnerable populations by immediately reevaluating safety net funding in light of this decision.

Safety net hospitals and health systems lead innovation in quality of care and access, and do so with limited resources. We must support safety net patients and the hospitals and health systems that serve them with a stronger funding commitment.

John R. Tongue, MD, President of the American Association of Orthopaedic Surgeons: The AAOS recognizes that there are provisions within PPACA that help providers deliver high-value healthcare services and offer musculoskeletal patients protections against insurance company abuse and educational tools to make better healthcare choices.

However, we cannot overlook provisions like the Independent Payment Advisory Board that threaten the doctor-patient relationship and the administrative burdens within the law that could greatly hinder providers' ability to deliver quality care by infringing upon exam room time.

The AAOS will continue its efforts to achieve a patient-centered solution to health reform by working with Congress to best implement the beneficial provisions of PPACA; repeal the detrimental provisions that still exist, and; to solve critical issues, like achieving a permanent solution to the flawed Sustainable Growth Rate formula and addressing federal medical liability reform, that the law failed to address.

John Toussaint, MD, CEO emeritus of ThedaCare and CEO of the ThedaCare Center for Healthcare Value in Appleton, Wis.: With the affordable care act being upheld, the work begun by the Center for Medicare & Medicaid Innovation will be sustained. These payment innovations are critical to transforming the healthcare industry. In fact, we believe there are three important components of true health reform, two of which are addressed by the bill — payment reform and the release of Medicare data to patients. The third component is the redesign of healthcare delivery to remove waste and improve quality. With falling revenues healthcare delivery organizations will have little choice but to become more efficient. We have shown that hospitals and physician groups can deliver much lower cost higher quality care using Lean principles and practice.

Rich Umbdenstock, President and CEO of the American Hospital Association: Today's historic decision lifts a heavy burden from millions of Americans who need access to health coverage. The promise of coverage can now become a reality.

The decision means that hospitals now have much-needed clarity to continue on their path toward transformation. But transforming the delivery of healthcare will take much more than the strike of a gavel or stroke of a pen. It calls for the entire healthcare community to continue to work together, along with patients and purchasers, to implement better coordinated, high-quality care.

Now that the Supreme Court has made its decision, hospitals will continue their efforts to improve the law for patients, families and communities.

If any of our readers are interested in sharing their insight on the Supreme Court's decision, please email Bob Spoerl, bspoerl@beckershealthcare.com, with your reaction.

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