Arizona Horizon Banner

June 21, 2012

Host: Ted Simons

Affordable Care Act

  |   Video
  • Health care expert Susan Gerard explains what’s at stake for Arizonans as the U.S. Supreme Court prepares to release its ruling on the Affordable Care Act.
  • Susan Gerard - Health care expert
Category: Medical/Health   |   Keywords: medical, health, act, affordable, care, ,

View Transcript
Ted Simons: By most accounts the biggest case the U.S. Supreme Court's current term is the legal challenge to the affordable care act. Here to talk about what's at stake for Arizona in that case is someone who has quite a resume when it comes to health policy in this state. Susan Gerard has served as a policy maker, direct of Arizona department of health. She now chairs the public health law review for the Robert wood Johnson foundation and serves on the board of the Maricopa integrated health care system. Thanks for joining us. We appreciate it. Trying to figure out what's going to happen once the Supreme Court decision comes down. Let's take it through steps. What happens if the law in its entirety is upheld?

Susan Gerard: Oh, I hadn't even thought of that. [laughter] Well, then we will have to move forward on a lot of front.

Ted Simons: That that means by 2014 most folks would be insured in some way, shape or form.

Susan Gerard: Right. I mean, that's what the plan is. Still even if the law is upheld you still need Congress to propose rate the money because a number of provisions are costly, and also states because of the Medicaid expansions, they also are going to have to fund big chunk of money.

Ted Simons: Arizona is working as well on a health insurance market, correct?

Susan Gerard: Right. Well, that was part of the healthcare reform, the health exchanges. They were given a nice bit of money, I think close to $30 million, Arizona alone got, to develop the program.

Ted Simons: So we would be a little bit ahead of the game there if the entire law is upheld?

Susan Gerard: That's why move forward because it takes a long time to set this up. I would say most states have moved forward at different rates of speed to do that.

Ted Simons: Okay. So what happens now if the entire law is struck down? How does that affect Arizonans?

Susan Gerard: Well, first of all I think it's interesting because I think some of the things that are in there are going to happen anyway because the market is moving in that direction. But then all the things that cost money are not going to move forward. That is I think especially going to be a problem when you couple that with the cutbacks we have already had in Medicaid in our state is how long can health-care providers especially safety net providers continue to provide care at that rate of uncompensated care. In hospitals it's increased by 88%. So everybody is like treading water thinking that we just have to get through to 2014 and we'll suffer along, but if they overturn it it's a game changer for all health-care providers to figure out what they are going to do.

Ted Simons: Are health-care providers preparing for that game changer?

Susan Gerard: I think you're starting to see some changes, but quite honestly I think most of the changes I have observed, especially with hospitals, is preparing for everyone having insurance in 2014. But no, actually I think we're not going to be ready the more I think about it.

Ted Simons: You're talking no obligation to keep any of the new benefits. If it's struck down it's life as we have had it. What you're saying is there are things that will likely parts of this that will come into being in one way, shape or form?

Susan Gerard: One of the big things is the way the market is moving with this whole accountable care organization, ACOs, more integrated health care models. That was part of the requirement. The computerized medical records. Everybody's moving in that direction anyway. That's not going to change. The rate of change might slow because you're not going to have the resources to do it. I think insurance companies will continue to allow children to the age of 26 to stay on their parents' policies. The exchanges are still a good thing even if you're not getting money to help them to allow people to go to a central marketplace so they can compare insurance. But anything that costs money such as the Medicaid expansion, closing of the doughnut hole for senior citizens with prescription medications, changes like lifetime benefits that used to be limited so people in the middle of cancer care -- I think a lot of people don't realize how many good things were in health care reform. They like to focus on the requirement that everyone purchase insurance and the Medicaid expansion that's going to cost states money. There's a lot of other things in there that benefit seniors and just regular people.

Ted Simons: Talk about this individual mandate. What if that is the only part of the affordable care act that is struck down? What happens?

Susan Gerard: I think that's still -- I think a lot of it can go on, but that was where the big chunk of money was going to come to do a lot of these other things. So I think it's going to require them to kind of cut back or they have to come up with other ways to finance it.

