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.