Ruling could throw health care into chaos [Dayton Daily News, Ohio]

June 17--WASHINGTON -- The U.S. Supreme Court is on the verge of ruling on the new health care law, a decision that could throw health care into temporary chaos as providers and patients scramble to adjust to a wave of uncertainty in the system.

The justices might issue their decision as early as this week. They could deliver a staggering political blow to President Barack Obama by striking down the 2010 law, the signature achievement of the president's first term that was designed to extend health care to millions of Americans currently without insurance.

The court also could stun conservative Republicans by giving their seal of approval to the law. Republicans in Congress joined by GOP state attorneys general objected that it unconstitutionally forced individuals to buy health insurance.

Instead, a growing number of analysts suggest that five of the justices will cobble together a fractured series of opinions that could leave parts of the law intact while striking down other sections. Such a ruling could create a chaotic situation for hospitals, physicians and patients.

"I think hospitals wants clear direction either way, not just in the Supreme Court decision, but in all areas of public policy," said Jonathan Archey, a lobbyist for the Ohio Hospital Association. "Whatever the Supreme Court does, we're still going to have the issues that the (law) was designed to deal with."

Just about everyone will be affected by the court's decision: Business owners, health care providers, consumers, insurers and public administrators are all anxiously waiting for the justices' decision.

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For Marty Grunder, owner of Grunder Landscaping in Miamisburg, the law means more regulations for small-business owners already burdened by red tape.

"It scares me, just in that it's more regulation that we don't totally understand, and entrepreneurs, I feel, already have enough regulations to deal with," Grunder said. "I hear administrators on both sides of the aisle telling everyone how important small business owners are and we're the backbone of the American economy, and that's true. But I don't see a whole lot of action from the Obama side that makes me feel warm and fuzzy about what's going on here."

Grunder employs about 50 people, and he offers them health insurance.

"I want to take care of them. I like them. I'm not trying to advantage of them," he said.

Health insurance is a key component to hiring and keeping good workers, he said.

But the law as it stands is confusing and just one more layer of bureaucracy weighing down a crucial segment of the nation's struggling economy, Grunder said. "We want the government to get out of the way and let us run our businesses and not worry about all these things."

Businesses in general are "very nervous" about the health care reform law and what the Supreme Court will ultimately rule, said Phil Parker, president and CEO of the Dayton Area Chamber of Commerce.

Employers know they need to offer health insurance to get quality workers, he said, but health care costs continue to rise, and there's little indication the law, if it stands, will do much to reverse that trend.

Elisabeth Dyer, a Harrison Twp. cancer survivor, supports the law and worries the court will overturn it.

Dyer, who survived four episodes of lymphoma between 2007 and 2009, has insurance through her husband, Hank Kropf, who works for Eastman Kodak Co. in Kettering.

She was worried the family would lose their coverage earlier this year during a round of layoffs at Kodak. Her husband kept his job and his health insurance.

Without the health care reform law, which prohibits insurers from denying coverage to cancer survivors and those with pre-existing conditions, there's no way Dyer would be able to get coverage again, she said. "Even cancer one time would knock me out," Dyer said. "But four times? There's no way. Because of the health care law, though, I can get coverage if I need it."

There's another key provision of the law that her family has found crucial: Their son, Sam, 24, is on his father's health policy. He works in television as a production assistant for the series "The Bachelor," "The Bachelorette" and "Bachelor Pad." In September, he had to be hospitalized after a nasty bout of pneumonia that doctors originally feared might be tuberculosis.

Sam Kropf spent six days in Cedars-Sinai Medical Center in Los Angeles. "He got into a hospital with the best care because he had insurance," she said. "That's why he's alive and healthy."

Last week, Humana, UnitedHealth and Aetna announced they would keep some provisions of the health care reform law in place regardless of the Supreme Court's decision -- the provisions covering dependents up to age 26, and providing access to independent appeals when claims are denied.

Whatever the court rules, Parker said, people will still need health care, and they'll still need to figure out a way to pay for it.

"Health care is not going to be for free. Even if you have coverage, it's going to have to be paid for. No one's going to provide the care for free. The docs, the hospitals, the nurses, everyone gets paid," he said.

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The court's key votes belong to Justice Anthony Kennedy and, to a lesser extent, Chief Justice John Roberts. With the court's four liberal justices likely to uphold the law and conservative justices Antonin Scalia, Samuel Alito and Clarence Thomas seemingly hostile to the law, Kennedy may emerge as he usually does -- the pivotal vote.

