What If?

State of Reform is proud to launch, in collaboration with the Univ of Washington School of Public Health – Health Policy Center Initiative, a series titled “What If: A Post-Supreme Court World.”  This is the first piece in a series of contributions to be hosted on our news site, by a range of authors, about the possibilities for health care in a still hypothetical world after a Supreme Court decision.

What if the U.S. Supreme Court strikes down the Patient Protection and Affordable Care Act?

What if, instead, it claims it has no jurisdiction – yet – thereby allowing the ACA to run until at least 2015?  Or what if the Court strikes down just the individual mandate?  Will our country walk away from 50 million uninsured?

In late March, three days of oral arguments before the Court brought us a springtime blast of coverage, commentary, and more than a few surprises. Now, all we can do is wait…

…and prognosticate.

In a series of posts, we and our colleagues at UW, will ponder possible futures under an Affordable Care Act ruled unconstitutional, all or in part…or maybe left unscathed. We’ll focus on implications for Washington State, yet always keep our eye on national policy, and politics.

—  If the individual mandate is struck down, how will Washington State move forward to maximize the number of its citizens with health care coverage? What carrots and sticks could the federal government use to encourage our young invincibles – they’re young, they’re healthy…they’re uninsured – to sign up? Could the state augment or add to the feds’ tools?

—  If the Court invalidates the ACA’s Medicaid expansion, how will that affect our state budget? Will we have even fewer dollars for eligibility, benefits, and reimbursement? What happens to efforts to ensure Medicaid clients have a medical home? And what about Basic Health: Could the Court decision breathe new life into our state’s highly regarded, but seriously weakened, program?

—  If the Court throws out the whole law, will reform activities come to a halt or have some gained a life of their own? Will our state continue to create an insurance exchange (and with what market rules)?  What happens to efforts to create accountable care organizations?

—  Finally, should justices Kennedy or Scalia or Roberts surprise us and leave the ACA intact, how will our state cope with 2014’s coverage expansions? Of course, this is not a new question for any of us. How do we get our state agencies, as purchasers and as regulators, ready? How do we make sure we have enough health care providers to handle the bolus in demand for care? Will national politics be conducive to ACA implementation or will we see efforts to hamper and defund its various provisions?

Past efforts to reform the health care system – in our state and our nation – generated two big, potentially contradictory, lessons: seize the opportunity, but think twice before you leap. Back in 1992, health system reform efforts in Washington State opened a window of opportunity that community health centers leaped into. They created the Community Health Plan of Washington, which today is a mainstay of our health plan market and safety net system. At about the same time, the national call for managed care spurred health plans to expand their geographic market and vertically integrate their products and services. But in the end they found themselves overextended, with providers in revolt and a market position unable to gain a competitive edge.

Which lessons will apply to the post, partial, or progressing ACA future? Let’s explore that together over the next few months…while we’re waiting.

Patricia Lichiello runs the Policy Center Initiative at the UW School of Public Health.  Aaron Katz is a Principal Lecturer at the Schoole of Public Health.  Both can be reached through info@stateofreform.info.