The media and political pundits were having a field day with predictions and countdowns. No matter what your politics were, opinions resonated all around you: What would the Supreme Court do? What would it mean?
Then the decision came down. With a 5 to 4 vote, the Affordable Care Act (ACA) was largely upheld and justified as a “tax.” States would retain the right to decide whether to participate in the Medicaid expansion portion of the bill and not risk federal expulsion from Medicaid if they refuse to enact the portion of the ACA related to Medicaid eligibility expansion.
Immediately after, Republicans and Democrats found ways to present the ruling as a victory. People who have not read much, if any, of this controversial healthcare reform bill in its entirety voiced strong opinions about the findings of the Supreme Court.
Yes, there are aspects of the ACA bill that provide for deeper coverage for many people, including those with cancer, buried in the ACA law. These include coverage of preventive screenings for cancer and for other diseases, without copayments or coinsurance charges to individuals; continued coverage of young people through age 26 under their parents’ insurance plan; elimination of lifetime caps on insurance coverage; coverage protections on the basis of preexisting conditions; and patient access to clinical trials expanded to private insurance. Like motherhood and apple pie, it is difficult to argue against most of those provisions, and, indeed, some major private insurers had already announced that they intended to continue many of those provisions even if the Supreme Court ruled against the ACA law.
The issue that we are having difficulty facing is that we are still left with a lengthy bill that few people have fully read, let alone understood, and a virtual battle of the politicos looming to play tug of war over the specifics of the ACA provisions. We are left with even more questions unanswered, such as:
Currently, Medicare represents approximately 50% of patients with cancer, with Medicaid running close to 5%, and commercial and other insurance picking up roughly the other 45%. If suddenly the percentage mix of Medicaid and commercial were to come close to reversing over the next 5 years, there would be a significant impact (as yet undetermined, but probably very painful) on the current healthcare delivery system.
Practices and hospital centers already are embroiled in a variety of proactive and reactive discussions about new relationships. Strategic planning in these organizations will now need to consider these potential ramifications of the ACA law, in addition to the myriad other challenges facing cancer programs today. We may have received a ruling, but we have not yet received the answers we need to face the future of oncology.
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