SCOTUS Decision: What Now?

The Supreme Court’s decision to uphold the Individual Mandate and limit Federal powers associated with Medicaid expansion is officially old news. There is no doubt that the decision will have sweeping ramifications for consumers, state officials, employers and health care providers, including hospitals and doctors.

Breakdown of The Decisions


What's Next For Small Business?

To use a baseball analogy, at best we are in the 3rd inning of the longest game in history.  There are entirely too many nuances, details and variables rendering precise predictions impossible.  We know now that the major impact of the SCOTUS decisions will be at the state level where political powers will square off on whether to expand state run Medicaid programs. 

Missouri and Illinois sit at polar opposites of the political spectrum.  As a result, it is plausible that the Mississippi River could draw a line between two very different approaches to serving low-income Americans.  These are the same low-income Americans that may have the opportunity to leave their employer sponsored plans for subsidized insurance through the state.  Employer groups with over 50 employees concerned about being fined for their low-income employees opting into the state plan may have less risk.  Conversely, employee groups under 50 employees hoping to desolve their employer sponsored plans in lieu of their employees gaining coverage through the state may now be more challenged.  The SCOTUS decision was less than 36 hours old when this post was written...much too young for knee jerk reactions in either direction.    

Today, much like earlier in the week, we continue down the path of implementing the Affordable Care Act.  Below is a listing of the major provisions scheduled over the next four years.


  • Medicare hospital value-based purchasing program
  • Increase in physician quality reporting requirements in Medicare
  • Additional Medicare pilot programs such as accountable care organizations
  • Increased requirements for hospitals to maintain not-for-profit status
  • Fees from insured (including self-insured) plans transferred to the Patient-Centered Outcomes Research Trust Fund


  • Increase Medicare payroll tax by 0.9% on high-income earners
  • Impose a 3.8% tax on net investment income of high-income individuals
  • New $500,000 cap on health insurers’ deduction for executive compensation  
  • Elimination of employer deduction for Medicare Part D subsidy
  • FSA limitations
  • Excise tax on medical device manufacturers and importers
  • Medical expense deduction floor increases to 10%  
  • Nationwide bundled payment pilot begins in Medicare
  • Increased Medicaid reimbursement for primary care
  • Medicare physician comparison data available to the public
  • Reductions in Medicare payments for select hospital readmissions
  • Expanded coverage of preventive services by Medicaid


  • Employer mandate and individual mandate
  • Employer and insurer reporting requirements
  • Federal minimum benefits standards are enforced
  • State health insurance Exchanges established
  • Premium tax credits and cost-sharing subsidies available to certain individuals in Exchange insurance products
  • Medicaid expansion to new populations (100% federal match to states for newly-eligible populations through 2016)
  • Annual fee on health insurers
  • Medicare/Medicaid DSH payment cuts begin
  • Independent Payment Advisory Board (IPAB) issues first report to Congress if Medicare spending exceeds growth target


  • Excise tax on high-cost employer-sponsored coverage