The Supremes Say the Mandate is Constitutional. But Voters Get the Final Word.

Washington’s best-kept secret since JFK and Marilyn Monroe came out today: the Supreme Court upheld the individual mandate in the ACA in a 5-4 decision made by Chief Justice John Roberts.  The President ducked a bullet in the ruling and comes out strong heading into the election on this issue; the decision will galvanize the right and embolden the left; and Chief Roberts finessed the issue by calling the mandate a tax, avoiding new precedent and getting the Supremes out of the nastiest domestic squabble since Bush v. Gore.  But the Supremes didn’t get the last word on the ACA: that rests with the voters in November.  Making Obama a one-termer is now the GOP’s only hope to stop health reform.

The Supremes’ decision means reform moves forward without delay. That means most of the 26 Red States that brought the case to the Court, and a handful of others, are now WAY behind in implementation and will likely have the Federal Exchange jammed down their throats in January 2014 for their intransigence.  That’s the Supreme irony of the case: for all their bitching about a government takeover, that’s exactly what those states will get for having done nothing while the case worked its way through the Courts.

The decision also means there is no impact whatsoever to Medicare. The cuts to Medicare Advantage (MA) remain and will continue to be phased in.  The Star Ratings bonuses and rebates remain untouched.  The new Part D coverage expansions — the “jelly” in the donut hole — are as sweet as ever.   Accountable Care Organizations (ACOs) move forward.  Minimum medical loss ratios (MLRs) take effect in Medicare Advantage in 2014. The coding intensity adjustment in MA remains.  The Retiree Drug Subsidy (RDS) continues to phase down by 2016, compelling more employers to push their retirees into MA and Prescription Drug-only Plans.  Insurer and provider taxes stay put.  And 9 Million Dual Eligibles continue their march into health plans.  It’s as if the case never happened.  And that means, as we’ve said many times here, it’s still all about Star Ratings, Risk Adjustment, and chronic care management as keys to survival in Medicare this decade.

Now the only thing standing in the way of ACA implementation in January 2014 is if Obama is deposed in November and the GOP can get enough votes for “repeal and replace”.  Republican nominee Mitt Romney — the original baby-daddy of the individual mandate in Massachusetts — said he raised over $1M in campaign contributions in the first two hours after the decision came down.  Obama will use the decision to try to reboot his health reform message.  And the election becomes a referendum on the ACA.

Strap on your crash helmet and hold onto your butt — the next 4 months will be the nastiest campaign cycle this country has ever seen.  But for now, the ACA lives.  And if you’re in health care, you should be turning cartwheels today.