Ted Simons: The impact on the market as far as individuals are concerned, major, if the individual mandate is struck down and everything else stays -- that's basically the big gorilla, isn't it?

Susan Gerard: It is. It is.

Ted Simons: Okay. What happens if the individual mandate and preexisting conditions -- stick with preexisting conditions. What happens if those two aspects are cut down? Stick with individual mandate and something else are struck down. What happens to the average Arizonan?

Susan Gerard: Well, probably the average Arizonan not much. But if you're one of those people with preexisting conditions or you're self-employed and have some chronic illness, you can't get insurance. So many low income people that cannot afford to get insurance. Those are the people that lose and we have a disproportionate share of people that live below the poverty line in our state. So those single adults that got cut by the state last year will continue not to have coverage.

Ted Simons: Wouldn't the average Arizonan not see -- we keep hearing about a jump in premiums possible if the law is upheld, we wouldn't necessarily see that if individual mandate and preexisting conditions were struck down?

Susan Gerard: Well, it's a combination. Preexisting condition is putting that population into your pool of insured can increase the cost for every individual, but if you bring in all those young people that currently maybe aren't purchasing insurance so you get that amount of money to come in, then that can decrease the premiums for everybody.

Ted Simons: Okay. So not necessarily a jump then.

Susan Gerard: Right.

Ted Simons: Medicaid expansion. What if that is the only thing? I'm trying to get all the possibilities covered. If that's struck down everything else stays.

Susan Gerard: That's very interesting. Does that mean that all those people then could get picked up on the other -- either in the pool for the high risk pool or the or get insurance through the exchanges and getting it subsidized? Less expensive to do through Medicaid but then it's a matter of who is paying the bill. Is it the federal government or state government.

Ted Simons: So there are different ramifications for every possibility.

Susan Gerard: Sure.

Ted Simons: Bottom line, say again back to the whole thing failing, the whole thing surviving, the whole thing failing, reform is still needed, is it not?

Susan Gerard: Oh, yes.

Ted Simons: And people realize that?

Susan Gerard: I think people do, but as we started off before on air, it's such a complicated -- I hate the word system because we have a very -- it's all spread out, it doesn't really make any sense. That's why people can't understand it because the way it grew it's all patched together. So I don't think people -- people really just understand how it affects them.

Ted Simons: And if it survives, if it's completely upheld, but say it does happen, there would still be reform needed as well as far as the healthcare act is concerned.

Susan Gerard: Right.

Ted Simons: Will we see it?

Susan Gerard: I doubt it.

Ted Simons: So we're just -- are we just muddling along as far as reform is concerned?

Susan Gerard: Sure. This affordable care act isn't all that needs to be done either. A lot of people think, we passed a bill, we're done. We're not done. We need to really change a lot of things in how our system works and doesn't work.

Ted Simons: All right. Great information. Good having you here. Thanks for joining us. We appreciate it.

Legal Briefs: Executive Privilege & Supreme Court Opinions

  |   Video
  • ASU law professor Paul Bender, an expert in constitutional law, explains “executive privilege”, a power President Obama invoked this week to avoid turning over to Congress certain Justice Department documents related to the botched anti-gun smuggling operation known as “Fast and Furious”. And, as the nation awaits U.S. Supreme court rulings on SB 1070 and the Affordable Care Act, Bender explains the High Court’s process for issuing opinions.
  • Paul Bender - Professor of Law, ASU
Category: Law   |   Keywords: ASU, professors, law, Bender, Supreme court, opinion, ,

View Transcript
Ted Simons: We're still waiting for the Supreme Court to issue opinions on cases involving Arizona's SB1070 and President Obama's health reform law known as the affordable care act. An article in the Arizona Republic explained how the high court goes about issuing its opinions. Here with more is ASU law professor Paul Bender, who has worked and argued cases before the U.S. Supreme Court. Thanks for joining us. Why have we not had an SB1070 ruling yet?