"He's always subject to the next morning's barometer readings,'' said Thomas Miller, a resident fellow and health analyst at the Washington-based American Enterprise Institute. "But based on the way oral arguments unfolded, the best reading is that he's a vote against the individual mandate, but not a vote for striking down the entire structure.''

"It's hard it to get five votes to throw everything out the door because of (the court's) nervousness about being something that sweeping,'' Miller said.

Judith Feder, a professor of public policy at Georgetown University and who worked on health care in the Clinton administration, said the Obama administration "would find a way to implement the law, no matter the decision -- short of the court throwing it all out. There are workable ways to implement the law.''

The 2010 law was the fourth serious attempt by an American president since World War II to overhaul the nation's health care system.

Each plan offered by Presidents Harry Truman, Richard Nixon, Bill Clinton and Obama aimed at extending health coverage to the millions of Americans without any insurance while simultaneously trying to check the rapidly escalating costs of health care. Obama's was the only measure that passed Congress.

The new law essentially expanded coverage in two ways. First, it provided federal financial assistance to middle class families to buy private insurance. To win the support of the health insurance industry, Congress included a requirement that everyone buy insurance or face a fine.

Backers of the mandate said it was the only way to get younger and healthier people to buy insurance instead of having a system dominated by older and sicker people. The more young people in the system, the less likely insurance premiums would rise as fast as they have in the past.

Congress and the insurance industry also agreed that with a mandate, insurance companies would no longer deny coverage to those with pre-existing conditions and would adopt what is know as a community rating in which everyone is covered -- including people who heavily smoke and are overweight.

The second way the law expands coverage is by admitting more people into Medicaid, the joint state and federal program that provides health coverage for low-income people. Because families of four making $32,000 a year would be eligible, as many as 16 million more people nationally and 970,000 in Ohio would be eligible for Medicaid.

To help pay for the law, most of which does not go into effect until 2014, Congress agreed to slice tens of billions of dollars in Medicare payments to providers, impose a new excise tax on medical equipment, and tax expensive insurance plans.

But the law's mandate ran smack into a series of constitutional objections. Unlike Nixon and Clinton, who proposed to extend coverage by requiring most companies to insure their workers, the individual mandate requires Americans to buy a consumer product, which conservatives argue violates the Constitution.

"We throw all kinds of burdens on employers,'' Miller said. "That may not be wise economically, but on constitutional grounds that's much harder to challenge.''

The justices could strike down the mandate and leave intact the requirements that insurance companies accept everyone, regardless of pre-existing officials. But health insurance officials point to states that tried to require insurance companies to cover everyone without a mandate and their studies suggest the result was higher premiums and fewer choices.

"Many states have tried these reforms without getting everybody in the system and they failed,'' said Robert Zirkelbach, a spokesman for the Health Insurance Association of America.

Others suggest the mandate is the glue that holds the law together. Rep. Pat Tiberi, R-Genoa Twp. and a member of the House Ways and Means Committee, said "if the mandate is not there, there are other parts of the bill that may collapse under its own weight.''

"I think we try and get our arms around the decision, but our goal has been to repeal ObamaCare and start over,'' Tiberi said. "There's no question there are things in there that have some support.''

An example is the requirement -- one of the few provisions of the law in effect -- that insurance companies allow young adults to remain on their parents' plans, such as Sam Kropf.

Even if the entire law is struck down, insurance companies are likely to continue allowing young adults to stay on their parents' plan because as Miller of AEI said, "The reality is that the under-26 thing is popular and relatively successful. So they're not going to roll that back.''

The justices could also invalidate the mandate and the expansion of Medicaid coverage. But if they uphold the Medicare reductions, than "it's going to be a big problem'' for hospitals, said Archey of the Ohio Hospital Association.

"The reason those (Medicare) reimbursement cuts were included is because more people would be covered and we wouldn't have much of an uninsured situation,'' Archey said. "If the Supreme Court gets rid of the coverage expansion and doesn't do anything about the reimbursement cuts, it's going to be a big problem.''

Yet Feder doubts that "the world comes to an end,'' unless the court strikes down the entire law. "There are ways to make it work,'' she said. "There are certainly ways to make it work if Congress were operating in a way that was inclined to fix things.'' But she insisted that "the administration will absolutely find strategies to move forward.''

Contact this reporter at (937) 225-7457 or peggy.o'[email protected].

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