ACA survival means hospitals should fight for every Medicaid dollar


That was pretty much the only word that came to mind after I learned the U.S. Supreme Court upheld much of the Patient Protection and Affordable Care Act last week. As I wrote in this space not long ago, I expected the opposite outcome, but I also had hoped I was wrong. I'm stunned and thrilled I was.

A lot of hospital finance executives should feel the same way. Hundreds of facilities on the long road toward closing down may have just been granted a reprieve. They may want to consider putting photos of U.S. Chief Justice John G. Roberts on their walls.

How tough is the current financial environment? Rebecca Black, a vice president of revenue cycle for Saint Joseph's/Emory Healthcare in Atlanta, told an audience at the Healthcare Financial Management Association's ANI conference in Las Vegas last week that she appeals claims denials for as little as $50.

"Some (providers) let something slide if it's under $1,000. I don't ... it's a matter of principle," Black said.

This is Emory we're talking about. Not exactly a bunch of struggling critical access facilities. Yet every dollar counts.

That Roberts decided to be the lone conservative to side with ACA may boil down to a single issue: Unlike the other right-wing members of the court, he's not adamantine. He would never huffily read a dissent from the bench insisting we must throw 14-year-olds in prison for the rest of their lives and that his colleagues didn't have the authority to say otherwise (Samuel Alito). Roberts never appears resolutely hostile and disengaged (Clarence Thomas). He politely asks questions during oral arguments and doesn't treat highly accomplished attorneys like they just stumbled into law school (Antonin Scalia). And he decided not to testily declare that the United States needed to continue to be the only industrialized nation on earth without some form of universal healthcare (Everyone mentioned previously, and Anthony Kennedy).

Roberts also has a legacy to protect. And unlike his predecessor, William Rehnquist, he didn't want it to have anything to do with putting stripes on his sleeves like the Lord High Chancellor character in the Gilbert and Sullivan opera "Iolanthe."

As I wrote here more than two years ago, after the ACA was signed into law, the nation's conservatives grumbled like a bunch of schoolyard bullies rooked of their lunch money. Now they're groaning like their hand-picked headmaster decided the underclassman should keep that change after all.

I suggest they peruse their Supreme Court history more closely. Roberts is part of a 60-year legacy of justices appointed by conservative presidents who veered out of their right-of-center grooves. William Brennan, David Souter and John Paul Stevens are among their brethren. Oh--I almost forgot Earl Warren.

The conservatives are fond of quoting and following the intentions of the founding fathers, part of the "originalism" they (and the Supreme Court justices) use to make sure what they believe are radical changes never occur.

In the meantime, there is going to be an after-school back-alley brawl over Medicaid. The court's decision leaves states to do as they please as to whether they would accept hundreds of billions of dollars from the federal government to expand the program.

Turning down the money won't look good. But more than half of the states' attorneys general sued to get the ACA overturned. Expect some of them--including Georgia, where Emory is based--to dig in their heels. And as I've spoken to some people knowledgeable about this issue, it would seem likely that many poor people might migrate to nearby states to obtain Medicaid coverage. That should thrill those redder regimes that have embraced "self-deportation" to no end.

If that's the case, hospital finance executives should waste no time getting their regional and state lobbies to ramp up the arguments for getting those Medicaid funds. Even if they spend a million dollars here or there to pressure the right politicians to carry the day, it will be worth it in the long run.

After all, isn't that what the Citizens United decision was for? - Ron (@FierceHealth)