Patients in waiting room

Today’s U.S. Supreme Court’s ruling to uphold the individual mandate and other provisions of the Affordable Care Act (ACA) is a historic decision that will “open important new synergies” for public health, according to leaders of the Colorado School of Public Health.

Dean David C. Goff, MD, PhD, and Associate Dean Tim Byers, MD, MPH, released a statement that called the decision a “turning point for the nation’s public health and health care systems.”

Meanwhile, campus Payroll & Benefit Services, which is the plan administrator for the University of Colorado Health and Welfare Trust, has been closely following the law and will continue to do so, said E. Jill Pollock, vice president of Employee Information Services, Office of the President. “Aspects of its requirements — like preventive care — had been incorporated with our health plans in whole or in part before the law became effective, so we believe the trust is well positioned, from both plan design and cost perspectives, to continue to provide excellent coverage at fair rates,” Pollock said.

At our campuses, views on the high court’s decision ranged from it being quite unexpected to one that is not overly significant due to health care reforms already under way. What’s certain to occur, experts agree, is that the law will remain a focus of heated debate for years to come as many of its provisions don’t take effect until 2014.

Parts of the ACA, President Obama’s signature legislation, were challenged as unconstitutional by 26 states, including Colorado, as soon as it became law in March 2010. Especially intrusive to constitutional rights, the states argued, was the law’s “individual mandate,” or requirement that most Americans have health insurance or pay a fine.

The court’s ruling stated that the Commerce Clause does not allow Congress to force individuals to participate in commerce. But, as the individual mandate is written in the law, it is a valid exercise of Congress’s power to tax.

“This was an unexpected decision,” said Kelly Hupfeld, JD, associate dean of the School of Public Affairs. “… Construed as a tax and subject to Congress’s even broader power to tax, the individual mandate is allowed to stand. No one, including the Obama administration, really thought this argument would work, especially because Obama insisted that it was not a tax as it was being debated in Congress.”

Hupfeld noted that well-established case law requires courts to uphold legislation as constitutional if at all possible, and that’s what the court did. “The ground on which they did, however, was solidly conservative,” she said. “It’s a victory for the ACA, but with consequences for future actions by Congress. If this was a political decision, as many argued that it would be, it was quite savvy.”

Errol Biggs, PhD, director of health administration programs in the Business School, said the high court decision is somewhat irrelevant given the changes  already occurring in health care. The market is shifting toward a system that aligns incentives — which have been out of alignment — between hospitals, insurers and physicians.

“I don’t think people should be excited one way or another (about the ruling) because the market is reforming health care anyway,” Biggs said. For instance, the market was moving toward a quasi-governmental provider, whether subsidized or not, to cover the uninsured if insurance companies did not offer plans at a reasonable price.

Biggs said he was surprised that the conservative-labeled Chief Justice John Roberts, who wrote the majority opinion, was the swing vote in the 5-4 decision. With much of the law not taking effect for two more years, Biggs noted, “this will probably be one of the centerpieces of people running for elected office in November.”

In their statement, Goff and Byers noted that the decision has much broader significance than the individual mandate ruling. “The ACA re-framed the mission of the U.S. health care system and providers toward a greater expectation to improve community health and the health of our population as a nation,” they said.

The change will create more opportunities for partnerships between health care providers and public health practitioners, they said. Regardless of the legality of the individual mandate, they noted, the public health initiatives supported by the ACA — including the National Prevention, Health Promotion and Public Health Council, the Childhood Obesity Task Force and other health promotion programs — are worth their place as national health policy priorities.

The politics and media coverage around the law and the court’s decision should not overshadow the nation’s investment in health care, Goff and Byers said. “We believe ACA is not the end point, rather the beginning of new efforts to improve community health.”

Rulon Stacey, president of University of Colorado Health, established this year when University of Colorado Hospital and Poudre Valley Health System formed a partnership, said today’s decision, no matter which way it went, would have had little impact on how University of Colorado Health is preparing for the future.

“We know the future will be less reimbursements for care providers, and it’s going to require organizations like ours to provide better care at lower costs,” Stacey said. He noted that hospital consolidations in 2012 — Memorial Health System in Colorado Springs could join UCHealth later this year if voters approve a lease proposal — have already surpassed 2011’s record number.

Hospital systems recognize that, in order to be successful in today’s health care environment, they must integrate clinical and administrative best practices, including shared medical records and collaborative care for the best patient outcomes, Stacey said.

Adit Ginde, MD, MPH, associate professor of emergency medicine, School of Medicine, said the upholding of the individual mandate will help make other provisions, such as eliminating the denial of insurance based on pre-existing conditions, more financially tenable. He said the nation’s overall health will benefit from guaranteed coverage for high-value preventative services.

He pointed out that health care systems will need to be prepared for increased demand for services. “Given the current shortage of health care providers, particularly primary care providers, the new influx of individuals with health insurance is expected to place increased strain on existing safety net systems, such as hospital emergency departments, which is the only place where health care access is guaranteed,” Ginde said. “…Reducing barriers to insurance coverage is an initial step to improve health care access, but unintended consequences should be monitored closely and addressed.”

Steven J. Summer, president and CEO of the Colorado Hospital Association, said the ruling allows the state to continue to focus on ensuring health care access and coverage to Coloradans. “We will continue to work with policy makers on both sides of the aisle to reform the health care delivery system and reduce the number of uninsured, as well as increase access to care,” he said.

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