Paul Bender: The case was just argued at the end of April, and it usually takes two or three months for the Supreme Court to prepare an opinion in a case because especially a case where there's dissent, and I think there will be dissent no matter which way it comes out, because somebody is assigned the majority opinion and they may take a long time writing it. Then they circulate it, then the people who are going to dissent read that and write their dissent. Then people who write the majority opinion may want to respond to that and there may be a lot of negotiation between justices, say you write the majority opinion I'm part of the majority, I say, I don't like that paragraph. I can't join it if you leave that in. That kind of thing happens. The same thing can happen with the dissent although it's not as important F. you don't like mine go write your own. It's important because that's the law. So they can be a lot of bickering about that kind of thing. So in fact it's a very short time for SB1070 because it has to come out before the end of the term F. it didn't have to come out before the end of the term it would probably come out in the summer, fall. But the U.S. Supreme Court unlike the Arizona Supreme Court has fixed terms. They start in the first week in October and start hearing arguments. Every case they hear argued from that time on they promise that they will decide by the time they recess for the summer. They usually recess for the summer at the end of June. So that creates a backup. We have every case that's been argued has to be decided probably by the end of next week, more likely by Wednesday or Thursday of next week. So you always have bunch off pins waiting at the end.

Ted Simons: Is it possible the healthcare act SB1070 and other cases have been decided, opinions have been written, but they are waiting to release them?

Paul Bender: Well, of course they have been decided although it's tentative until it comes down and of course opinions have been written. I don't think anybody is still writing a majority opinion with one week left in the term. But you're waiting until everybody on the court is satisfied to let the opinion come down. As soon as everybody is finished it will come down, but with a case with a lot of different opinions and a lot of acrimony, the process of fin finishing can take a lot of time.

Ted Simons: SB1070 where there are separate parts, that would add to the complications?

Paul Bender: Opinions have tended to get longer. When I was a law clerk, the that my justice, justice Frankfurter wrote, they came out quickly because he worked quickly. If he was going to do something himself he would say I'll take this one and two days last he would have a draft. If you're a law clerk and somebody said, you want to write a Supreme Court opinion, you're not going to do that in a week or two. You're going to take a long time and think about it. In chambers where the law clerk writes the first draft it takes a long time N. most cases a law clerk writes the first draft.

Ted Simons: Interesting. How much does the court consider the possible impact of a ruling in terms of what is released, how it's released?

Paul Bender: Well, how is always the same. They announce it in court. They used to read their opinions. It could take all day. Some read the footnotes. Some time ago they changed. Now they make usually very, very brief announcements. Sometimes when someone is really angry or really cares they may spend a few minutes more. It's always done that way. Whether they time opinions to come down at a certain time, I don't think so. I don't think they think that way, hey -- they don't do things on Fridays. They just -- that's their tradition lately. It's going to be Monday through Thursday. I don't think they care whether it is. More importantly, I think they now are reluctant to hand down two or three really important opinions on the same day because that's unfair to the media. For example, with the affordable care act and 1070, I would suspect they are not going to come down the same day. They will come down on different days. That may be deliberate to make sure they don't put the media in a position of having to write about two really important cases in a short period of time.

Ted Simons: Which would come first, do you think?

Paul Bender: Of those two? Since SB1070 was the last case argued in the term and I'm pretty sure it's fairly contentious, I would think the chances are it will be the last case. But you never can tell. It all depends when the opinion finished, who is writing. Very personal matter.

Ted Simons: From a distance we all see something very formal going on with papers being passed and what do you think about this, how do you think about that, please ask the justice to do this. Is it that way or can it be as personal and informal as a telephone call at night?

Paul Bender: You mean the process of writing the opinion?

Ted Simons: Yes.

Paul Bender: It can be anything but my sense is that especially because law clerks are writing the first draft, law clerks are not going to go collaborate with other law clerks. Most justices tell them not to. I don't think there's very much collaboration when opinions are first developed. There was a time when there was more that justice Brennan for example used to to get votes fort side he wanted would talk to the people on the other side, hey, if I change it this way would you change the opinion? I don't think that happens very much now. I think the opinion preparation is initially a private thing. The justice and the law clerk. But when the opinion is circulated, then another justice may say, I'm with you on everything but not that. So would you please take that out, or you could say this better. Then there gets to be that. But that's more like editing rather than true collaboration. Supposedly they know what each other thinks because at the conference when they decide the case tentatively they say what they think. In the old days, those conferences would go on for a long time, so people would make speeches. I remember one case justice Frankfurter told me he talked for 45 minutes about a case to the other justices. They say very little at the conference. I affirm or I agree. When you're preparing an opinion you don't know what the other justices think except for what they said in oral argument. That's one of the functions oral argument serves. It let's the persons writing the opinion know what the other justices are thinking.

