Todays Supreme Court ruling on the Patient Protection and Affordable Care Act of 2010 advances the broad effort to extend health-care coverage and control medical costs, though it raises questions about how certain provisions of the policy will be implemented, Stanford University School of Medicine experts said. Here are some initial comments on the courts landmark decision.

-Jay Bhattacharya, MD, PhD, associate professor of medicine and a member of the Stanford Center for Health Policy/Center for Primary Care and Outcomes Research:

Barring legislative action to amend it, the law will be enacted over the coming years, though perhaps not exactly as envisioned. Despite the positive ruling, today’s ruling has at least two important implications for health policy.

First, the ruling empowers state governments to take an active role in delaying or preventing implementation of the key provisions of the law. In particular, states now have the power to turn down additional Medicaid funding provided by the law and not risk losing existing Medicaid funds. Cash-strapped states will almost certainly consider this option since they will ultimately be on the hook for financing at least a portion of this expansion. Medicaid is supposed to cover 20 million of the 35 million people who will gain insurance under ACA. If enough states decide to deny the Medicaid expansion, this may substantially reduce the ability of ACA to expand insurance coverage.

Second, the court has ruled that the ACA can impose a tax on people who opt to not buy insurance, as opposed to requiring people to buy it. From a policy point of view, this is important because without the mandate, the state health insurance exchanges have no chance of working. Without the mandate, it would have been possible for healthy people to not buy insurance until they became ill. Financing health insurance for the 15 million people who will gain insurance through the exchanges depends on more or less forcing relatively young and healthy to pay for the relatively older and unhealthy. The law, as envisioned, thus requires a large-scale redistribution of money through this mechanism. There’s still an open question of whether the penalty for not signing up for insurance is large enough to deter people from waiting until they are sick to sign up for insurance.

Overall, the ruling will make the implementation of the ACA a bit more difficult. While the federal government’s role in health policy remains undiminished, the ruling places more power in the hands of the states.

Bhattacharya is a health economist, who has a specific interest in vulnerable populations, the decisions they face that affect their health status and the effects of government policies and programs designed to benefit them.

-Laurence Baker, PhD, professor of health policy and research, chief of health services research and a fellow at the Stanford Center for Health Policy/Center for Primary Care and Outcomes Research:

This is a ruling Republicans and Democrats could come to appreciate. Politics aside, upholding the individual mandate and the insurance reforms associated with it positions the U.S. health-care system for advances centered around individual choice and market-based solutions. Working within the structures of reformed market mechanisms offers a path to improvement in our health-care system that emphasizes the individual choices Americans have cherished, while emphasizing individual responsibility. Restricting the Medicaid expansion further emphasizes this.

In the history of health reforms across countries, including the U.S. Medicare program, it is common to find reforms that generate vigorous debate at the time they are passed, but come to be valued by the population. There is every reason to believe this could be the same. It moves our system in a positive direction, and that will take some significant efforts, but it does so with what are in the grand scheme of things reasonable and measured changes.

Originally posted here: