June 28, 2012
Today's Supreme Court decision to uphold most of the Patient Protection and Affordable Care Act (ACA)—and most notably, the individual mandate that all Americans purchase health insurance or pay a financial penalty—is likely the most significant health care-related ruling in U.S. history.
When President Barack Obama signed the bill into law in March 2010, the American health care system seemed destined for sweeping reform. Yet constitutional challenges soon surfaced, with two such cases climbing the judicial hierarchy and landing in the Supreme Court, threatening the President's signature legislative achievement.
Now that key provisions of the president's reform have survived the process and a mixed ruling on Medicaid expansion has prevailed, what lies ahead for health care in America? RAND experts sound off in the wake of the Court's momentous decision.
Future of Medicaid Still Uncertain
With most of the key provisions of the Affordable Care Act upheld, we expect close to 30 million Americans to gain health insurance coverage. Yet the part of the ruling dealing with Medicaid is significant. We don't know how many states will respond, and it will take thoughtful, quantitative analysis to gain insight into this. Our next challenge will be to analyze the effects of states opting out of Medicaid expansion, and how this might influence insurance coverage, exchange enrollment, and federal spending on subsidies.
— Christine Eibner, economist
Program Design Key to Achieving ACA's Goals
As federal and state policymakers move to implement the ACA, there are a plethora of decisions that must be made about how to structure the program elements. These decisions and the evolution of health care reform can be improved by the independent, objective analyses that RAND can provide. We can help identify best approaches to program design and implementation, and how to assess the impact of the ACA in achieving better quality, lower costs, and improved health. RAND's work in the area of pay-for-performance and value-based purchasing is one example of how RAND is helping policymakers design incentive programs to improve quality and lower costs.
— Cheryl L. Damberg, senior policy researcher
With Ruling Settled, Reform Can Begin
The ACA contains a myriad of provisions to reduce health care costs and improve quality independent of the mandate. For example, reforms have advanced primary care in ‘patient-centered medical homes’ and ‘bundled payments’ for common episodes of care have been taking root, but could potentially accelerate in the private sector with federal funding confirmed. Now that the uncertainty of the Supreme Court decision has been lifted, transformation of health care delivery can move rapidly ahead.
— Peter Hussey, policy researcher
Supreme Court Not the Only Group Whose Decisions Matter
The passage of the law and this ruling are the start of health care reform, not the end. There are now many decisions to be made. State governments need to make preparations for the insurance exchanges and the expansion of Medicaid. Health insurance companies must ensure their offerings are in compliance with the law. Businesses should assess the impact of the new options on their employees to determine if they should continue to offer health insurance. Health care providers need to assess whether they have the capacity to provide care to as many as 30 million newly insured Americans. Finally, individuals should look at the new options that will be open to them in 2014.
— Carter C. Price, mathematician
Federal health care reform had just begun in 2013 when Oregon authorized a study to improve how the state pays for health care. A comparison of the projected impacts and feasibility of four options can help Oregon's stakeholders choose the option that best suits their needs.
RAND analyzed three options to reform health care payment in Oregon (two state-based plans that would ensure coverage for all state residents and a state-sponsored plan offered in Oregon's nongroup market) and found benefits and trade-offs for each.
As Congress considers repealing and replacing the Affordable Care Act, it will need to consider how federal budget scoring can affect the fate of legislation. Depending on the ultimate cost of a replacement, finding enough savings to offset costs while maintaining budget neutrality could make it hard to pass a replacement.
A continuous coverage requirement aims to discourage individuals from waiting until they become sick to buy insurance. This works well in theory. But there is little evidence on how it might work in practice.
Increases in insurance coverage were larger in states that expanded Medicaid, but take-up was lower among men, Hispanics, and adults under 36.