Like many others I was glued to the TV set in my hotel room waiting for the news from the US Supreme Court about the Patient Protection and Affordable Care Act Mandate. I had predicted it would be rejected under the Commerce rules (i.e., which did happen), but I was surprised that it was upheld in terms of the Tax rules. Although presented by the Administration as anything but a tax when passed, their arguments at the US Supreme Court caught traction with the justices leading to a victory for the Administration. It truly was a surprise, and in the words of Gomer Pyle "Surprise, surprise, surprise!"

Once the dust settles I also believe that it will be a pleasant surprise for all of us. Without the mandate, our attempts at health care reform were destined for failure under the Patient Protection and Affordable Care Act reform bill. "Hall Passes" to some hurt everyone. Unless everyone is included in the reformed system (i.e., universality), the likely outcome for Patient Protection and Affordable Care Act is dismal. I don't agree with everything that is in the bill in the first place, but it does include several serious attempts at trying to get a control on our escalating health care costs. Without this our country is faced with a serious economic challenge. I dislike being told what to do by the government, but sometimes I don't want to do what I should do.

What will the near-term impact be?

• Escalated implementation of exchanges and move to a new way of getting coverage
• Most likely higher near term costs as carriers reveal their uncertainty of the future costs
• Higher provider costs as providers become increasingly concerned about the burgeoning Medicaid population as many more are transitioned to Medicaid coverage
• Expansion of existing initiatives to reduce the cost of care and improve quality (e.g., the Oregon Coordinated Care Organizations, ACOs, and other value based reimbursement initiatives)
• Increased scrutiny by employers whether they should terminate their plans, particularly in industries with significant part-time employees
• Increased exporting of manufacturing to other countries to minimize costs
• Greater focus by the hospital community to validate their capacity and potentially reduce resources to improve cost effectiveness
• Increased transition to self-funded programs to avoid some of the requirements of the Patient Protection and Affordable Care Act Mandate

For me, both personally and professionally, I am glad the mandate survived. I continue to wish that the Patient Protection and Affordable Care Act had better provisions to improve the affordability of health care, but it does take dramatic steps towards that even though they are buried in the 2000+ pages.

I hope it is enough, but am not as optimistic as I would like to be. The affordability equation is both a personal one (i.e., how much do I have to pay) and also a national one (i.e., how much can we afford in terms of GDP). Right now we are quickly approaching a cliff where none of us will be able to afford the system. With economic improvement (i.e., GDP growth) we will be able to push the edge of the cliff a few years out while we figure this problem out. So let's get the economy going and hope for the best!