The Supreme Court is almost certainly going to strike down at least a part of the law, the mandate that requires those who are uninsured to buy insurance. That's easily the most controversial, and least explained and defended, part of the law, because with it came subsidies and Medicaid expansion to make the mandate affordable. But additionally, with the mandate comes the critical reforms for insurance companies: guaranteed issue and community rating. And if the mandates falls, so do these reforms.
Let's briefly revisit what these reforms are. Guaranteed issue means simply that health insurance companies can't turn you down because of pre-existing health conditions, or because of your age or gender or any other circumstance. Community rating requires that insurers can't gouge certain segments of the population, usually women and seniors, in premiums. They wouldn't, for example, be allowed to charge a woman many times more for the same basic coverage that a man of the same age and in the same location would be charged.
The law immediately put guaranteed issue in place for children, and would bring for the rest of the population in 2014. If the law falls, so possibly does that coverage for minors. As of now, the major health insurers in the country are saying that they will continue to honor at least some of the law's provisions, although possibly not this one.
In its statement, United stopped short of saying it would continue to follow that provision for kids who are ill. While it "recognizes the value of coverage for children," United said, "one company acting alone cannot take that step," adding that it is "committed to working with all other participants in the health care system to sustain that coverage."That statement alone proves the problem with relying on the insurance companies to keep these reforms alive. One of them can't and won't do it unilaterally. So how long their commitment to these reforms will last is anybody's guess. See, the mandate was a critical factor in the health insurance companies' support for the law: if they had to take on all comers, including the sickest, and were prevented from charging them outrageous premiums, the pool of patients had to be broadened to the whole population to bring in the cheap, healthy people.
The big question, and the question that dominated the oral arguments when the Court heard the case, is whether these reforms—including an expansion of Medicaid—are "severable" from the mandate, whether they can stand if the mandate is struck down. The administration argued that they could not, that trying to maintain them without the mandate would drive up costs and reduce coverage as insurers have to try to provide coverage to all sick comers without having a healthy population to spread out costs to. That would be the opposite of what Congress and the administration were trying to achieve with the law.
So we're left with the likelihood that the woman in the short film, the one who'd never had a chest x-ray and just discovered she has spots on her lung, will never be able to be insured. We're back to the status quo presented in the film. (Note that the Affordable Care Act doesn't address other problems highlighted by the film—dental and vision care— problems that have to be tackled as well. But if the ACA goes down, we're starting at ground zero again with basic medical care being out of reach for tens of millions of Americans.) That's looking ahead at what could be lost, but what about the immediate losses?
Let's explore, over the fold.
Well, in large part, it'd once again be up to big insurance. Right now they say they'll continue to provide coverage for young people up to age 26 on their parents' plans. That's excellent news for Susan Gardner and her daughter and the millions of other young adults who weren't dumped into the world of the uninsured. But it leaves them at the whim of their insurance companies, who would be able to abandon this provision at will. At the very best, they'll be left with tremendous uncertainty. Again.
Here's what we know will be lost, the hundreds of millions of dollars saved by seniors, just in a year, on prescription drug costs with the closing of the "donut hole," the coverage gap in which many seniors pay for their drugs out of pocket. Republicans have specifically said they don't intend to close that gap if the Supreme Court opens it up again. More money out of seniors pockets. Again.
More than 54 million Americans have received some kind expanded health care services because of the ACA, including "services such as colonoscopy screening for colon cancer, Pap smears and mammograms for women, well-child visits, flu shots for all children and adults, and many more." That's good, old-fashioned preventative care that millions of people received without having to make a co-pay, helping them stay healthy or catch potentially life-threatening diseases while they're still treatable. Maybe the insurance companies will keep this provision alive, maybe they won't. And maybe they'll use these tests to deny coverage to patients in the future, if the ACA falls. That'll be up to the insurance companies to decide. Again.
What else will be lost is not entirely quantifiable, but the recent testing-ground Oregon has provided gives some hints. The state's experiment in holding a sort of lottery for expanded Medicaid coverage among the working uninsured. What difference does health insurance and access to medical care make for the working poor?
The newly insured were more likely to describe their health as good, and to say that their health was getting better, according to self-reported data that researchers are now combining with objective measurements for a deeper follow-up study. The uninsured reported being in worse physical and mental shape and were less likely to describe themselves as happy.Even with the Affordable Care Act, the nation's health care system needs improvement. Without it, we'll have lost tremendous ground. The ongoing recession has created even more uninsured, and the ongoing housing and student loan crises will make health care even more financially out of reach for millions. More than that, there won't be the political will of our leaders to tackle this problem one more time. That's if the Supreme Court ruling doesn't preclude the federal government from trying to change the system at all.
Getting insurance also had powerful financial effects, the study showed. The insured were 25 percent less likely to have an unpaid medical bill sent to a collection agency and 40 percent less likely to borrow money or skip paying other bills in order to cover their medical costs. [...]
The uninsured described borrowing medication from family members and friends, taking it every other day, and asking doctors to diagnose multiple conditions and write multiple prescriptions on a single visit. The insured said they had largely abandoned such strategies.
Nearly all of the uninsured also described how avoiding doctors to save money resulted in trips to the emergency room. (Unnecessary or preventable emergency room use costs some $38 billion a year, researchers estimate.) [...]
Not having insurance “affects your whole life,” said Christine Toman, 61, who has a chronic pulmonary condition and hepatitis C and did not win coverage. “I went to work. I paid my bills. And now I feel like a hopeless, hopeless old woman that’s in the way, and it’s sad to feel like that. I’d like to die with some pride.”
Ms. Toman, in a husky voice and a soft wheeze as she labored to breathe, said that she occasionally goes to the emergency room when her conditions became acute. But she generally just forgoes care.