ACA Future Uncertain? 'Equally Potent Threats Lie Ahead'

Marrecca Fiore; John E. McDonough, DPh, MPA


June 28, 2012

Editor's Note:
John E. McDonough, DPh, MPA, is a professor of Public Health Practice at the Harvard School of Public Health and director of the HSPH Center for Public Health Leadership. Between 2008 and 2010, he served as a Senior Advisor on National Health Reform to the US Senate Committee on Health, Education, Labor, and Pensions. As an advisor to the late Sen Ted Kennedy, Dr. McDonough played a key role in the creation and passage of the Affordable Care Act (ACA).

He wrote about his experiences working with Congress on this legislation in the 2011 book, Inside National Health Reform.

Dr. McDonough spoke with Medscape immediately after the Supreme Court announced its ruling on the ACA on Thursday. Although relieved by the decision to largely uphold the act, Dr. McDonough still worries about the future of this landmark law.

Medscape: What was your reaction after hearing the decision?

Dr. McDonough: I was relieved and surprised, because I was expecting the worst -- and it was a 5-4 decision, so the worst almost happened. I was convinced, along with many others, that if it was completely upheld, it would be a 6-3 ruling. So Justice Kennedy surprised us, and Justice Roberts surprised us.

Medscape: Why is this legislation a win for physicians and patients?

Dr. McDonough: This law is already providing real meaningful benefits to millions of Americans in improving health security, and it will make profound lifesaving differences for many millions of other Americans in the coming years. If it had been overturned completely, it would have been many years before we could return to and address our badly dysfunctional healthcare system. This ruling keeps reform on track; it allows for improvement moving forward.

Medscape: The individual mandate doesn't take effect until next year, and the Medicaid provision has been modified in that the federal government can no longer withhold all Medicaid funding from states that do not comply with expansion efforts. What are your concerns about this law going forward?

Dr. McDonough: It's important to note that equally potent threats lie ahead, particularly on November 6th -- when it will be determined by voters, on the basis of which parties are elected to the White House and to Congress, whether health reform stays or goes. If the Republicans take the presidency in November and gain meaningful majorities in Congress, I have no doubt that in January 2013, efforts to repeal the ACA will begin.

Medscape: Imagining that this is the last hurdle for the ACA, what's next in the effort to reform the US healthcare system?

Dr. McDonough: I don't think people really appreciate that this is the only federal law ever passed that has attempted to achieve healthcare reform for every single American. Even the 1965 law that created Medicare and Medicaid was restricted to those who qualified for the benefits under the law. On a variety of fronts, this law is improving quality and efficiency, addressing public health, and tackling fraud and abuse. It sets very aggressive agendas to fix the healthcare system, and if this act were to go away, it would take so long to have this opportunity again.

Medscape: We recently conducted a poll on the ACA, to which more than 8100 of our physician and other provider members responded, and they were divided in their support of the individual mandate and Medicaid expansion. Overall, there is some fear on the part of healthcare providers that these provisions, as well as other provisions, in the ACA could harm the practice of medicine. How would you respond to those concerns?

Dr. McDonough: I go around the country and give talks to physicians on the healthcare law, and what I find is a striking unfamiliarity with what the law actually does. When I talk to physicians about what is actually in the law, there is a lot of surprise. A lot of health policy analysts will have you believe that this law is going to harm patient care in America. Well, currently, patient care in America is harming a lot of patients. This law reduces or eliminates the harm being caused to patients by the current healthcare system.

This law, like every federal law, has in it things that need to be fixed. And in a normal Congressional environment, Congress would already be working to fix those things. But we're in such a partisan maelstrom that normal compromise hasn't been possible, and we may have to wait until after the November elections to see that compromise and those fixes happen.

Medscape: You live in Massachusetts, and the individual mandate of the ACA very much resembles the health insurance mandate that was included in Massachusetts' historic health reform law. What can the country or those with concerns about the individual mandate learn from Massachusetts? Has there been any backlash from this requirement?

Dr. McDonough: None. The requirement to have health insurance has been the law in Massachusetts since 2007; we've gone through 2 gubernatorial races, and neither Republican challenger in those races tried to repeal any part of the law.

We've achieved more than a 98.1% coverage rate for residents and a 99.08% coverage rate for children. So it is working. We still have issues with the cost of healthcare, which every state has, and we haven't solved that problem yet. But we're intensely focused on solving those problems. So if people want to know what the future of the individual mandate will look like, they can look at Massachusetts and see that it's working.


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