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Forum on the Supreme Court’s Decision on the Affordable Care Act: Implications for Health Care & Public Health

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This post was written by Katie Keith, Assistant Research Professor, Georgetown University Health Policy Institute Center on Health Insurance Reforms, and Cameron Stokes, Georgetown Law 3L.  Any questions or comments about this post can be directed to

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On July 11, 2012, the George Washington University School of Public Health and Human Services hosted a forum on the Supreme Court’s Decision on the Affordable Care Act: Implications for Health Care & Public Health. The keynote speakers and panel of health policy experts discussed the impact of the decision on everything from exchanges to delivery system reform and public health. (Watch the full event here.)

The event featured three keynote speakers: U.S. Department of Health and Human Services Secretary Kathleen Sebelius, former Senate Majority Leader Tom Daschle, and the O’Neill Institute’s own adjunct lecturer Sheila Burke who served as Senator Bob Dole’s chief of staff. The keynote addresses were followed by a panel that featured Karen Ignagni of America’s Health Insurance Plans, Ron Pollack of Families USA, Sonya Schwartz of the National Academy for State Health Policy, Georges C. Benjamin of the American Public Health Association, and Mindy Hatton of the American Hospital Association. The panel was moderated by Sara Rosenbaum. The keynote speakers and panelists focused on the following issues:

Looking to the States: Expanding Medicaid and Beyond. All three keynote speakers emphasized the role of the states in implementing the ACA, and suggested that states will adopt many approaches in doing so. Secretary Sebelius touted letters from 12 governors that already committed to developing state-based exchanges and pledged to continue HHS’ close partnership with the states and provide maximum flexibility in shaping state markets and establishing exchanges. Although Burke praised HHS’ efforts and flexibility thus far, she cautioned that many implementation issues have yet to be decided by HHS, and state political dynamics and budgetary pressures are just as, if not more, complicated as they are at the federal level. Schwartz further noted that the states face an ambitious agenda ahead of 2014 and, among other critical decisions, must decide 1) how to regulate their insurance market in a post-ACA world; 2) how to enroll the uninsured in Medicaid and the exchange and prepare for the significant changes to come; and 3) how to establish benchmark plans while grappling with issues related to access, financing, and provider networks that accompany these high-stakes decisions.

The speakers had mixed opinions on whether states would expand their Medicaid programs in 2014. The Secretary expressed confidence that states would do so given the generous federal matching funds and because hospitals and doctors will support the Medicaid expansion. Secretary Sebelius and Daschle also pointed to the experience with state implementation of CHIP and the original Medicaid program to suggest that states would eventually opt in to the Medicaid expansion. Burke, however, cautioned that these comparisons may be less relevant because 1) the implementation of CHIP and Medicaid occurred when states faced far fewer challenges than they do today and 2) states are anxious about the possibility that the federal government could change its mind and move away from its promise of full (or near full) federal funding or distribute block grants that could result in more financial risk for the states.

Schwartz and Pollack similarly suggested that the inducement of federal funds will result in all states expanding their Medicaid program with Pollack arguing that states that fail to do so would be committing “fiscal malpractice.” Schwartz noted that the expansion would not be surprising because the vast majority of states have already implemented Medicaid programs that are more generous than required under federal law by, for example, covering pregnant women up to 185 percent of the federal poverty level and covering prescription drugs.

Looking to the Election: Debating the Role of Government. In defending the law, Secretary Sebelius emphasized the need to focus on what the ACA means for Americans outside of Washington—rather than politicians inside the beltway—and pointed to the benefits that have already been realized. Echoing these sentiments, Daschle described the passage of the law as a “transformational moment” for the nation while Burke noted that the ACA’s sweeping policy changes which will improve the way the United States finances and delivers healthcare, regardless of political challenges.

Despite continued opposition and an often rancorous debate, the keynote speakers noted that there are many areas of agreement regarding healthcare and that much of the divisiveness of the health reform debate stems from an underlying tension about the desired role of government. Daschle and Burke predicted that the 2012 presidential election will have critical implications for the future of the ACA and beyond. Burke also noted that Republican repeal and replace efforts could continue for years, but that efforts to “replace” the ACA could return the law’s most popular provisions in a different form. Other panelists suggested that states may wait until after the election to make a final decision (or even change their decision) on whether to expand Medicaid.

Looking to the Future: Remaining Obstacles. Daschle predicted that debates over the ACA will continue to play out in four remaining obstacles. Burke raised additional obstacles including more legal challenges, efforts to repeal the law in full or through the reconciliation process, and looming fiscal debates about tax reform, deficit reduction, and the debt ceiling. She added that discretionary funding, such as the ACA’s Prevention and Public Health Fund, could be particularly at risk during these negotiations. Burke also questioned whether states will be ready for all of the new reforms to go into effect in 2014; whether the Secretary has the authority to extend these rapidly approaching deadlines; what options will exist for uninsured low-income adults in states that choose not to expand Medicaid; and how employers will realign their workforces in response to the ACA’s requirements.

Other ongoing challenges included the affordability and the capacity of the healthcare workforce. Ignagni emphasized the need for “workability” and noted that the industry is focusing on how the law’s requirements interact to make sure people can find and purchase affordable coverage. And, while Benjamin noted that the ACA enhances reimbursement for primary care providers and institutes scholarship programs for physicians, Ignagni and Burke added that there is a shortage of healthcare professionals and states may need to revisit their scope of practice laws or otherwise rethink our traditional notions about the healthcare workforce. Pollack raised the issue of limited access to dentists and the potential for using dental therapists to assist patients in light of the ACA’s requirement that certain plans cover pediatric dental benefits.

Above all, the keynote speakers and panelists stressed that the Supreme Court’s decision signaled a new beginning for implementation of the ACA and much work remains to be done by states and the federal government to ensure that millions of Americans receive the benefits promised under this landmark legislation.

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