The law of the land for almost a decade, the Patient Protection and Affordable Care Act of 2010 is as controversial now as it was when it was enacted. Republicans’ negative view of the legislation remains diametrically opposed to that of Democrats, public opinion is divided, and the courts continue to issue often contradictory rulings on challenges to the ACA.
The latest upheaval on the legal front came in December when federal judge Reed O’Connor held the ACA to be unconstitutional. Ruling in a case brought by 20 Republican governors and attorneys general, he found that the entire law was invalidated when Congress voted last year to eliminate the tax penalty for people who fail to buy health insurance, beginning in 2019. That provision, which was designed to ensure that younger, healthier people are part of the insurance pool, had been one of the ACA’s central pillars. Without the coverage mandate, O’Connor, who was appointed to the federal bench in the northern district of Texas by President George W. Bush, wrote, the ACA “can no longer be sustained as an exercise of Congress’ tax power.”
The decision, which is certain to be reviewed on appeal and may ultimately be decided by the Supreme Court, unleashed a high level of consternation among Democrats and health care advocates. The response of Sen. Chris Murphy of Connecticut was typical: “This is a five-alarm fire — Republicans just blew up our health care system. The anti-health care zealots in the Republican Party are intentionally ripping health care away from the working poor, increasing costs on seniors, and making insurance harder to afford for people with preexisting conditions.”
Murphy may be overstating the case, but the ruling does raise a host of questions about the future of the ACA, commonly referred to as Obamacare, and its impact on health care delivery. Republican-controlled states might decide not to enforce the law, individuals now paying premiums may drop out of the system, and the insurance market and health care stocks could face increasing volatility. If O’Connor’s decision is upheld, an outcome which a preponderance of legal experts doubts, it also could adversely impact the manner in which community pharmacies are reimbursed for filling prescriptions under the Medicaid program, a possibility that the National Association of Chain Drug Stores and its allies are already gearing up to forestall.
The looming uncertainty and intense controversy that surround Obamacare point to important truths about the health care system, truths that predate the ACA and persist to this day: Despite spending much more per capita on health care than any other country, the U.S. still has large numbers of uninsured people, and costs continue their upward spiral.
Solving those two persistent problems was the primary objective of Obamacare’s architects. The ACA has made significant headway, through Medicaid expansion and subsidies on federal and state insurance exchanges, to extend coverage to more Americans. The number of uninsured has been cut from 44 million in 2013, the year before the major provisions of the law took effect, to some 28 million in 2017, according to the Kaiser Family Foundation.
The record is far less impressive when it comes reining in health care costs. Despite slower growth in 2017 — the Centers for Medicare and Medicaid Services (CMS) recently put the rate of growth at 3.9%, down from 4.8% the prior year — expenditures on health care reached $3.5 trillion, or 17.9% of GDP. CMS projections indicate that health care spending will rise an average of 5.5% a year from 2017 through 2026 to reach $5.7 trillion. As long as health care costs grow faster than the economy, the nation will be on the road to economic ruin, with funding for other pressing needs squeezed out.
For that reason — not to mention the health and well-being of Americans — President Trump and members of both parties need to put politics aside and find a bipartisan approach to fixing a broken health care system. The nation’s pharmacy chains and others in the private sector are already hard at work on the development of new ways to increase access, improve patient outcomes and lower costs. A reliable, stable framework for health care coverage would allow them to accelerate their efforts.