The culmination and uncertain future of healthcare reform

My daughter had her culmination from elementary school on Monday. The graduates sang a song wondering aloud how they'd fare and if they'd make something of themselves. It's a tough concept for a bunch of 10-year-olds to be confronted with. However, it makes as much sense for these times as my 1970s-era culmination, when we all danced to the musical version of a leisure suit: Hot Butter's "Popcorn."

The healthcare sector is facing a similar culmination and doubts about its future when the U.S. Supreme Court rules on the constitutionality of the Patient Protection and Affordable Care Act. Healthcare delivery irrevocably changed with the passage of the ACA. It will change again when the ruling is made.

I like to think I'm an optimist regarding the survival of healthcare reform, but the hostility aired by the High Court during oral arguments to Solicitor General Donald B. Verrilli's presentation of facts makes me a doubter it will survive. Justices Antonin Scalia and Clarence Thomas will not support the ACA under any circumstances, and its fate hinges on two or three equally conservative votes.

Moreover, there is an uncomfortable reality that has been woefully underreported in the press. Barack Obama won the presidency in 2008 in part by out-fundraising the GOP. It seems to me that the conservative bloc on the court--which does more than its share of palling-around with right-wing groups--was buttonholed by their buddies in those circles to make sure that that fundraising gap would not repeat itself. The result was the Citizens United decision, an uncomfortable overreach by the Court that looks way too convenient to have not been politically motivated. And those same circles are far more vehement when it comes to the ACA.

What will healthcare and its financial component look like should the ACA get thrown out? The impending train wreck that was in place before it got passed. Although reform lacked serious cost controls, it had enough of a superstructure to tack them on later after it became more popular with the public. And while some insurers said they would retain the more popular facets of the ACA--such as allowing children to remain on their policies until the age of 26--none of them will make enough of a difference to matter in the long term.

The Centers for Disease Control and Prevention recently reported that 58 million Americans were uninsured at least for some part of last year, and there is absolutely every reason to expect that number will continue to increase. Employers had planned to shift many of their employees into the exchanges staring in 2014. Absent reform, its subsidies for purchasing coverage and the ability to piggyback cost controls down the line, many of these workers will eventually just lose their healthcare coverage completely.

Hospitals will be hit with a double whammy--not only continuing to treat the ever-growing ranks of uninsured but also the loss of the hundreds of billions of dollars that would have come as the result of the ambitious expansion of Medicaid incorporated into the ACA. If reform is tossed out, I wouldn't be the least bit surprised if this decade ended with 500 fewer facilities in the American Hospital Association's directory than at its start.

The only upside is that the continuing cost and coverage spiral healthcare delivery will be dumped into will all but require a single-payer solution. However, it will be decades of mortal political combat before that comes to pass.

I sincerely hope I am wrong about all of this. In fact, nothing would make me happier than to have this column make me look like an utter fool. But the Supreme Court has become a radical body, and has made radical decisions for more than a decade now. A majority of its members perform their jobs with little care for the long-term consequences of their actions, and know they have absolutely no accountability.

My daughter, who has long aspired to be pediatrician and has the intellectual chops to do so, is indeed stepping into the future. What kind of future that is will become much clearer any day now. - Ron (@FierceHealth)