Kevin R. Loughlin, MD, MBA
If one had to choose a single word to describe the future of Obamacare, it would probably be “uncertain.” The delays in its implementation, the problems with its website, and the departure of US Secretary of Health and Human Services Kathleen Sibelius all contributed to an inauspicious beginning.
The question that now faces the country is what health care will be like as the Affordable Care Act moves forward. Let’s review some of the issues.
The Supreme Court ruled, in National Federation of Independent Business v HHS, that Obamacare was legal, but was a tax. As such, the Medicaid expansion portion of the law could not be imposed on the states. At present, 27 states, including the District of Columbia, have implemented expansion, 3 are engaged in open debate, and 21 are not moving forward with expansion.1
This non-uniform implementation of the law poses several legal conundrums. Rivkin and Casey have opined in the Wall Street Journal2
that, if the Medicaid expansion provision is an indirect tax, then the “Uniformity Clause” (Article 1, Section 8, Clause 1) of the Constitution requires that the tax “be uniform throughout the United States.” These legal authors raise the issue that the uneven implementation of the Medicaid expansion of the ACA could be legally interpreted as unequal taxation and, as such, form the basis of future legal challenges to Obamacare. The more recent Hobby Lobby (Burwell v Hobby Lobby) decision by the Court allowed that closely held, for-profit corporations are exempt from the ACA if their owners religiously object to portions of it, and if there are less restrictive means of furthering the law’s interest.3
This ruling opens the way for subsequent challenges to the ACA based on religious beliefs.
Another pending legal issue related to Obamacare is the Halbig case, which challenges the massive tax credits provided to people with financial need who enroll in the program. Again, this challenge relates to the uneven enrollment by the states. These tax credits are only available to citizens in states that have set up the health insurance exchanges under the ACA. The outcome of this challenge remains uncertain.
Enrollee Payment Issues
There have been ongoing reports that not all individuals who enrolled in ACA have paid their premiums. Robert Pear reported that, as of May, about 80% of enrollees had paid their premiums.4
The ultimate size of this shortfall is hard to predict, but the potential impact to insurance companies and physicians is significant.
ACA and Unemployment
The unemployment crisis in the United States is a complicated issue. A Wall Street Journal
article, “The Full-Time Scandal of Part-Time America,” by Mortimer Zuckerman,5
presents a cogent case that the ACA mandate that employers provide health insurance to anyone working more than 30 hours per week has fueled at least part of the unemployment crisis by incentivizing employers to lay off full-time employees in favor of part-time workers. The statistics he presents are daunting. In June, full-time jobs decreased by 523,000, while part-time jobs increased by about 800,000. Simultaneously, the number of involuntary part-timers soared to 7.5 million compared with 4.4 million in 2007. Zuckerman cites the Bureau of Labor Statistics as stating that nearly 91 million Americans over the age of 16 years are not working, an all-time high and almost 10 million more than in 2009. The long-range impact of ACA on full-time employment remains a major concern.
With the goal of universal health coverage implicit in the ACA mandates, there will be increasing workforce pressures to provide clinical services. Urologists, whose practices include many elderly patients, are likely to be among those who will most acutely feel the pressure of responding to patient access issues. It is very likely that healthcare extenders such as physician assistants and nurse practitioners will be widely integrated into urological practices. This reality is one of the motivations for the American Urological Association’s initiative to help train more allied professionals, as well as for the organization’s annual census, which will help ascertain the regional concentrations and subspecialty distributions of urologists.
ICD-10 and IPAB
Major provisions of the ACA are still evolving. The implementation of ICD-10 coding has been delayed a year. Its eventual implementation promises to impose an additional burden on urologists in regard to the complexity of day-to-day practice.
It has been estimated that there are 5 times as many codes in ICD-10 than in ICD-9, which translates into training costs for urology office staff and decreased office efficiency.6