The U.S. Supreme Court is expected to rule this week on the Patient Protection and Affordable Care Act of 2010 — a landmark case on the proper reach of the federal government and a flashpoint of passionate debate nationwide.
The court’s most important decision since Bush v. Gore has profound implications for tens of millions of Americans, for this year’s presidential race, for the power of Congress to regulate commerce, for businesses big and small and for the giant industry that is U.S. health care. The ruling could come Monday.
One thing the decision will lack, however, is finality: If the court upholds the law, Republicans will immediately begin working to repeal or nullify it; if the law goes away, the urgent problems of the nation’s health care system will not go away with it.
Georgia Attorney General Sam Olens, who joined with 25 other state attorneys general in the legal fight against the act, acknowledges that defeating this law won’t change the need for significant health-care legislation.
“We need to have a more affordable health-care system. We need to deal with the folks who have pre-existing conditions,” Olens said. “It’s not like if this thing goes we stop working.”
Stand or fall, the act has already had deep impacts in Georgia. Big companies have changed their health plans because of the law.
Hospitals and doctors across Georgia are transforming their approach to many aspects of care. Older people have received new Medicare benefits; younger people have been able to stay on their parents’ insurance for years longer.
Because of a provision in the health care law, Harold Culbreath Jr. of Monroe was able to obtain health insurance last month for the first time in five years. At 37, he has hemophilia and diabetes. If the law is struck down, it’s not clear what would happen to the coverage that Culbreath and more than 1,400 Georgians with pre-existing conditions have been able to buy since the law was enacted.
“If the Supreme Court overrules the health care law and declares it unconstitutional, it will be devastating,” Culbreath said.
Others believe that letting the law stand would be just as devastating. Olens, for example, says the law will force many companies to drop health plans for employees.
For those lacking benefits
While Georgians who get insurance at work may experience some changes, the law’s greatest impacts will probably be for those who buy their own insurance and the 1.9 million Georgians who have no insurance at all.
About 350,000 in Georgia — the self-employed, the unemployed and those working at companies that don’t offer benefits — already buy their own health plans directly. Almost every consumer in this “individual market” can share a story about getting walloped with rate increases, resorting to a high-deductible plan or being locked into expensive coverage because of a health condition.
Dr. Edwin Gerson, an Atlanta radiologist, said he shopped for his own plan in 2009 after his medical partner dropped out of his group plan to join Medicare. He opted for a policy from Blue Cross Blue Shield of Georgia at a cost of $408 a month and an annual deductible of $2,600.
“I was very happy at the beginning,” Gerson said.
His satisfaction did not last long. Blue Cross hit him with a rate increase after less than a year, and the increases kept coming.
“This has gone up 93 percent in two and half years,” he said.
Gerson said he has no health issues and has never even met his deductible on the plan. He said he hoped that a provision of the health law might help him, since it requires special reviews of rate increases of 10 percent or more. Gerson became even more outraged when told that the provision didn’t apply to his plan because it was “grandfathered.”
His conclusion: insurers can still charge whatever they want.
“They are padding their surpluses and CEO bonuses and shareholder profits on the backs of those who have no say-so,” Gerson said.
Blue Cross Blue Shield of Georgia said it tries to avoid rate increases, but the rising costs of health care forces it to raise premiums. “We owe it to our members to cover those costs and ensure access to a broad network of providers,” the company said in a statement.
Now that he’s turned 65 — which was part of the reason he got hit with an extra increase on top of the regular rate hike — Gerson has signed up for Medicare.
“Having been forced out of the private insurance market,” he said, “I will now be relying on my government to provide my health care, whereas before I was willing to bear that cost personally.”
Some experts say Gerson shouldn’t give up yet: The most significant reforms of the insurance market are yet to come.
The biggest changes for people who buy their own coverage would arrive in 2014, when the new state-based “insurance exchanges” would open for business. At the same time, insurers will no longer be able to turn people down because of a health condition.
The idea of the “exchange” is to pool these chronically ill people with a larger group of generally healthy people, enabling the insurer to spread its risk.
The most controversial provision of the health care law is the “individual mandate” that requires almost every American to have insurance.
Many say the mandate is an overreach by the federal government. Some experts argue, however, that the mandate is critical because it would push more young and healthy people into insurance pools, offsetting those with costly health problems.
“People in the individual market are likely to be better off if the whole law is upheld,” said Bill Custer, a health policy expert at Georgia State University.
Most insurers say the law can’t work without the mandate. Some experts say it could, if subsidies to help pay for care attract enough healthy people to voluntarily buy policies.
“It’s not impossible, but it’s clearly going to be harder to do without the mandate,” Custer said.
More could get Medicaid
If the court leaves the individual mandate in place, most of the one in five Georgians without coverage today will get it. Many of those — an estimated 650,000 people statewide — will gain coverage through the expansion of the Medicaid program, the state-federal partnership for poor and low-income people.
Some uninsured Georgians with pre-existing conditions have already found insurance through a provision of the law.
Jeff Cornett, an advocate for Hemophilia of Georgia, hopes the Supreme Court upholds the law. He said its provisions would offer people with hemophilia, a rare genetic condition that prevents blood from clotting properly, a chance to transform their lives by allowing them to get coverage for a condition that can cost upwards of $300,000 a year to treat.
“It’s going to allow people to purchase quality, affordable health insurance,” Cornett said. “That’s all our people ever wanted.”
Cornett said that for years he has had to push people with the blood disorder toward jobs at large companies that offer robust health insurance plans. That was the only way they could get coverage for an expensive condition.
“I have very talented young people who come to me and say, ‘I’m a great song writer, and I really think I could make it in the music business,’” he said. “I say, ‘You need to go to work for a big employer.’”
Cornett said the health law has already begun to change that with provisions that eliminate lifetime caps on benefits and a government-funded pre-existing condition insurance plan, as well as the ban on considering pre-existing conditions that would begin in 2014.
How will it work?
With much of the health care law yet to be put in a place, it’s hard even for experts to agree on exactly how it would all work — or whether it would.
Many health care providers still wonder how Georgia would meet the new demand for health care that would likely result when almost everybody has insurance.
Georgia already has a significant shortage of primary care doctors, especially in rural areas. Hospitals who serve the uninsured today also wonder how they will get paid in the future to serve the Georgians who still won’t have insurance.
About 600,000 people in Georgia will be uninsured, even if the Supreme Court upholds the law completely, said John Haupert, CEO of Grady Memorial Hospital. Many will be illegal immigrants. Others will get exemptions or be subject to the penalty if they don’t comply with the mandate.
Grady is already facing a $1.4 million deficit, despite having cut more than 200 jobs last year.
“Where’s the funding going to come from to pay for those patients?” Haupert said. “Something’s going to have to give.”
Opposition is galvanized
The Affordable Care Act has divided Americans as few other issues in recent years.
Passage of the act galvanized the tea party movement, which was born about a year before the act passed, and stirred an angry backlash across the country. Polls in recent months have shown that about 50 percent of Americans — slightly more in some polls, slightly less in others — oppose the law.
Support for the law has varied more widely from poll to poll, with some surveys showing support anywhere between 36 percent and 45 percent of respondents. An AP poll last week measured it at 33 percent.
As divided as Americans are on the Affordable Care Act, they do agree on one thing: More than three-quarters in the AP poll said the president and Congress should start fresh on health care reform if the court overturns the current law. Only 19 percent said Congress should leave the system as it is.