The Supreme Court Decision: Who Pays?

Ten days prior to Thursday’s Supreme Court ruling on the Affordable Care Act, the LA Times published a story headlined with an decades-old question: “Who covers the uninsured?” Indeed, the question who pays has been central to the healthcare debate for decades. For those of us in Emergency Care, the Supreme Court answered that question on Thursday.

It was a question that has been critical to the healthcare system since 1986, and no more so than for emergency physicians. That was the year the federal government passed a law requiring emergency departments to care for all in need, regardless of their ability to pay. Many know that requirement as a bedrock principle of American healthcare. We in emergency care stand by that principle. It also, incidentally, happens to be a 26-year-old hugely unfunded mandate. The law required hospitals to provide the care but didn’t give them a means to pay for it – until now.

As an emergency room physician quoted in the LA Times story put it, “Whether people know it or not, whether people appreciate it or not, access to emergency care became a right in this country in 1986.” After the Supreme Court’s decision, we can now say that there is an acknowledgement that we need a mechanism to pay for that right.

Agree with the policy or not, the individual mandate was Congress’s attempt to answer the question, “who pays”? In fact, the law’s language speaks to directly to this: people who don’t buy health insurance will be required to fork over a “shared responsibility payment.”

That may seem like some form of Orwellian double-speak to some, but for those of us in emergency care, the issue of patient responsibility has always been a critical ingredient in the battle to lower costs. We know that a disproportionate amount of emergency care is provided to a relatively small percent of the population, many of whom are uninsured. For the past 26 years, the “system” has in essence swallowed the cost of that uncompensated care, most of it provided in Emergency Departments like ours. That cost has been spread among hospitals, swallowed by insurance companies, and passed on to other healthcare consumers in the form of higher insurance premiums.

To be clear, the Affordable Care Act is not going to fix healthcare in America. The issue of controlling costs still needs to be addressed. That task will only be accomplished through true, ground-up innovation by the hundreds of thousands of physicians groups, hospitals, healthcare companies, and individual doctors and managers that comprise the healthcare system in America. End of life care is also critical component of that discussion. It will also require each of us, as consumers of health care, to make decisions which improve our health and cause us to utilize as little of a precious resource as is possible by healthier living and minimizing personal risk.

But what the Affordable Care Act will do, at least in theory, is reduce the amount of uncompensated care in Emergency Departments over the long run. It remains to be seen, though, whether other healthcare reforms, including other provisions of the law the Affordable Care Act, will increase access to preventative and primary care in this country. If that happens, we would at least be on the path to a fairer, more effective, and more cost-effective healthcare system.