A growing number of health experts are warning of potential collateral damage if the Supreme Court strikes down the entire 2010 Affordable Care Act: potential chaos in the Medicare program.
"The Affordable Care Act has become part and parcel of the Medicare system, encouraging providers to deliver better, more integrated, better coordinated care, at lower cost," says Judy Feder, a public policy professor at Georgetown University and former Clinton administration health official. "To all of a sudden eliminate that would be highly disruptive."
Sara Rosenbaum, a professor of health law and policy at George Washington University, puts it a bit more bluntly: "We could find ourselves at kind of a grand stopping point for the entire health care system."
And it's not just Democrats warning of potential problems. Gail Wilensky, who ran Medicare and Medicaid under President George H.W. Bush, says she doesn't think it's likely that the court will strike down the entire health law. But if it does, she says, "it seems like it takes everything with it, including those aspects that are only very peripherally related to the expansion of coverage."
So why are experts so worried?
One reason is that the law changed the payment rates for just about every type of health care professional who treats Medicare patients. Every time Medicare sets a payment rate, it needs to cite a legal authority. And for the past two years, says Rosenbaum, that legal authority has been the Affordable Care Act.
So if the law is found unconstitutional, she says, every one of those changes "doesn't exist anymore because the law doesn't exist."
And the result? "You have agencies sitting on two years of policies that are up in smoke," she says. "Hospitals might not get paid. Nursing homes might not get paid. Doctors might not get paid. Changes in coverage that have begun to take effect for the elderly, closing the doughnut hole might not happen. We don't know."
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