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Potential Ramifications of the Supreme Court’s Ruling on the Accountable Care Act

Posted By Benjamin Miller, Thursday, June 7, 2012

Collaborative Care Policy Month

It's impossible to avoid all the politics in the news surrounding the Patient-Protection and Affordable Care Act. Since its 2010 passage, we have had political parties fighting to maintain and to repeal the law. And now, we have the Supreme Court of the United States (SCOTUS) currently deliberating whether the entire law or the individual mandate are constitutional.

While just about any decision is possible from the Supreme Court, 1 of 3 outcomes is likely:

   1. Uphold the entire law,

   2. Uphold the law except the individual mandate,

   3. Strike the entire law.

What are the collaborative care ramifications for each?

1) SCOTUS Upholds the Entire Law. For proponents of collaborative care, there is a lot to love about PPACA. First we have the wondrous notion of health insurance expansion. For anyone who has worked in primary care, one of the biggest psychosocial barriers many of our patients face is that of not having health insurance that can help cover services whether they are physical health or mental health. Second, we have the issue of access that comes along with coverage. If more patients have access to services, there is an increased likelihood that more patients can be seen in collaborative care settings. While there are other provisions of PPACA that address "integration” of behavioral health (section 5604 and 2703 as an example), it is not likely that the SCOTUS decision will impact these as it does the coverage and access issue.

2) SCOTUS Strikes the Individual Mandate. What's interesting is that Massachusetts, the "canary in the coal mine" for much of what we are seeing unfold nationally with health reform is doing quite well with healthcare. First, residents of the Commonwealth are quite supportive of the Massachusetts individual mandate law. Jonathan Cohn has written extensively about Massachusetts and the mandate before. One key point he makes is that the individual mandate would likely have less of an impact on folks than most people are aware:

"Perhaps more important, the mandate didn’t actually change life for most people in Massachusetts, at least in ways they could perceive. Most people already had insurance that satisfied the requirement. And while nationally the proportion of people with insurance is lower than it has been in Massachusetts, overall the same basic truth holds: The majority of people already have insurance that would satisfy the mandate."

From the Kaiser Family Foundation:

"The vast majority of Americans already gets insurance from their employers, Medicaid, Medicare, the individual market, or other sources of coverage, and will essentially automatically comply with the mandate once it goes into effect in 2014. The Congressional Budget Office (CBO)projects that about 80% of the 272 million non-elderly people in 2014 would be insured even in the absence of the ACA and would therefore already fulfill the mandate’s requirement."

So much of what we hear in the media about the individual mandate is noise. Since this is the most "controversial" piece of the legislation before SCOTUS, let's just pretend that this piece of the legislation is "struck down," what will we do? What will this mean? I would encourage those interested to read the brilliant post by Sarah Kliff and Ezra Klein from the Washington Post on this topic.

3) SCOTUS Strikes the Entire Law. Let me be somewhat controversial for a second and posit that even without PPACA, the good work happening on the ground, the innovation, will continue regardless. Let's be honest, even with a fully supported (financially and politically) PPACA (including the mandate), there are still major hurdles that must be addresses in healthcare. Does PPACA truly defragment healthcare and make it the system we all want? Not really, but it does help.

To demonstrate my point, let me offer a case study on behavioral health.

As we have written about extensively before, the separation of behavioral health from the larger healthcare system is an inefficient and often ineffective model of comprehensive healthcare. Despite decades worth of research highlighting this inseparability, we still have a bifurcated system (mental/physical) that has a tough time taking care of the whole person. Policy barriers, primarily financial policies, make sustaining integration efforts a challenging proposition; however, integration efforts do not stop just because policy has not changed to accommodate their innovation.

Take for example:

Cherokee Health Systems

Maine Health's Integration Program

California's Integrated Behavioral Health Project

Colorado's Advancing Care Together practices

Alaska's Southcentral Foundation

And the list goes on and on. Despite policies that may make their integration efforts challenging, they keep going.

When we think about the implications of major policy decisions on much of our work, sometimes these decisions help and sometimes they hurt our efforts; regardless of the decision, practices in our communities continue to innovate.

According to West et al. innovation can be defined as "the intentional introduction and application within a role, group, or organisation, of ideas, processes, products or procedures, new to the relevant unit of adoption, designed to significantly benefit the individual, the group, or wider society."

While policies can support or hinder the adoption of these innovations, the benefits that the community receives far outweighs whether or not it is supported by someone, somewhere in healthcare policy land.

Integrating behavioral health and healthcare is a truly unique opportunity to demonstrate the power of teams as well as influence such important policy issues like the "triple aim."

So let's imagine that next week SCOTUS knocks down PPACA in its entirety. What will we do? Will we hide away worried that policy is no longer in our favor? Will we decide that all our efforts are for naught?

The answer is simple: No! We will do what we must to continue to create a high performing and effective system we all deserve. Regardless of the ruling, you cannot stop the innovation in our communities. We will wake up, have our coffee, see the outcome of the decision and continue going back into the trenches working towards a comprehensive whole person system. We will see this ruling as just another bump in the road and keep on moving towards change.

Onward, towards change and continued innovation!


Ben Miller
Ben Miller is the President of CFHA and hosts the CFHA Game On blog.  He is also the founder of the Occupy Healtcare movement.  He is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is responsible for integrating mental health across all three of the Department’s core mission areas: clinical, education, and research.

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Randall Reitz says...
Posted Friday, June 8, 2012
Astute observations about the 3 outcomes. I'm hoping for option 1, but predicting option 3.
Permalink to this Comment }

Randall Reitz says...
Posted Friday, June 8, 2012
Ben, Politico liked your blog post so much that they copied the basic format, almost to the word:
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