Decision Day: Upheld!

Perspectives from Nashville and beyond on the Supreme Court’s landmark health reform opinion

Well, it's finally happened. Every commentator and politico who has been preparing multiple speeches over the last weeks, ready to respond to any eventuality can now make their choice. In a somewhat surprising decision this morning, the U.S. Supreme Court ruled 5-4 in favor of upholding the Affordable Care Act. Conservative Chief Justice John Roberts joined in with the court's left-leaning members in upholding the law.

The Court upheld the controversial individual mandate stating "Congress had the power to impose the exaction in Section 5000A under the taxing power, and that Section 5000A need not be read to do more than impose a tax. This is sufficient to sustain it."

As promised earlier this morning, the Nashville Post team will be on call all day covering the decision and its implications for Middle Tennessee's vital health care sector.

Here is the news as it's coming in:

2:30 p.m. Mother Jones takes a look at how big a deal the decision really is, paying particular attention to the Medicaid expansion bit: “Threatening to withhold all Medicaid funding if a state doesn't participate in the new program is, as Roberts says, pretty close to being "a gun to the head." But if you look at the actual funding levels enacted in the law, it's more of a popgun than an AK-47. The feds will finance 100% of the Medicaid expansion through 2016, 93-95% through 2020, and 90% beyond 2020. So yes, the level of coercion is high, but the level of funding demanded of the states is very low. There's both a carrot and a stick here.”

2:22 sees Chief Justice Roberts’ support for the law as a canny move to, in fact, gut the Commerce Clause, which some viewed to be a bigger issue than the health care debate itself.

2:10 p.m. — Left-leaning ThinkProgress has four reasons the decision to uphold the law may be good news for the economy.

1:47 p.m. — The leaders of Vanderbilt University Medical Center haven't been shy about discussing their uninsured patient load in recent years. So Jeff Balser, vice chancellor for health affairs for the university and dean of the VU School of Medicine, unsurprisingly focuses on the increased access promised by the reforms. “Vanderbilt maintains a steadfast commitment toward improving the nation’s health. The Affordable Care Act will allow Americans greater access to health care and health insurance. We are pleased the Supreme Court chose to uphold the constitutionality of this legislation.”

1:34 p.m. — Ed Fishbough, a spokesman for hospital operator HCA, said: “We will continue to work with patients, payors and the government to ensure a smooth transition as the provisions of the law are enacted. We are pleased that millions of Americans will have coverage for better access to vital medical services, preventive care and acute care.”

1:24 p.m. — Mary Danielson, director of corporate communications at BlueCross BlueShield of Tennessee, understandably says the insurer is pleased to see coverage expand to thousands of Tennesseans but adds that it doesn’t like other parts of the law. Broader coverage, she said, is “a goal we believe in, and one we’ll continue to support by implementing the law in a manner that best benefits our members and the state.

“We’ll also continue to work with parties on both sides of the aisle to change those parts of the law, such as the health insurance tax, that will raise premiums for our members and disrupt the market. And, working with policymakers and other Tennessee health care leaders, we’ll continue to push toward delivery system reforms and solutions that reduce costs and improve quality.”

1:06 p.m. — The backers of the Nashville Medical Trade Center think today's ruling will help them market their project: “The resulting changes to the health care system will only heighten the need for efficiency and the reduction of costs. We believe the Supreme Court ruling will only accelerate the need for a global center for health care innovation, and that is what the Nashville Medical Trade Center will be. It has been clearly demonstrated that effective use of information technology and medical technology, which will be showcased by hundreds of companies in the trade center, can reduce expenses and improve the quality of health care.”

12:40 p.m. — Our sister publication Nashville Medical News also has been busy this morning collecting reactions from a number of local and regional health care players. Check out their progress here.

12:05 p.m. — The National Conference of State Legislatures breaks it all down in a convenient chart.

12:00 p.m. — The Tennessee Medical Association reacts: “Until the Supreme Court made its decision, we had to take tentative steps toward change. Today’s decision allows us to make more definitive plans regarding reforms to our healthcare system in Tennessee.

We are surprised by this ruling but have been working to develop resources for our members to explain the Affordable Care Act provisions that will impact their patients and their practices. While the decision has a certain finality, we all need to understand that healthcare reform remains a fluid process. The TMA stands by the principles it feels are necessary to create a better environment for patients and physicians. 

Physicians remain concerned about the lack of efforts to reduce wasteful hassles and regulations, the creation of an unaccountable, dictatorial oversight board (IPAB), lawsuit abuse, the unwillingness of Congress to fix the Medicare fee schedule for physicians, the limited supply of physicians to care for an expanded patient base, and the rights of patients to choose who provides their medical care. As healthcare reform continues to evolve, the TMA will stay focused on supporting what we see as helpful to our patients and fighting those provisions that threaten good medicine.”

11:47 a.m. — The Tennessee Hospital Association says: “Today, the United States Supreme Court announced its decision on the constitutionality of the Patient Protection and Affordable Care Act (ACA).  Though the opinion still is being fully interpreted, it appears the court upheld the validity of most of the key provisions of the ACA. 
Though much work remains to be done on all fronts, the Tennessee Hospital Association believes the court’s action is an important step toward meaningful health reform.  Such reform will help to preserve access to quality care for patients in Tennessee.
While Tennessee hospitals are making demonstrable strides in decreasing the cost of care through nationally recognized patient safety programs and aggressive efficiency measures, systemic change is imperative.
Last year, Tennessee’s hospitals provided $2.4 billion in uncompensated care as a result of the high number of people who are uninsured or under-insured.  With basic health coverage for all in Tennessee, hospitals are in a better position to absorb the $4.3 billion in cuts that will be required of them under the ACA over a ten-year period.
Hospitals will continue to do their part to provide access to high-quality care for patients and communities they serve.

