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Consumer-Directed Healthcare Reform

As the U.S. Supreme Court nears its decision on the constitutionality of federal health care reform, the Montana Policy Institute endeavors to emphasize the need for true reform centered on the patient consumer. We believe that patients and their doctors are best equipped to make decisions about what care is best, not bureaucrats in Washington, DC, or our state capital of Helena. The root problem lies in the fact that there is a vast wedge between patients and their healthcare providers caused by heavy government intervention and the unintended consequences of a third-party payer system. The following consumer-directed options will help individuals and families make – and own – their decisions.

Individual ownership of insurance policies. Equalize tax treatment by extending to individuals the tax deduction that allows employers to own insurance. Also make those plans portable when workers leave or change jobs.

Leverage health savings accounts. Coupled with affordable high-deductible plans, HSAs empower individuals to monitor their health care costs while establishing incentives for individuals to use only those services that are necessary. HSAs are growing in popularity but will be undermined by federal healthcare reform.

Allow interstate purchase of healthcare insurance. Allowing consumer to shop for plans beyond their state borders will enhance competitiveness in the health insurance market. Because of fewer state regulations, plans in other states are more affordable. Because it will empower consumer choice through competition, interstate purchase will drive down prices and, possibly, force states to deregulate.

Reduce mandated benefits. Other than consumer overutilization caused by insulation from actual cost, there is nothing that contributes more to the inflation of healthcare costs than state benefit mandates. States should reduce or eliminate mandated benefits to empower consumers to work directly with health insurers to tailor plans to their needs. Consumers won’t be able to do this unless health insurers have flexibility to fulfill the needs of individuals. In a freer health care market, there is no reason to assume that insurers will treat the insured any differently than, say, the grocery store treats its customers by providing many products at prices consumers are willing to pay.

Block grant federal Medicaid funding to give states flexibility to create voucher programs for low-income individuals to purchase their own insurance. An income-based sliding scale voucher program is an effective reform option that states such as Florida have enacted to give low-income individuals more control, fight costly fraud and abuse, and save on considerable administrative costs of running a large bureaucracy.

Eliminate unnecessary scope of practice laws and allow non-physician healthcare professionals to practice to the extent of their education and training. Enhancing the provider pool increases competition without compromising access to quality care. It empowers patients to decide how best to get the care they need.

Reform tort liability laws. Defensive medicine needlessly drives up medical costs and creates an adversarial relationship between doctors and patients.

 

Issues and Likely Outcomes of Pending U.S. Supreme Court Decision on PPACA

The U.S. Supreme Court (the Court) is about to proffer its decision on various issues relating to the Patient Protection and Affordable Care Act (PPACA). The following Q & A outlines the issues before the Court and likely outcomes:

 

Q: What is the actual name of the case and who is involved?

A: NFIB v. Sebelius. The NFIB stands for the National Federation of Independent Business and is the plaintiff in the case. The NFIB is joined by a couple individual citizens and 26 states through their Attorneys General. Montana’s Attorney General elected not to join the suit. The defendants in the case include U.S. Secretary of Health and Human Services Katherine Sebelius, U.S. Secretary of the Treasurer Timothy Geithner, U.S. Secretary of Labor Hilda Solis, and their respective agencies.

 

Q: When is the Court likely to rule on the case?

A: It could happen at any time. The Court has to clear its docket by June 30. This case is one of the most anticipated in American history. The U.S. Constitution created the Supreme Court for cases such as this to preserve the original intent by “checks and balances” on power. This case gets to the essence of the American Experiment in limited government, states’ rights and individual liberty.

 

Q: There’s talk that the Court may not even be able to rule on the case. Is this true?

A: Yes. The theory is that the Anti-Injunction Act (AIA) may regard the individual mandate to purchase healthcare insurance as a tax. If so, the AIA would call into question whether the Court has the jurisdiction to rule on the case prior to the 2014 effective date for the individual mandate. Legal experts predict that the Justices will unanimously reject application of the AIA to the case.

 

Q: What are the substantive issues before the Court?

A: There are four issues before the Court:

1. As mentioned, whether the Anti-Injunction Act strips the Court of jurisdiction in the case.

2. Whether the new law’s requirement that individual Americans must purchase and maintain federally-approved forms of health insurance starting in 2014 exceeds Congress’ powers under the Commerce and Necessary and Proper Clauses of the U.S. Constitution.

3. Whether the new law’s mandate to the states to expand Medicaid coverage to 133 percent of the federal poverty level exceeds Congress’ authority under the Spending Clause of the U.S. Constitution and thereby violates state sovereignty under the 10th Amendment, which of course stipulates that powers not expressly granted to Congress are reserved to the states.

4. If the Court strikes down one part of the new law – e.g. the individual mandate or the Medicaid expansion – whether any remaining part of the law can be “severed” and implemented.

 

Q: What are the likely outcomes?

A: There are three likely outcomes:

1. The Court upholds the law. This would mean that at least five of the nine members of the Court agree that the individual mandate and Medicaid expansion do not violate the Commerce, Necessary and Proper, or Spending Clauses of the U.S. Constitution. The entire law would go into effect in 2014. Justice Anthony Kennedy will be the swing vote, in particular on the constitutionality of the individual mandate. Justice Kennedy said during oral arguments that the individual mandate “changes the relationship of the government to the individual in a fundamental way.” He also suggested that a federal requirement to buy insurance is “unprecedented” and, therefore, the government has a “heavy burden” of justification.

