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Experts weigh in on Supreme Court's health care decision

Now that the U.S. Supreme Court has decided the constitutionality of the Affordable Care Act (ACA), experts from across Emory University will be looking at the impact of the decision on the country's health care policy and public health, and the precedents it may set in constitutional law, federalism, family law and regulatory reform. Below are comments on the ruling by Emory health policy and legal experts:

Timothy Buchman, Director, Emory Center for Critical Care

Tim Buchman"The Supreme Court decision brings to mind Churchill's comment in the midst of World War II, when he remarked, "Now this is not the end, this is not even the beginning of the end, but it is, perhaps, the end of the beginning." Today's Supreme Court decision marks the end of the beginning.

Upholding the PPACA, the Court effectively acknowledges that every American will require health care sometime during his or life. The Court effectively  acknowledges that every American must have a way of obtaining that health care and affording that health care, regardless of pre-existing medical conditions.

The Supreme Court decision, in ending the debate about the Constitutionality of the individual mandate, says to each of us that we have a collective obligation as Americans to support each other in affording that health care. We have major challenges ahead in deciding how much health care we can afford — not as individuals, but as a nation — and in ensuring that the dollars we spend deliver best value — to the nation, and to each of us as individuals.

David Howard, associate professor of health policy and management, Rollins School of Public Health

David HowardInitial reports have spun the decision as a victory for the Obama administration and the Affordable Care Act (ACA). Not so fast. The court permitted the mandate, but, under the ruling, states that opt out of the ACA's Medicaid expansion can continue to participate in Medicaid. Seventeen million uninsured people were supposed to obtain coverage through ACA-mandated Medicaid expansions. What happens now if states opt-out? Many of the people who would have been eligible for Medicaid may qualify for subsidies to buy private insurance in one of the exchanges. The cost of these subsidies is borne entirely by the federal government, placing additional pressure on the budget. This could be a major headache for the administration. Look for the issue of whether to expand Medicaid in accordance with the ACA to play a bigger role in upcoming state elections.

Kathleen Adams, professor of health policy and management, Rollins School of Public Health

Kathleen AdamsIt is a tremendous day in America in that almost 40 million families and their children who struggle with the challenges of being poor or near-poor will be guaranteed a pathway to obtaining affordable health insurance. They will no longer face barriers in the form of pre-existing conditions, lifetime limits or the simple inability to use a large portion of their income for insurance. Numerous studies have shown that insurance increases access and use of preventive and other needed health care services. Indeed, reports from the Oregon experiment are showing that insurance coverage through Medicaid is making families healthier and more financially secure.

While most of the law was upheld, it is of great concern that the Medicaid expansion was not upheld as written. This means that states will have a choice of whether or not to participate.  Historically, there has been wide variation across the states in terms of the generosity of their Medicaid program, their decisions to expand it through waivers and more currently, their steps forward in terms of insurance exchanges. While the mandate is critical for the insurance exchanges to work, the fact that states can now opt out of the Medicaid expansion will make the availability to coverage dependent on state residency and indeed, the ease with which the expansion for the poorest and the near-poor, far more complex. We will still have a 50-state program in a sense.

Robert Schapiro, dean and Asa Griggs Candler Professor of Law, Emory Law School 

Robert SchapiroIt's a surprise from many perspectives. There's certainly been a discussion of Chief Justice Roberts wanting to reduce the political profile of the court, particularly in the wake of the Bush v. Gore decision of 2000. He has wanted make the court appear to be less of a political entity. That would certainly explain his actions in this case. He accepted many of the arguments brought by various conservative challengers to the ACA, but in the end he provided the deciding vote to keep the court out of this contentious political debate. 

There are two key issues in this case: the underlying constitutional law and how the court sees its role in our political system. In crafting a decision on narrow grounds, Chief Justice Roberts seemed more concerned with defining a modest role for the court. In some ways this harkens back to Chief Justice Roberts' famous comment that judges are like umpires and nobody comes to the game to see the umpires. Well, in this case, many people came to see the umpires, but in the end the decision was to step back and not have the umpires be the central players in this kind of World Series of public policy debate.

William Buzbee, professor of law, Emory Law School

William BuzbeeThe alignment of the justices in this decision will get a great deal of scrutiny. Chief Justice Robert's willingness to go against his conservative colleagues and a strong Republican party attack on the health law will likely enhance his reputation for independence, despite his overall voting record which has been strongly aligned with his usual conservative colleagues on the bench.

In future cases, advocates of the decision will likely use points of agreement among the justices' opinions to argue that the law has shifted. Opponents of such a move will focus on the lack of a shared opinion, and also seek to limit the various opinions' language to the factual setting of this case.

The same holds true in figuring out where the permissible line stands under Congress's power to induce states to act under its Spending Power. Congress went too far here, but the new line between permissible and impermissible is not clear.

Additional comments by Buzbee >>

Learn more about the Emory experts commenting on the Affordable Care Act >>

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