Ted Simons: Does that collaboration change court to court? You mentioned that the initial round may be relatively brief. Everyone knows, but in the past, perhaps in the future, could you have real conversation going there?

Paul Bender: Absolutely. It's very personal. It can change from time to time. For example, I would think justice Kagan is a collaborator. She just seems to be that kind of a person. I would expect she would try to talk to other people more than some other people like I would assume Clarence Thomas is not a collaborator on his opinions. I think justice Breyer probably is. It can turn on which case it is. It can change. But this court I don't think spends a lot of time talking to each other.

Ted Simons: Yeah. That could change.

Paul Bender: Of course. It could change. I think that's too bad. I think the court would be better if there was more collaboration and discussion.

Ted Simons: Before we get to the executive privilege argument, when it comes to SB1070, the affordable care act, do you suspect in to to -- there's fragments all over the place, in general will we be seeing broad opinions? Will we be seeing narrow opinions?

Paul Bender: You can't tell. You really can't tell. They will sometimes come out with broad opinions. These are such broad, delicate cases, probably the chances are that the opinions will be narrow, but if the conservatives, for example, were to get a fifth vote, write a broad opinion, limiting federal legislative power over things like medical insurance, they could write a broad opinion.

Ted Simons: Let's get to this executive privilege, the president invoking executive privilege to shield some Justice Department documents regarding "Fast and Furious." What is executive privilege and how often is this invoked?

Paul Bender: It would be more important to ask is there executive privilege. We know that there is presidential privileges. In the Nixon case, which was a prelude to Nixon resigning, the Supreme Court said Nixon had to divulge certain documents but in saying that it said there's a presumptive privilege of the president with regard to things he said or things said to him. That's not what's going on in the current situation with Eric Holder. The president didn't participate in any of those conversations that they want records of. Nobody knows whether there is a general executive privilege so that executive department can say we don't want to give you this information because we want to keep it confidential. There are some areas where it's clear there is privilege, material that would affect national security and other things like that. Otherwise there's no -- the reason there's no law is because there's very little litigation. The reason there's very -- think about it. House is about to vote to hold Eric Holder in contempt. Supppose they do that. So they refer that prosecution for contempt to who?

Ted Simons: Obviously they can't refer it back to Eric Holder. They refer it to some federal court somewhere?

Paul Bender: No. Has to go to a federal prosecutor. Probably the District of Columbia. He works for Eric Holder. So you don't find too many cases where Congress gets a federal executive department lawyer to sue another member of the executive department for contempt or to charge him with contempt for not turning something over. So that's why there's very little litigation about this and therefore things are usually compromised. Somebody backs down. They both back down.

Ted Simons: What if Congress doesn't back down? They decide to take this as far to a wall as they can and try to get some sort of court decision on this. It almost seems like both sides are not willing to do that because you have too much to lose.

Paul Bender: I think both sides are unwilling to do that. I can't believe Eric Holder will let a United States attorney prosecute him for contempt of Congress. He's the boss.

Ted Simons: There's no other way for that -- [speaking simultaneously]

Paul Bender: It's worked out politically. I think that's probably the best way to work those things out. How would a court -- a court isn't the right person to decide how much of this should be private and how much not. The whole notion that anything should be private presumptively I think is questionable. The Supreme Court said presidential communications are presumptively private because we want to let the president feel free to say things and have things said to him without them being disclosed, but they never said that about any other member of the executive branch. They say it about themselves, that communication between their law clerks and themselves are confident sham, but this case involves discussions within the Justice Department by mid level, maybe high level officials about things. There's no law that makes it clear that that's privileged in any way.

Ted Simons: All right. Interesting stuff. Lots of stuff going on.

Paul Bender: Well, there always is this time of year. Very exciting time of year for people who teach constitutional law.

Ted Simons: Next week a lot of lessons going on.

Paul Bender: School's out.

Ted Simons: Good to have you here. Thanks for joining us.