Why Historic SCOTUS Case Doesn’t Really Matter For Massachusetts

The health care battle that begins this morning at the U.S. Supreme Court is one of the most important of our lifetime. But the direct effect on Massachusetts, which created the framework for the federal Affordable Care Act (ACA), is minimal, at best.

“The real bottom line is that consequences for Massachusetts are not that great, except the extent to which we care about the uninsured in the rest of the country,” says Harvard School of Public Health professor John McDonough.

Here are the main issues before the high court as they pertain to the Commonwealth:

1) The Individual Mandate — The question for the high court is whether the requirement that residents have health insurance is constitutional. But either way, it is already part of state law in Massachusetts and would stand regardless of what the Supreme Court decides. A related provision, that says residents can’t be denied insurance if they have a pre-existing condition, is also already in state law.

2) Can the ACA stand without the Individual Mandate? – Again, this doesn’t matter for Massachusetts. Harvard Law School professor Lawrence Tribe says: “There are no legal issues before the Court in which a decision would either trump the Massachusetts law or compel a review of that law.”

Massachusetts residents would lose some additional benefits provided by the federal law such as preventive care with no copays and coverage for dependent children up to age 26 (this is in the state law but state law doesn’t apply to self-insured, usually large, employers).

3) What if the justices decide the federal government can’t force states to expand coverage for low income residents? Massachusetts is doing this voluntarily and Health Care Connector director Glen Shor says he doesn’t expect that will change. “Public support for health care reform has remained strong in Massachusetts because it is based on the facts,” says Shor. The law, Shor argues, “can weather many a political storm because, at its core, it is making people’s lives better in Massachusetts.”

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  • Martha Bebinger

    Hi Josh – on #2 – I asked several administration officials about the
    cost impact if the ACA is overturned altogether and they suggested it
    would not be significant.  Do you have an estimate?

    On #3 – what I am hearing is that the move towards ACOs will continue in
    Massachusetts, independent of what happens with the ACA, driven by
    changes in the state market and the expected legislation.

    Thanks again!

  • Momajob

    The real answer is that Massachusetts, as a state, has police powers while the Federal Government doesn’t — it can only regulate economic activity that substantially effects interstate commerce in the aggregate.SCOTUS is deciding the limits of federal authority under the commerce clause, not the police powers of state. A decision one way or another on the Obamacare means nothing to MA. 

  • Cha

    What about currently uninsured people from NH visiting MA emergency rooms? Presumably those uninsured NH people would be insured under the federal ACA?

    • Martha Bebinger

      Hi Cha – yes, there are some hospitals on the border that would hopefully see fewer uninsured, out of state, patients.

      Thanks for your comment.

  • Laura Cohen

    I think it is a little misleading to say that the SCOTUS decision doesn’t really matter for MA because the state benefits from the ACA and these benefits are beyond what is in Chapter 58:
    1. MA stands to receive a significant increase in federal dollars under the ACA because of the enhanced Medicaid match rate ($1.8 billion between 2014-19) and federal premium subsidies ($125 million). We haven’t received this money yet (2014) but I would think the additional funding would help alleviate some of the state cost concerns. 2. Also, the article doesn’t mention the great number of MA residents who no longer have lifetime limits as a result of the ACA: 2,520,000 (912,000 men 19-64; 975,000 women 19-64 and 633,000 children). If you look at CPS data from 2009-2010, there were 5,635,900 children and non-elderly adults so almost 45% of that population benefited. I don’t think that is insignificant gain. 

    • Martha Bebinger

      Hi Laura – thanks very much for your note. 

      On the enhanced Medicaid match, is this above what Massachusetts would expect to receive?  I’m wondering because I asked several state officials about the financial impact and they said we would not see a significant hit.  I’ll ask again.

      On the lifetime limits, you are referring individuals in self-insured plans, yes?  I was told that most of the self-insured plans here don’t include the lifetime limits, although they are allowed.  What is CPS data? 

      Thanks again for any clarification you can provide.

      • Laura Cohen

        Hi Martha-

        The enhanced Medicaid match under the ACA would result in an additional $1.8 billion to MA between 2014-2019- that is according to a report put out by the UMass Center for Health Law and Economics called “Re-Reforming Reform.” So my assumption is that if the SC decides that Congress is “coercing” the states to accept the Medicaid expansion and strike the expansion from the law, MA would loose that additional money. However, I’m by no means an expert at all on Medicaid funding so I could be wrong about how much of an impact that additional funding could have for the state. 

        In terms of the lifetime limits: Chapter 58 didn’t eliminate all lifetime or annual bans in state plans.  Here is a great article from the MA Bar Association on the difference between how Chapter 58 and the ACA deal with lifetime and annual limits: http://www.massbar.org/publications/lawyers-journal/2011/june/protecting-consumers-the-elimination-of-lifetime-and-annual-limits-on-health-insurance-benefits. 

        However, I too was under the impression that most self-insured plans in MA voluntarily comply with the state’s consumer protection laws so I’m not sure how to reconcile that fact with the data from the White House (that is where the 2.5 million MA residents with no lifetime limits as a result of the ACA comes from- you can access the data here: http://www.whitehouse.gov/blog/2012/03/05/new-data-affordable-care-act-your-state). Perhaps they only looked at the number of residents with self-insured plans and assumed that all self-insured plans had lifetime limits?

        CPS stands Current Population Survey Data and that is where I got the total number of children and non-elderly adults in MA. Here is a link to that: http://www.statehealthfacts.org/profileind.jsp?cmprgn=1&cat=1&rgn=23&ind=2&sub=1.  

        Hope this helps! 

  • http://twitter.com/josharchambault Josh Archambault

    #2 makes a difference
    from a state budget perspective, and for the Connector. The Feds pick up a much
    larger percentage of the cost under ACA for these expansion categories. The Connector loses
    the fees from roughly 100,000 lives. Additionally, without getting into the administrative weeds, I
    think the Connector is a much better administrator and is more transparent
    compared to the MassHealth office. In my mind, that has policy implications going forward.


    #3- Only time will tell.
    But if you have small margins now because of a down economy and reductions
    in public reimbursements, do you want to make very expensive upgrades and
    system changes if they are not required by law? The fate of the ACA impacts the
    system delivery conversation directly.

    Of course, our attention
    would refocus on what the legislature would require under a payment reform bill
    here in the state, but that is another discussion.

    I would be very
    interested to hear why you think otherwise?


  • Martha Bebinger

    Hi Josh – thanks for your comments – always great to hear from you.  On #2 – do you think it matters if these folks are in Masshealth or Comm Care?  On #3 – it seems like some of these changes will continue in MA regardless of what happens with the ACA – do you agree?
    Best -

  • http://twitter.com/josharchambault Josh Archambault


    Just for the sake of conversation, I slightly
    disagree with John here. I think the issue is more complex, and largely depends
    on how much the Court acts to strike down certain portions of the law. 


    The future of the law would make a big
    difference at:

    1) The Connector (just ask the staff working
    long hours to bring it into compliance and the Board worrying about being
    sustainable under ACA)

    2) Our Medicaid program (100,000 new enrollees
    transferred over from Commcare)

    3) Hospitals in Massachusetts. (Trying to
    prepare for ACA regulations, ACOs, and large Medicare cuts)

    4) Medical device companies (Preparing for a significant
    tax increase on their products.)


    With that being said, John is right that if the
    mandate is struck down along with the “insurance reforms” it would make little
    difference here in Massachusetts, but that is not the only section of the
    law being debated. I think it is slightly too simple to say the ruling has
    “not that great” an impact on our state, the flurry of action in the
    public and private sector over the last couple years says otherwise.