With President Trump’s nominee for the Supreme Court all but confirmed, there are huge implications for healthcare. If the Court rules the ACA/Obamacare is unconstitutional, “a host of provisions may be eliminated” including:

• protections for people with pre-existing conditions,
• subsidies to make individual health insurance more affordable,
• expanded eligibility for Medicaid,
• coverage of young adults up to age 26 under their parents’ insurance policies,
• coverage of preventive care with no patient cost-sharing, and
• lower drug costs for seniors using Medicare’s drug benefit.

Today, a brief summary of the court case and analysis of two major implications.

A week after the election the Court will hear the Trump Administration and Republican State Attorneys General argue that the entire ACA/Obamacare must be struck down. Health policy nerds (guilty!) will recall that lower courts ruled that Congress’ elimination of the individual mandate killed the entire ACA; this is the Trump/Republican AGs’ argument.

Democratic Attorneys General have argued that the mandate can and should be separated from the rest of the ACA.

We don’t know how the Court will rule. We do know that after Barrett’s confirmation, the Supreme Court will have a 6-3 supermajority of conservative justices. According to HealthAffairs, writing about the lower court’s ruling, Judge Barrett “does not clearly state her own view but signals support for the dissent’s view (full invalidation of the ACA).” [emphasis added]

Seniors and Hospitals will be dramatically impacted if the Supreme Court overturns the ACA/Obamacare (we’ll address other implications tomorrow).

Seniors

Ending the Medicaid expansion will eliminate benefits for seniors and others in Medicaid expansion states with incomes just above the poverty line.

The ACA closed the “doughnut hole” in the Medicare drug plan, saving a million seniors about $3,200 each. If it is overturned, seniors with high drug costs to treat chronic diseases such as MS, hepatitis C, some cancers, and some autoimmune diseases will see much higher costs.

Hospitals

Many hospitals are already in financial distress, especially in rural areas and states that did not expand Medicaid.

Tennessee and Texas lead the nation in hospital closures, with one-fifth of the Lone Star State’s rural hospitals already closed or close to it. Just north, a grassroots movement in Oklahoma driven by closure of a half-dozen rural hospitals, is gaining traction.

While Becker’s reports all but one of the hospitals going belly up are in states that didn’t expand Medicaid. 

If the Court overturns the ACA/Obamacare, many more rural and smaller hospitals will shut down, leaving healthcare deserts behind.

(Work comp is also affected – albeit indirectly)

What does this mean for you?

If you are a senior concerned about the cost of drugs, and/or live in a rural area, the Court’s decision will have real consequences.

You Bet Your Life was a 1940’s radio quiz show featuring comedian Groucho Marx; contestants vied for prizes and cash.

If you or your family members have pre-existing medical conditions, the election is a reprise of the show – Republicans want to end coverage for pre-ex, and Democrats will keep that coverage in place.

If the Trump Administration’s Texas lawsuit backed by Republican Attorneys General succeeds, you can lose coverage for pre-existing conditions if you change healthplans, switch jobs, move, marry, divorce, or have a child. If Trump and Republicans win the case in Texas;

• Democrats have pledged to pass legislation to ensure pre-ex conditions are covered without higher premiums, while
• Republicans have no plan to cover you.

Briefly, Republican Attorneys General have sued to overturn the ACA, and the Trump Administration is aggressively supporting the suit.  The Trump Administration and AGs’ claim the entire law must be thrown out because the individual mandate — a penalty imposed on people who chose to remain uninsured – was killed by the Republican Congress in 2017.

In so doing, it would end protections for those with pre-existing conditions.

Make no mistake, if Trump et al win the suit and you have to change health insurance plans, you are at real risk of losing coverage  – or having to pay so much you can’t afford it.

Despite President Trump’s assertions, there is No Republican plan to assure those with hypertension, diabetes, a history of heart disease, cancer, anxiety disorder, or any other health condition will be able to afford health insurance.

If you just won lotto, you’re all set. If not, you’re screwed.

Ignore Trump’s claims that there is a replacement plan in the works because:

• Congressional Republicans have voted dozens of times to overturn the ACA (which would eliminate insurance for your pre-ex conditions) without any plans to require insurers to cover those conditions
• Republicans don’t have any plan, bill, or proposed legislation that would ensure people with pre-ex conditions could get affordable insurance
• one Republican bill would let insurers charge us older folks 10 times more than younger people.

What they do have is bait-and-switch.

As Groucho would say about the Republican claim they’ll cover your pre-ex;

What does this mean for you?

If you or a family member have a pre-existing condition, this election is about you.

If you aren’t sure, here’s a list.

And if you think you can hide your condition, you can’t. 

Healthcare will be the most significant near-term impact of this election.

If Joe Biden wins and the Dems take the Senate, here’s what we can expect.

Biden’s healthcare plan addresses the biggest problems with the ACA (known to some as Obamacare).

1. Individual health insurance plans are way too expensive.
2. About a third of all states didn’t expand Medicaid
3. The big insurers have little competition.
4. Medicare – and Medicare recipients – are paying far too much for drugs

Briefly, the Biden Plan would:

• Cap individual health insurance premiums at 8.5% of income
• Set up a public option like Medicare anyone could buy into
• Allow 60-65 year olds to buy into Medicare
• Have Medicare negotiate drug prices with manufacturers
• Solve the Medicaid expansion problem by covering low-income folks in non-expansion states through a Federal program
• Ban surprise medical billing for insureds that require out of network hospital care
• Ensure pre-existing conditions are covered

The additional costs would be paid for in part by savings (e.g. drug costs) and abolishing the capital gains tax break for those making more than a million dollars a year. (More detail on this plan, along with pros and cons – is here.)

Does this solve the ACA’s problems?

It’s not a cure-all, but Biden’s plan does go a long way to fixing the ACA’s two biggest problems – healthcare is still unaffordable and prices are still too high.

For most families covered under the plan, healthcare costs would likely decrease significantly. The 8.5% cap on insurance costs is a major change as insurance premiums in many areas are north of $12,000 a year.

Healthcare providers would:

• Scream if folks now covered by private insurers switched to a Medicare-type program as reimbursement would drop;
• Cheer if a lot more patients had health insurance; hospitals’ indigent care costs are escalating rapidly

The real problem with healthcare costs in the US is our prices for services are way too high. Covering a lot more Americans thru a government plan would force facilities and providers to get a lot more efficient.

Over the last six years I’ve done many a deep dive into the ACA’s shortcomings and why they exist; posts are here.

Bob Laszewski penned a very good piece on the plan here. Well worth a read.