IN MY OPINION

 Isn't it ironic that the future of the Affordable Care Act which was crafted in part by lawyers, approved in the House and the Senate primarily by lawyers, and subsequently challenged in the courts by lawyers will now be decided by lawyers who now are justices in the Supreme Court?

In about six weeks, the Supreme curt will render its decision on the constitutionality of the Affordable Care Act (ACA). They can choose to affirm the whole act, rule the whole act unconstitutional, or only rule parts unconstitutional. Their decision will affect all of us involved in the delivery of healthcare even though the vast majority of the change promised in the ACA has not yet even gone into effect.

My initial reaction was that it would not change the life of the average physician if the whole law was reversed in June. We would still get up every day, see our patients, and bill third parties for our services.

However, long-term there will be consequences if the act is overturned. This law was just the first step in what was contemplated to be a change in the delivery and payment for healthcare in our country. What should have been a procedural discussion became a political discussion and the act that is now being reviewed by the Supreme Court is a "politically compromised bill" that evolved so that it could gain the votes necessary for passage. The vision of healthcare reform was to create a system where outcomes driven by best medical practices were rewarded, a system where there would eventually be a seamless interface of communication between physicians utilizing the electronic medical record, and a system where preventive medicine would perhaps drive up costs initially but, in the long-term, reduce the burden as diseases were either prevented or caught earlier in their evolution.  

The mandate, about which we have heard so much, was a key provision in the reform bill. Of the 40-50 million uninsured individuals in our country, the vast majority are under 50 years of age and are working. Unfortunately, they do not have the resources to purchase insurance commercially, have pre-existing conditions that bring up the premium significantly, or they do not have group health insurance offered to them where they work. The mandate required these individuals to purchase some type of insurance from pools that were to be set up specifically for these patients. Their insurance would not be the best of the best nor would it be the worst of the worst. It would however, allow these patients to see a physician who would be compensated for the care they render. The crux of the debate was:  Can the government impose a penalty (tax) on individuals for non compliance?  This article is not to debate the issue, but what is wrong about requiring people to have health insurance? We require people to have auto insurance, have a drivers license, have homeowners insurance if they have a mortgage, etc., etc., etc. Early on we heard about the public mandate. That was eliminated from the bill due to political fighting, but in reality, what would have been wrong if we allowed this group of patients to "purchase" Medicare. The program already provides coverage for any person in the country with a permanent disability irrespective of age. Would it be so bad to allow healthy people to purchase Medicare?

So what happens tomorrow if the law is overturned? There will be immediate issues with the change in the donut hole as it relates to Medicare part D. There will be changes in that the "wellness visit", included in the act, will no longer be paid for by Medicare. How many diseases will be found later since patients will have to decide to pay for the visit or not have it at all? More importantly, what about the associated laws (HITECH Act) and perception of how healthcare is going to be delivered? Does ACO planning stop? Do the doctors who have sold their practice to hospitals and other organizations because they feared reform now develop seller's remorse? Do the purchasers of medical practices take a deep breath and try to determine what the next steps should be? Will health insurance premiums go down now that community-rating standards for underwriting will not go into effect in the future? Or do they go up because the anticipated, expanded risk pool driven by the mandate has now been cancelled?

Unfortunately, if all or part of the act is reversed we will probably go back to the status quo, as it existed in 2009. There is something inherently wrong when healthcare reform and the delivery of care has been changed into a political debate that will be decided by justices appointed to the Supreme court because of their conservative or liberal ideation. I have always believed that we should not let perfect get in the way of better. Let's hope those in Washington would agree.

About the Author:  Dr. Schimmel is the President of Allied Health Advisors, LLC, a boutique healthcare consultancy in Miami.  He can be reached at 305.803.2469 or LarryHS@comcast.net.