Over the past 2 years, we have written about the impact of accountable care organizations, value-based purchasing, health insurance exchanges, and other programs relevant to the oncology community. These initiatives were all born out of the Affordable Care Act (ACA), which, on June 28, 2012, had its major day of reckoning. In a 5 to 4 decision authored by Chief Justice John Roberts, the US Supreme Court upheld the ACA’s individual mandate—the requirement that most Americans obtain health insurance that meets the definition of minimum essential coverage.
The Court also issued a fractured opinion on Congress’s authority to expand Medicaid to a larger portion of the population (and Congress’s authority to penalize states that did not wish to participate in the expansion). Although the Court upheld the authority of Congress to expand the Medicaid program to states that wanted to participate, the Court also held that Congress could not withhold existing Medicaid funds from states in an effort to penalize a state’s refusal to participate in the expansion.
What does the decision mean for the oncology community? First and foremost, the path to implementation of the ACA will move forward. Programs that promise to have the most impact on the cost–value debate in oncology will progress: the Independent Payment Advisory Board, the Patient-Centered Outcomes Research Institute, and other cost-saving institutions will continue their task of finding the most value in healthcare dollars. Oncologists can expect their patient pools to rise as millions more Ameri cans gain access to health insurance through state health insurance exchanges.
The question of the future Medicaid expansion, however, looms large in the wake of the decision. Under the ACA, Medicaid eligibility was expanded and simplified, beginning in 2014, by creating an overarching Medicaid eligibility category for all individuals aged <65 years with incomes less than 133% of the federal poverty level who meet citizenship/lawful US status and state residency requirements and who do not meet any of the program’s other multiple categorical groupings. Although the Court ruled that Con - gress is allowed to expand Medicaid to cover the new population under Congress’s spending powers, a majority also ruled that states that do not wish to participate in the Medicaid expansion cannot be penalized for this decision by having their existing Medicaid funds withheld.
It remains unclear whether states will proceed with the planned expansion or opt for a smaller Medicaid population. On the one hand, the direct cost to states in expanding eligibility is limited because the federal government will fund the vast majority of these costs. On the other hand, 6 Republican governors have already publicly stated that they will opt out of the expansion. Whether this is political posturing or a political reality remains to be seen. What is clear, however, is that until the issue of the Medicaid expansion is solidified, oncology providers and manufacturers remain in limbo.
The expansion offers an extended patient population (albeit with a lessthan- generous payer) and a more simplified eligibility system. Should several states begin to opt out of the expansion, this national eligibility system will become a patchwork of different eligibility standards and a headache for oncologists. Guidance is expected from the Centers for Medicare & Medicaid Services in the coming months, which will provide answers to many of these questions. The ultimate decision of whether a state will participate in the expansion, however, may not come for some time.
