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The Patient Protection and Affordable Care Act – more widely known as “ObamaCare,” has been one of the most hotly contested pieces of legislation in recent memory. Passed two years ago this month by a Democratic Congress, the law enacted almost immediate tax cuts but phased in benefits over four years, between 2010 and 2014.
The bill is unpopular with the American public. Indeed, widespread public discontent over the bill and the process by which it became law led to an historic route of Democrat congressional candidates in the 2010 mid-term elections. Meanwhile 26 states have joined in a lawsuit contesting the law’s constitutionality.
At issue: Does the federal government have the constitutional authority – under the Commerce Clause or some other clause in the Constitution to require individuals to purchase a product from a private company? And secondarily, does the PPACA’s requirement that states expand their Medicaid eligibility to conform to federal guidelines in order to continue to collect federal Medicaid matching funds constitute an unconstitutional encroachment into state authority?
The Supreme Court is hearing oral arguments this month – and has received an unprecedented number of briefs from various interest groups.
Also before the Court: If one or two parts of the law are deemed unconstitutional, what happens to the remainder of the law? Usually, the standard congressional practice when crafting legislation is to include a so-called “severability” clause. This clause says that if any part of the law is struck down by the courts, Congress intends for the rest of the law to remain in effect. However, Congress included no such provision in the PPACA. Unless the Courts “read in” language to the law that isn’t there (something that courts are loathe to do with co-equal branches of government), the courts will have to scrap the whole thing.
How will the Supremes rule? It’s anyone’s guess.
But let’s assume the law stands, as written. What’s in store for you, as the taxpayer?
The Big Picture
The biggest winners under the PPACA are those currently uninsured or underinsured by the system, and who have trouble getting coverage on their own. Those who are uninsured but with pre-existing conditions will have improved prospects for access to coverage. The law already requires insurers to cover all children, regardless of pre-existing conditions or previous coverage status. This particular requirement took effect in 2010 – and had the prompt effect of driving many insurance companies who had been selling individual child-only insurance policies to exit the market. After all, if parents know their child can get coverage as soon as she gets sick or hurt, there is no reason whatsoever for healthy parents to buy into the system. The result will be that parents of healthy children will opt out of coverage until they need it – a destructive insurance market phenomenon called “adverse selection.” If the adverse selection problem is large, insurance markets cannot function. This was the reason behind the so-called “mandate.” And if the court strikes down the mandate portion of the law as unconstitutional but not the rest of it, the system rapidly breaks down.
Other potential winners may include U.S. companies that do significant business abroad. If they can offload the costs of insuring their work force to a universal single-payer system, they can become more competitive in the global economy, where American firms must compete with firms that have no significant medical insurance expenses for their workers whatsoever, other than their corporate taxes – because their workers receive coverage via the government.
Who loses? Those who currently have access to good health insurance coverage. Generally, executives lose, as do managerial staffs, professionals, certain government employees, some union employees who are receiving so-called “Cadillac” medical insurance plans, the elderly and those who may become elderly.
What is in effect now?
Beginning in 2013, the IRS will assess a 3.9 percent Medicare payroll tax will take effect on certain “unearned income.” The tax will apply to people with incomes of more than $200,000 per year – or $250,000 for married couples. An additional 0.9 percent Medicare contribution tax will also apply to higher income individuals, unless Congress acts to repeal this provision.
As of 2014, all uninsured U.S. residents must purchase a qualified health insurance plan. The plan has to include a specific list of benefits, and have deductibles below a certain amount. Generally, Health Savings Accounts/High Deductible Health Plan combos (HSA/HDHPs) will not qualify under the new federal guidelines. This is the mandate that is before the Supreme Court this year.
Those with pre-existing conditions can purchase coverage through a new series of health insurance exchanges beginning in 2014.
If you remain uninsured after the first day of 2014, you will have to pay a “penalty” of up to 1 percent of your income. This penalty is low enough that we expect many to choose to pay the penalty rather than buy coverage, especially since pre-existing conditions, as of 2014, are no longer an obstacle to obtaining coverage. However, this could significantly aggravate adverse selection problems within the system, driving up costs in relation to revenues. The Congressional Budget office has already increased its 10 year cost projection from just under $1 trillion to $1.79 trillion over the next 10 years.
Patience for Patients.
The intent of the law was to bring millions of Americans under the medical insurance umbrella who are not currently covered by it. If this happens, however, it may spark a dramatic increase in demand. Unfortunately, while it doesn’t take very long to pass a law, it takes years to create a new doctor, nurse, medical technician or hospital. Demand could overwhelm the available supply – driving up costs, increasing wait times, or both. In areas with high concentrations of currently uninsured people, wait times to see a doctor could more than double.
Meanwhile, restrictions on compensation will make economies of scale a crucial concern for health care providers. Many smaller doctor’s offices and clinics may go out of business – forcing more and more people into larger clinics and hospitals.
Effects on Medicare
To pay for universal coverage, Congress stripped a half trillion dollars from Medicaid over the next eight years. We expect to see increased rationing of care in both the Medicare and Medicaid systems. Cost controls will increase, and some treatments will be restricted or denied all together to older patients.
Employers will also cut back coverage and possibly hiring. A sharp tax on insurance companies will get passed on to employers, which may force them to slow down their hiring plans. Furthermore, Congress will begin taxing highly generous Cadillac health plans out of existence, with a 40 percent tax beginning in 2019. This may make it nearly impossible for you to see a specialist without a referral, because most insurance will be provided via HMOs and PPOs under managed care plans.