Philadelphia-region reaction to the health care ruling

U.S. Senator Bob Casey (D-PA) was more muted in his comments on the ruling than many of his fellow Democrats. The senator, who is running for re-election against a foe of the health reform, said in a statement:

"The fact that this law was upheld means that Pennsylvanians will not lose their coverage due to preexisting conditions, young adults will be allowed coverage under a parent's plan and older Americans will not have to face dramatic increases in prescription drug costs. I will continue to work with other senators to make improvements to the legislation."

Jane Shull, executive director of Philadelphia FIGHT, an AIDS services organization, worried that the ruling may encourage Gov. Corbett and the legislature to decline to expand Medicaid coverage for low-income residents, now that the court has removed the threat of penalties for failing to do so.

"I think we should be concerned about Pennsylvania," she said. "We have a conservative governor, we have a conservative legislature."

Bioethicist Arthur Caplan, who recently left the University of Pennsylvania for New York University, agreed. He called the ruling "a moral victory for the underinsured and noninsured," but said the Medicaid restriction is a problem.

"The Republican thunder and awe campaign failed," Caplan said. "Now we are shifting over to the guerilla warfare phase . . . You've got to still win the support of the American people to do what is the right thing to do."

The ruling surprised some leaders in the health profession.

Larry Kaiser, who leads the Temple University health system, was one of them. "I really thought the individual mandate was going to go," he said, but at his organization, "We've been making plans based on full implementation of the act," he said.

David F. Simon, executive vice-president and chief legal officer at Jefferson Health System, said,"The decision was a very unexpected twist. I don't know of anyone who predicted this result publicly or privately."

He expressed concern about bringing new patients into the health care system when the reform law is reducing Medicare and Medicaid payments. Instead of expanding Medicaid, as encouraged by the federal health law, he says subsidized insurance coverage may be a better option, since low payments have led many providers to refuse Medicaid patients.

Joel Ario, who was Pennsylvania health commissioner during the Rendell administration and now is working as a health policy consultant, said the Supreme Court ruling means more momentum for the law. It will be harder for Republicans to repeal the law, no matter how the elections this fall go.

"There'll be a real head of steam," he said. "It'll be very hard to do anything but continue to move forward."

He expects that most states will accept federal money to expand Medicaid as they have in the past. They'll be pressured by medical providers who don't want uninsured people showing up in emergency rooms and by employers who don't want to pay higher premium costs to support people without insurance, he argued.

One of health care reform's authors, New Jersey Democratic Rep. Frank Pallone, Jr., issued a statement saying the ruling "reaffirms our nation's commitment to make sure that all Americans have access to quality affordable health care and health insurance."

"For the millions of Americans who have gone without health insurance, the seniors who have struggled due to inadequate coverage, the women, children and young adults that have been denied coverage for preexisting conditions, the Court's ruling is not only a victory, but a validation that they deserve to have the most basic of human needs met - access to health care," Pallone wrote. "I am proud to have been a part of its creation and prouder still today to learn of the Court's decision to uphold its constitutionality."

U.S. Rep. Joe Pitts, a Chester County Republican, was quick to criticize the ruling. "Just because the Supreme Court declares something constitutional," Pitts said, "does not mean that it is a good idea. The health care law is not the reform Americans need or deserve."

"It is a dual edged sword," said Kevin Flynn, president of the Philadelphia-area group Health Care Advocates, in a statement about the Supreme Court ruling. "Americans have better access to coverage, but fewer plans are being offered and because there is a mandate, insurance companies are raising prices because Americans 'must' purchase health insurance."

"It will take 10 years before the cost savings tied to the preventative care mandates will be realized," Flynn wrote. "In the interim, premiums will be used to cover the costs."

Marilyn J. Heine, president of the Pennsylvania Medical Society said she's "pleased that this decision will make health care insurance available to most Americans."

However, Heine, who is an oncologist and emergency medicine specialist from suburban Philadelphia, criticized the law itself for not including medical liability reform and Medicare payment reform.

"These two issues have plagued health care in the past, and will continue to do so in the future," she said. "By ignoring these two elements, the ACA (Affordable Care Act) is only a partial fix for what ails health care access."

Not surprisingly, New Jersey Governor Chris Christie panned the ruling. "The Supreme Court is confirming what we knew all along about this law - it is a tax on middle class Americans," he said in a statement.

"I do not believe a one-size-fits-all health care program works for the entire country," Christie wrote. "Each governor should have the ability to make decisions about what works best for their state. Today's Supreme Court decision is disappointing and I still believe this is the wrong approach for the people of New Jersey who should be able to make their own judgments about health care.

