Health Reform Upheld: A Summary of the Supreme Court's Decision

In a 5-4 decision, the Supreme Court handed down its long-awaited decision on the health reform bill, National Federation of Independent Business v. Sebelius, this morning. This historic decision has upheld the constitutionality of the Patient Protection and Affordable Care Act (ACA) as a whole (striking down only one penalty provision as unconstitutional), upholding measures improving access to and the quality of healthcare in the United States by expanding coverage, increasing benefits, and ensuring access to preventive services for many. This is a victory for communities and public health advocates throughout the country, and a relief for the many Americans already benefiting from some of the ACA’s programs.

Chief Justice Roberts delivered the opinion of the Court, and upheld the constitutionality of the individual mandate under Congress’s Taxing Power. [See here for a table of how all of the Justices' voted]. The individual mandate provision of the ACA states that individuals shall purchase health insurance, or pay a penalty. The Court considered the substance and application of the payment, and not its label. It was noted that the payment is collected by the IRS through the normal means of taxation. While undoubtedly intended to induce individuals to purchase health insurance, that a tax may have the purpose of influencing behavior rather than generating revenue is not problematic. This payment was likened to the taxes imposed on cigarettes for the purposes of smoking deterrence. Furthermore, the fact remained that the payment for failing to obtain insurance did not amount to a punishment for unlawful activity since it was not limited to willful violations of the mandate (as unlawful actions frequently are). Consequently, the Court concluded that mandate “leaves an individual with a lawful choice to do or not do a certain act, so long as he is willing to pay a tax levied on that choice.” Page 44.

The Court was unpersuaded by the argument that the individual mandate fell within Congress's Commerce Power. The Constitution grants Congress the power to regulate commercial activity, however, the Court found the mandate not a regulation of existing commercial activity, but instead compulsion to engage in commercial activity, an action beyond the limited power given to the government under the Constitution.

While the individual mandate was upheld, the Supreme Court, however, did strike down the penalty of the Medicaid expansion provisions of the ACA as unconstitutional. Under the Medicaid program, the federal government provides funds to participating states, and in return the states agree to follow certain standards. The ACA expanded eligibility for Medicaid, and required states to expand coverage of their state’s Medicaid programs in accordance with the ACA, or lose all federal Medicaid funding (typically 50 to 83 percent of the state’s Medicaid program spending).

Although the Spending Power grants Congress the authority to create cooperative state-federal spending programs such as Medicaid, states must voluntarily accept the terms of such spending programs. The Court held that, because the ACA penalizes states who choose not to participate in the Medicaid expansion by withholding existing federal funding under the Medicaid program, the provision was coercive. In choosing not to participate in the Medicaid expansion, states would lose over 10 percent of their overall budget (page 51), an effect the Court found to leave states with no real option but to accept the terms of the program, making participation non-voluntary and the program unconstitutional.

Furthermore, the expansion was found to be not a modification of an existing program, but instead the creation of a new one. Medicaid as initially enacted covered four distinct categories of people: “the disabled, the blind, the elderly, and needy families with dependent children.” However, the expansion changes the program into one that covers the entire nonelderly population with incomes less than 133 percent of the poverty level (or 138% FPL if you count the 5% modified adjusted gross income or MAGI). The Court found this not to be a mere modification of an existing program to provide healthcare to needy populations, but instead a transformation of the program into “an element of a national plan to provide universal health coverage.” Pages 53-54. The Court concluded by explaining that its opinion did not prevent the federal government from offering funds to expand Medicaid eligibility, only that states choosing not to participate in the new expansion could not be penalized through the loss of their existing federal Medicaid funding.

Today the United States has taken a great step towards reshaping the American healthcare system. The ACA and its reforms to the system will have a lasting affect on the way people receive and pay for personal medical care, improving access and quality while containing costs, and improving the health of our nation as a whole.

Amanda Swanson
Guest Blogger for Illinois Health Matters

*To read a summary of the Supreme Court hearings on the ACA, please see the post Supreme Court Wrap Up – A Law Student’s Perspective.

Today is World Blood Donor Day

The Affordable Care Act includes many provisions aimed at increasing individuals’ ability to access health care.  However, even if the financial and other external barriers are overcome, problems with accessing health care will still exist if health care facilities do not have the supplies they need to treat patients, including sufficient blood products.  Today is World Blood Donor Day, a day to celebrate Illinois’ blood donors and inspire those in good health to begin donating blood.

Every year the transfusion of blood and blood products helps save millions of lives.  Transfusions also improve the quality of life and life expectancy for patients suffering from life-threatening conditions, and support surgeries and complex medical procedures such as cancer treatments.  All of these benefits cannot be realized without timely access to safe blood.  Although 60% of the population is eligible to donate blood, only 5% actually do.  The American Red Cross has reported that blood donations are down for 2012, and more donations are needed now to ensure there will not be any blood shortages this summer.

The World Health Organization designated June 14 as World Blood Donor Day, an international event to raise awareness of the need of safe blood and to thank voluntary blood donors.  This year’s theme is “Every blood donor is a hero.”  Individuals who choose to donate even when it may not be convenient put the needs of others before their own in a life-saving gesture of human solidarity.  Blood donors are indeed heroes; the donation of one pint of blood can save up to three lives.  To celebrate this day, organizations all over the world are planning events to raise awareness and thank donors.  LifeSource, Chicagoland’s blood center, created a Blood Donor Photo Tribute to thank those heroes who save lives by donating regularly.  The Red Cross, Nexcare, and supermodel Niki Taylor have partnered together to celebrate and thank blood donors by offering limited edition Nexcare GIVE bandages to those who present to give blood this June.

