The US Senate conducted their expected vote to repeal the ACA (Affordable Care Act), as demanded by Minority Leader Mitch McConnell (R-KY). Dems lined up in unity to protect ACA, and the effort was defeated as expected, and along purely partisan lines 51-to-47. This effectively kills the House bill to repeal the ACA. So, in this regard, the ACA’s prospects of proceeding toward full implementation (in 2014 and thereafter) was enhanced by this outcome.  

Nonetheless, and at the same time, you all saw the parallel potentially calamitous legal ruling from Florida US District Court judge (a Republican appointee) Roger Vinson. This judge opined that the ACA violates the Constitution and therefore cannot proceed in the 26 states (25 of which are R states) that have filed suits against on common grounds. These filings all claim that the law is over-reaching and violates the controversial “Commerce Clause” of the Constitution. Unlike two other court decisions opining against the law’s ‘individual insurance mandate,’ Vinson’s ruling would void the entire law. He opines that the individual mandate provision is such a central and interwoven provision of the ACA that halting implementation of the act is necessary, and thus requiring that the whole law be voided. However, he didn’t issue an injunction to actually halt its implementation, believing the federal government is obligated by tradition to honor his decision, unless or until his order were to be successfully appealed.

Regardless, the federal government says it will NOT halt implementation, which already has proceeded to issue rebate checks to millions of seniors to cover their ‘donut hole’ prescription costs; establish high risk pools for those unable to get insurance; and implement various insurance reforms including allowing children up to age 26 to piggyback on their parents’ coverage. Federal attorneys cite in their defense that two similar courts have opined that the law can stand as is. But this new decision complicates things.  Proponents of the ACA are a bit scared. As we have noted before, the controversy must and will go to the Supreme Court before it is resolved, and most likely first through the federal appellate courts, meaning this controversy will drag on for a year longer. 

State and other ACA opponents will ask that implementation be halted following this decision; while the Administration and supporters will ask for a stay of this ruling until they appeal it. People who already have received new benefits, including voting seniors, won’t like having to pay back their benefits if the law is voided!  So this will be interesting to watch.

The Republican governors in the states of Wisconsin and Florida have already stated they will halt all activity around health reform and the ACA. I suspect Arizona will follow. But, most states are going to proceed, if cautiously, noting they will otherwise get too far behind to catch back up, and hoping they can contain or slow health care cost increases through such efforts.

Most DC constitutional legal experts still seem convinced the law will sustain legal challenges at the Supreme Court, based on historic decisions and precedent around the Commerce Clause. And Congress hasn’t stopped its own pro- and con- actions around the ACA.

I think that’s important to consider for us as doctors and health care professionals and patients. We are politically spread over the spectrum like the general public. But health care is not a mainly partisan issue. Do people have the freedom to avoid health coverage, and then allow EMTALA to require us physicians and hospitals to provide the care, and/or include the costs of uncompensated coverage for all other American at an average of $1000 per year? I think fixing the ACA is smarter than repealing it (this also seems consistent with ACC reform principles). But I also agree with most Republican opponents of the ACA that the deficit must be seriously addressed, something liberal Dems don’t want to take very seriously.  

I think individual liberty requires taking responsibility for yourself. As physicians, we get stiffed if people want to opt out of health coverage (or refuse to chip in for their fair share of health care costs). So does every insured person currently have to pay for those who don’t chip in for their own health care needs -- and we all end up needing health care. But this is the discussion we need to have as a nation.

I still suspect the law will stand, and get amended significantly to fix its glitches and gaps. No guarantees though. And all said, it’s important to remember that with or without the ACA, folks, we’re heading  up a metaphoric creek without a paddle if we irresponsibly drift along with the status quo any further. Health reform is essential to remedy the economic nightmares created by the incessant and future projected cost increases of US health care, public and private; and the fact that the average family is now spending more than a third, and will be spending in less than 5 years nearly half, of their income (45%) on health costs is unsustainable for business, families, or government! Hello. We live in a time with amazing health care options and services. But we have to figure out how to pay for them, and how much to pay for as a society. Doing nothing in the current circumstance is NOT an option.

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