U.S. Rep. Allyson Schwartz (D-Pa.), a leading congressional advocate of health care reforms, said in a statement, "With this decision, seniors can afford lifesaving medications, children with pre-existing conditions can get the care they need, 30 million more Americans can afford coverage, families won't go broke because of an illness, small businesses can provide affordable coverage for their employees, and young adults can remain on their parents' coverage."

New Jersey Democrat Bob Menendez also lauded the ruling. "The health care law is not perfect, and I intend to help fix what needs work, but this is good news for families and seniors all across New Jersey."

Planned Parenthood of Southeastern Pennsylvania called the health reform law "the greatest advance in women's health in a generation."

"The law will provide access to birth control and cancer screenings without co-pays, guaranteed direct access to OB/GYN providers without referrals, and an end to discriminatory practices against women, such as charging women higher premiums and denying coverage for "pre-existing conditions," the group said in a statement.

The Pennsylvania Association of Staff Nurses and Allied Professionals called the ruling a "modest step in the right direction." While the law attempts to expand the number of people with insurance, the group said the bigger problem in the U.S. is "the crisis of the insured."

"Health insurance has lost all meaning," the group said, "when accessing such insurance means up to $5,000, $10,000 or more in out of pocket co-payments and deductibles."

Hospital groups seemed pleased with the ruling.

Carolyn F. Scanlan, president and CEO of the Hospital & Healthsystem Association of Pennsylvania, said more people with healthy insurance will lead to a healthier population and leave hospitals with fewer unpaid bills.

Over in New Jersey, Betsy Ryan, president and CEO of that state's hospital association, said the ruling would "allow the much-needed reform of our healthcare system to continue. ... There's widespread agreement that our healthcare system is unsustainable on its current course and changes are needed to make healthcare both high in quality and high in value."

Ralph Muller, CEO of the University of Pennsylvania Health system said the decision was a "pleasant surprise." He said, "I think the act should have been upheld and I'm glad that it was."

If the whole law had been thrown out, he said, "it would have been pure chaos out there."

Throwing out just the individual mandate would have led to a proliferation of insurance plans with widely varying benefits. That would have added to administration costs for hospitals. The health insurance exchanges created in health care reform will lead to more uniform benefits and that will simplify billing, Muller said.

Congressman Chaka Fattah (D-PA) represents one of the poorest congressional districts in the country. He said in a statement, "The impact of President Obama's visionary healthcare reform has already begun to make a positive impact for American families and in every sector of our society. The Supreme Court has said it can no longer be questioned as the law of the land. Now we in the Congress can move ahead to finish the job of providing comprehensive and affordable healthcare for all."

"One of the things that the ruling does is just provide a lot more clarity and certainty for everyone . . . Having things in limbo is toxic to getting things done, said David Grande, a health policy researcher at the University of Pennsylvania. The Supreme Court decision "helps hospitals. It helps doctors. It helps patients know what the future is going to look like. That's a really important thing, to be able to plan for the future."

As implementation moves forward, it will be more difficult for Republicans to repeal portions of the law, he said. "The Republicans may try to nibble away at the margins of some of the provisions of the law," he said. "They've been doing that for the last year but the overall impact on the Affordable Care Act has been minimal."

Administrative changes that have been put on hold while awaiting the Supreme Court decision will now move forward, said Mark Pauly, a health economist at the University of Pennsylvania's Wharton School. "I think we're kind of back to where we started when health reform was passed.Now we have to see about moving ahead. This potential detour has been avoided."

One likely future political issue - the cost - may not emerge until full implementation of the bill in 2014. Pauly estimated the cost of expanding Medicaid and subsidizing lower-income people in the private market at $200 billion a year.

He said states would be "foolish" to turn down federal money for expansion of Medicaid.

Ezekiel Emanuel, a University of Pennsylvania bioethicist and former White House policy advisor, said an analysis by the president's Council of Economic Advisors found that most states would save money by expanding Medicaid. States now pay for the cost of poor, uninsured patients by compensating hospitals for uncovered care, among other things. The states "might, for ideological reasons, say no to expanding Medicaid," he said, "but from an economic standpoint, they should do it."

- Philadelphia Health Commissioner Donald F. Schwarz said that the court's ruling on Medicaid is of particular relevance in Pennsylvania because the state is paying the full cost of medical coverage for 70,000 people in one state program. They could be covered by the expanded Medicaid program in the reform law. The federal government would then foot all of their insurance bill.

"It is a good deal," Schwarz said. Still, he said, "I worry that politics, partisan politics, would stand in the way. I hope that it wouldn't. People in Pennsylvania historically have been smart about this and have been reasonable in helping [bring] about health insurance for all people."