In ruling's wake

The Supreme Court finally made its ruling on King v. Burwell, a decision that affects the health insurance exchange concept in the Affordable Care Act (ACA). Was this a disruption or a distraction?

There is little doubt that the 34 states using the federal exchange rather than a state-created one would have faced challenges if the High Court ruled subsidies provided to members are not legal. They would have needed to develop an alternative, and some states had been slow or unwilling to come up with a Plan B.

It turns out that their “let’s hope” gamble paid off. The justices ruled 6-3 that the subsidies should stay available across the U.S.

In the grand scheme of healthcare reform, most cardiovascular specialists, subspecialists and their healthcare organizations recognize that the volume model of yore must go, with value becoming the new norm. The question is, how? And that remains unanswered, even as we enter into models such as bundled payments and accountable care organizations.

Cardiology hasn’t shied away from forays down the path to value, which shifts some of the risk of high healthcare costs from Medicare and possibly other payers to providers. Somewhat perversely, Medicare still provides incentives to stay in volume mode, too. Most programs are trying to determine when they should jump ship on volume and commit to value.

The insurance exchanges have increased the number of insured Americans. Some of these patients may have put off care because they lacked insurance, making them challenging and possibly costly cases from the start. Under the value scheme, hospitals may risk going in the red as they put resources into rectifying the situation.

On the other hand, hospitals also often either have to write off the cost of care for uninsured patients or pass costs to the insured and their carriers. The emergency department serves as primary care for some uninsured patients, which is expensive, less efficient and burdensome.

More than 6 million people who receive subsidies through the federal health insurance exchange got a reprieve with the ruling. If the Supreme Court had ruled these subsidies were illegal, chances are some kind of bridge would have been built for some of them, albeit hastily and perhaps poorly.

This won’t be the last battle involving the ACA. Disruption, whether it stems from the ACA or is directed at the ACA, should preserve what works and replace what doesn’t. If not, then it is merely a distraction.

Candace Stuart

Editor, Cardiovascular Business