Whether you’re considering donating blood for the first time or are a regular donor looking to schedule your next appointment, knowing how to get started can make the donation process much easier for you.  Most organizations enable you to schedule appointments online, and you can choose from a list of donation centers and blood drives close to you to find the location and date that is most convenient.  You could also host a blood drive at your place of work, worship, community center, or school.  All you need to provide is a room or a place to park a donor coach vehicle, some tables and chairs, a contact person and a couple volunteers to recruit donors. 

Additionally, Illinois law also helps to make blood donation more convenient for people by permitting eligible employees to, upon request, use one hour of paid leave to donate blood.  This is available to full-time employees who donate blood and who have been employed for six months or more by any unit of local government, board of election commission, or any private employer in Illinois who has 51 or more employees.  Your employer can provide you with more information about whether this option is available to you and, if it is, what documentation you will need to provide to take advantage. 

It is easy to become an everyday hero and help save lives right in your own community.  To be eligible to donate blood, you must be at least 17 years old, weigh at least 110 pounds, and be in good physical health.  Individuals with certain health conditions or who have engaged in certain behaviors or traveled to certain places may be ineligible to donate.  Please see the websites for the American Red Cross (national), LifeSource (Chicagoland), the Central Illinois Community Blood Center (central Illinois), or Community Blood Services of Illinois (east-central Illinois) for more information on eligibility and how you can donate.

The selfless act of donating blood is incredibly important to the health and well-being of Illinoisans, and Illinois Health Matters wants to thank all of these life saving heroes.

Amanda Swanson
Guest Blogger

Illinois Health Information Exchange: Legal and Policy Issues

The adoption of electronic health records and a health information exchange (HIE) in the U.S. healthcare system, and the improvements in quality and cost that will result, has caused quite a stir across the country.  Even amidst all of the excitement and optimism, many people are concerned about potential negative consequences, and much of the controversy centers around the interplay between individuals’ privacy rights and the effectiveness of these new technologies.

The Illinois Office of Health Information Technology was created in 2010 by executive order to coordinate and direct Illinois HIT and HIE initiatives.  The OHIT and the Illinois Health Information Exchange Authority are working together to create the Illinois HIE (ILHIE).  To ensure that patient privacy rights are adequately protected, OHIT created an ILHIE Legal Task Force to identify and address Illinois laws raising complex challenges to the exchange of health information.  

While the Health Insurance Portability and Accountability Act’s (HIPAA) Privacy Rule lays out federal requirements governing the disclosure of a patient’s protected health information (PHI), this law sets a floor.  States are free to enact more strict privacy regulations, and Illinois has done so in a number of areas. The Legal Task Force has created ten workgroups, each assigned a specific disclosure issue which the group will investigate and then recommend improvements to the Illinois disclosure laws in that area.  These workgroups include PHI pertaining to behavioral health, substance abuse, HIV/AIDS status, and genetic testing. 

In addition to the legal barriers, OHIT is currently investigating key policy questions impacting the information put in the ILHIE and access to information.  

The first concern is whether patients should be granted a choice as to whether his/her information will be included in the ILHIE for use by health care professionals and others, and the extent of the effect given to this choice.  Next, if patients are given this choice, the question becomes whether all patients should be given the chance to affirmatively decline or consent to the inclusion of their PHI in the ILHIE.  If a patient decides he/she does not want to use the HIE, the permissibility and/or extent to which the patient’s data can be collected by the ILHIE for limited mandatory reporting (such as public health reporting) must also be addressed.    

Another issue arises when a patient may desire that only specific aspects of his or her medical record are not exchanged, or that specific providers can be denied access to the information, and whether this request can be accommodated or whether the patient’s entire record must then be excluded from the ILHIE.  Finally, if patients are given the choice as to whether or not to participate in the HIE, it must be determined what requirements, if any, should be placed on health care providers to inform the patient of the HIE and answer any questions, thereby ensuring the patient’s choice is truly meaningful.

Aside from the questions surrounding whether to include information in the HIE, barriers arise with respect to linking up the information within the HIE to the specific patient seeking health care.  One question being addressed is whether the ILHIE should use a unique patient identifier to enable patient records to be accumulated and matched to the patient with accuracy.  This is an important issue: problems can arise when other identifying information (such as name, birthday, gender, zip code, and/or all or part of the social security number) is used for this purpose, because patients having data in common, the entering of data in different formats at different facilities, and data entry errors can all prevent accurate record matching.  If a unique patient identifier is not created for the ILHIE, the question then becomes whether regulations should be imposed upon providers to ensure a certain degree of patient matching accuracy is achieved with the use of their EHR system with the HIE. 

The final policy question being addressed by OHIT concerns whether Illinois should enact its own laws and regulations governing patient rights with respect to their EHR, to supplement the rights already given to patients through federal law such as those giving patients the right to access their own medical records and request corrections.

For more information on the HIE or your information privacy and security, please visit the education page of the ILHIE or the Office of the National Coordinator.

Amanda Swanson, J.D., LL.M.