2. The Court strikes down particular aspects of the law but leaves the remainder intact. There are several variations of this outcome. What would be most likely under this general outcome is the Court strikes the individual mandate and leaves the rest of the law in place. The employer mandate, Medicaid expansion, exchanges, new and increase taxes, and other provisions would move forward. This outcome would leave the Act’s major expenditure provisions in place but remove the primary means of funding those expenditures, requiring further action by Congress. The Court may also choose to sever the Medicaid expansion as a “coercive” use of federal power over the states.

3. The Court rules that the law is unconstitutional and nonseverable. If the individual mandate or the Medicaid expansion is struck down, the Court could argue that the remaining provisions no longer function “in a manner consistent with the intent of Congress.” This decision would also dismantle provisions of the new healthcare law that have already implemented, which would include exchanges and co-ops set up in the states. Congress and the health care industry have indicated they would act quickly in this case to salvage the Act’s most popular and economically sustainable provisions (e.g. children remaining on parents’ policies) pending further legislative actions.

 

Potential Scenarios on the SCOTUS ruling of the PPACA

The United States Supreme Court will rule within days on the constitutionality of president Obama’s Patient Protection and Affordable Care Act (PPACA). We’ve taken a look at what we feel are the three most likely outcome scenarios and attempted to unravel them.

But before we do that, let’s break down the four main issues that were argued before the Court:

1) Whether or not the federal Anti-Injunction Act is applicable to this case – This rarely-invoked Act is from the 19th century and basically states that a tax cannot be challenged in court until it has actually been assessed. Since the individual mandate’s penalties wouldn’t go into effect until 2014, the Supreme Court could not hear challenges to it until taxes are collected in 2015. Virtually all legal scholars and analysts agree it is very unlikely the court will find the Act applicable.

2) Whether the individual mandate is a tax – The individual mandate, also known as the “minimal coverage provision,” is the core of the PPACA. It requires that all individuals purchase health insurance regardless of their health, economic situation, or wishes. The question whether this mandate exceeds the constitutional limits of the “Commerce Clause”, which allows Congress’ regulate commerce between and among the states. While the federal government has routinely regulated terms of commerce, it has never before required it in order that it could regulate it.

3) Severability – If the Supreme Court rules some provisions of the PPACA unconstitutional, will the remaining portions stand, or must the whole Act be scrapped? The individual mandate is what funds the Act’s major provisions. Without out the Act becomes fiscally ruinous. Rather than the Supreme Court creating health care policy themselves, many argue that if they find the mandate unconstitutional they should allow congress to start over. The PPACA does not contain a severability clause, which some see as a simple oversight and others see as a fatal flaw.

4) PPACA’s Medicaid expansion constitutionality – As of now, the PPACA requires states to expand their Medicaid programs to cover more people, or risk losing all federal dollars for Medicaid. While federal dollars routinely come with restrictions, the states’ argument is that a threat of cutting off Medicaid dollars is too forceful, or “coercive” deeming it unconstitutional.

Potential Outcome #1: Court upholds the entire law

The Court concludes the individual mandate is not unconstitutional and the bill stands as written. The timeline for implementing exchanges and other provisions of the law continue as scheduled, pressing states that have not been complying with the law until after the Supreme Court ruling to scramble to get up to speed to meet the deadlines or risk the federal government entering into their states to enforce the law. States will need to comply with all of the law or risk losing all of their Medicaid funding, and ultimately this forces the states to take over the care of all those individuals that qualify. Furthermore, the precedent will be set giving the federal government the authority to order people into enter into a contract and/or purchase a product, and therefore fundamentally changing our system of government.

Potential Outcome #2: Court overturns a portion of the law

This is a very broad grouping of all the possibilities that could occur, but let’s point out the major portions that are most likely being focused on and their implications.

The Court invalidates the individual mandate, but decides to let the remainder of the bill stand. The question then turns to what portions of the bill are considered essential to the mandate. Community rating and guaranteed issued insurance reforms would most likely be removed. Insurers simply could not provide them without the funds the mandate would genererate. Without forcing consumers to buy insurance, the young and the healthy will continue to opt out. Without the removal of the community rating and guaranteed issue reforms, it will mostly likely result in the bankruptcy of many insurance providers, and ultimate death, of the health care industry.

Another portion of the law that could be struck down is the forced expansion of Medicaid. This would have serious impacts on the exchanges, as most of the insurance subsidies provided through them will likely be to newly Medicaid-eligible participants. The question of coercion has never been decided by the Court.

If only the individual mandate and/or the forced expansion of Medicaid are overturned, there are still many provisions remaining, such as the forced state exchanges and the employer mandate, to name just a few. The fate of these provisions will likely be decided by congress and the Executive in 2013.

Potential Outcome #3: Court overturns the entire law

Due to lack of a severability clause, if the Court invalidates the individual mandate, it could strike down the entire bill. It would deem that if indeed the individual mandate were struck down, the remaining provisions would no longer function “in a manner consistent with the intent of Congress”.

Yes, some people will be back where they were before the ACA for a short time, left without insurance, but this opens the floodgates for new, free-market based ideas to be presented to not only create actual permanent change and affordability for Americans, but to change the mindset and practices of insurance providers, as well.

 

For more resources on free-market based health care reform, please see the footnotes attached as well as the following:

• Arduin, Laffer, & Moore Econometrics. (2009). The prognosis for national health insurance: a Montana perspective. Montana Policy Institute. <http://bit.ly/LgEdjh>

• Issue Brief: Pitfalls of the Patient Protection and Affordable Care Act for Montanans. Montana Policy Institute.

• Montana Policy Institute – Free-Market Health Care Resource Page http://www.montanapolicy.org/main/page.php?page_id=37

• Patient Centered Reform Online <http://www.patientcenteredreform.com>