The Supreme Court decision: a victory for uninsured patients.

T HE SUPREME COURT’S RULING TO UPHOLD most elements of the Accountable Care Act (ACA) provoked a political and legal firestorm that likely will continue past the 2012 election cycle. Numerous commentaries have already been written about the political and legal ramifications of the ruling. Ultimately, however, the Court’s decision is likely to have its biggest impact not on politicians or legal experts but rather on those who the current system fails: the uninsured. Perhaps the most influential part of the Court’s ruling was its decision to uphold the individual mandate. The mandate, scheduled to phase in over 3 years, will require most US citizens and legal residents to purchase insurance or face an annual tax penalty of either $695 per person (maximum $2085 per family) or 2.5% of household income, whichever is greater. Assuming that most uninsured Americans opt to purchase insurance rather than face the penalty (which is what occurred in Massachusetts following implementation of the individual mandate), many of the young and healthy who are currently uninsured—the so-called invincibles, who feel they do not need health insurance—will become part of the insurance market. Premiums from these relatively low-cost members will help subsidize sicker, more costly patients, allowing insurance providers to fulfill their obligations to insure everyone, including those with preexisting conditions. For the first time in recent US history, the insurance system could function as it was intended by covering a broad population, both healthy and sick, at more affordable rates. The upholding of the mandate also increases the chances of success for another key provision of the ACA: the creation of state-based insurance exchanges where individuals and small businesses with up to 100 employees can purchase coverage. The exchanges represent a free-market strategy allowing consumers to directly compare plans just as they use websites to compare airfares, hotels, and rental cars. On the exchanges, plans that meet minimum standards will be listed in 1 of 4 categories ranging from bronze (the minimum coverage deemed acceptable) to platinum (the most generous benefits). Lowincome legal residents with incomes of 100% to 400% of the poverty level will receive premium subsidies on a sliding scale when they purchase coverage through the exchanges. Because the Court upheld the mandate, more Americans will utilize the exchanges, which should enhance their impact. The Court’s ruling on the constitutionality of Medicaid expansion was more concerning. Expanding Medicaid is a key component of the ACA’s strategy for increasing coverage. The ACA calls for states to expand Medicaid eligibility to all US citizens up to 133% of the poverty line, and will provide 100% federal funding for the first 3 years of the expansion, which gradually reduces to 90% support by 2020 and beyond. According to the Congressional Budget Office, Medicaid expansion should provide coverage to approximately 17 million of the approximately 30 million Americans expected to gain coverage through the new law, which would represent an approximately 30% increase in Medicaid enrollment. According to the Court’s verdict, the federal government may not penalize states that opt out of the Medicaid expansion by withholding existing Medicaid funding. Some state governors have stated they will not participate in the Medicaid expansion—even though the costs in the first years are paid by the federal government. Uninsured persons in states that do not participate in the Medicaid expansion and who earn less than less than 100% of federal poverty level ($23 050 per year for a family of 4) will earn too little to qualify for premium subsidies and will remain uninsured. We hope that most states will ultimately decide to accept the federal funds and expand their Medicaid programs. Not only would such expansion improve the health of lowincome residents, but it would be a boon to the economy by generating health care jobs to serve the increased number of people seeking care. Because of the Court’s decision, other popular provisions contained in the ACA will also move forward. Most notably, parents may continue to enroll their dependent children up to age 26 years in their plans—an option that has already allowed more than 3 million young adults to gain coverage. New requirements aimed at protecting consumers will also persist, including minimum standards for provider networks, data and quality monitoring, a minimum medical loss ratio (the percentage of premiums spent on clinical services) of 80% to 85%, and a prohibition on lifetime caps on coverage. In addition, opportunities remain for providers to improve the quality and efficiency of health care through the Medicare and Medicaid Innovation Center and the Medicare Shared Savings program. Since the job of the Supreme Court is limited to determining the constitutionality of a law, their review cannot fix some of the limitations of the ACA. Important coverage gaps will persist for some low-income residents, such as those earning too much to qualify for federally subsidies, as well as for undocumented immigrants. Safetynet providers may also be harmed by the ACA because