11:39 a.m. — One small local company set to benefit from the Supreme Court's decision is software developer Medalogix. Philip Nannie talked to founder Dan Hogan here.

11:10 a.m. — The Hospital Alliance of Tennessee sees positives: The Hospital Alliance of Tennessee (HAT) advocated for federal health reform that would expand access to health insurance to achieve near universal coverage, while implementing thoughtfully designed Medicare payment modifications that would enhance efficiency and quality, reduce costs, and reward provider performance excellence.

The goal of the Affordable Care Act is to reduce the number of people without insurance by expanding coverage to about 30 million uninsured people.  However, an estimated 26 million U.S. residents will remain without coverage, including illegal immigrants and those who can’t afford to pay out-of-pocket for health insurance.  

In addition, the ACA contains enormous reductions in hospital payments, projected to be $155 billion over the next 10 years.  It would have been extremely troubling to abandon the health care expansions and mandates in the ACA but keep the payment reductions.  Regardless of the US Supreme Court decision, Tennessee’s not-for-profit hospitals will continue to care for the many uninsured people.

And while the U.S. Supreme Court decision is significant, it is interesting to note that many of the reforms embedded in the law are already underway, particularly at hospitals.  Hospitals are improving care and reducing costs by focusing on efficiency across the continuum of care, investing in health care information technology and establishing strategic partnerships for better coordination of care.

Understanding the implications of the U.S. Supreme Court decision will require diligent effort by all of us to determine how to care for more people at a lower cost. It will be essential for all of the stakeholders to work together to improve our efforts for prevention and promote better outcomes.

11:05 a.m. — The Tennessee chapter of the NFIB reacts: “While we're certainly disappointed, NFIB respects the decision to uphold the individual mandate by the Supreme Court. Clearly, this mandate has now become a tax on all Americans and a broken campaign promise from President Obama not to raise taxes.

"We are concerned about the precedent that this will set in Congress’ ability to mandate other aspects of our lives, but we will move forward from today to continue to fight, harder than ever, for real health-care reform for our membership.

“Under the health-care law, small-business owners are going to face an onslaught of taxes and mandates, resulting in job loss and closed businesses. NFIB will continue to fight for the repeal of health-care in the halls of Congress. Only with a full repeal of the law will Congress have the ability to go back to the drawing board to craft real reform that makes reducing costs a number one priority.

"The power and control of health-care decisions should be in the hands of the consumer, not the government.”

10:35 a.m. — Lt. Governor Ron Ramsey is "intensely" disappointed: "Democrat Governor Phil Bredesen called Obamacare the 'mother of all unfunded mandates' and stated it will cost Tennesseans 1.1 billion dollars in the next few years. However, the fight does not end here. The court may have made its decision today but the people have yet to speak. When they do, Mitt Romney will be elected president and I will do all I can to aid him as he fulfills his solemn promise to repeal this insidious law." For full statements from Ramsey and other Tennessee politicians, click here.

10:30 a.m. — Congresswoman Diane Black joins the fray: “The Supreme Court’s flawed decision is a gross interpretation of Congress’ taxing responsibility under the Constitution. One thing this decision certainly does not change is the need for Obamacare to be repealed — immediately. As a member of the Ways & Means Committee, I will work with my colleagues on repealing this ‘tax.’”

10:25 a.m. — Tennessee conservative Congressman Chuck Fleischmann had the following to offer: “The Supreme Court made the wrong decision today. The Constitution places specific limits on the government, and the court unfortunately did not recognize those limits in allowing Obamacare to stand. While the Supreme Court may consider the individual mandate a tax, the Obama administration repeatedly claimed that this was not a tax when they tried to pass Obamacare. Like many conservatives, I believe the individual mandate cannot be justified as a tax.”

10:17 a.m. — For the record, here's the opinion. For Chief Justice John Roberts' discussion of the individual mandate as a tax, go to page 37 of the PDF.

10:10 a.m. — The decision will reinforce the case for many of the technological investments being made by providers. Other legislation has laid the groundwork for EHRs and such but the Journal's Michael Hickins writes that the Affordable Care Act incentivizes more holistic care, which one trade association exec says "can't be achieved without the implementation of technology."

9:48 a.m. Seeking Alpha keeps track of more stock reactions as the morning wears on.

9:42 a.m. — United Neighborhood Health Services CEO Mary Bufwack offered the following: "We estimate that 55,000 currently uninsured people in Nashville/Davidson County will gain insurance and access to health care over the next few years because the U.S. Supreme Court has upheld the constitutionality of the Affordable Care Act. These uninsured people will gain coverage under Medicaid expansion in 2014 or because they will be able to afford to purchase coverage through the new state Health Insurance Exchange."

9:15 a.m. — Trading of shares of HCA (Ticker: HCA) and Community Health Systems (Ticker: CYH) was briefly suspended just before the decision came down. In anticipation of positive news, the stocks had been up more than 8 percent. Dipping slightly in the immediate aftermath of the decision, they remain strongly up on the day along with other operators such as LifePoint (Ticker: LPNT). Many view the law as a boon to hospital operators in that it has the potential to take a large bite out of their bad debt numbers.