The politics, business and delivery of health care underwent a permanent, seismic shift in 2010. Whether or not you are a supporter of the Affordable Care Act (ACA), there is little debate that it was a game changer. It altered the way in which we as a country approach the challenges we have faced for years in ensuring the delivery of health care services to our population.

The ACA — the argument goes — was passed to lower health care costs, improve access and quality, promote transparency, and bridge the chasm that exists between the health care “haves” and the “have-nots.” All are worthy and laudable goals, to be sure. Depending on whom you speak with, evidence exists that both supports and contradicts the idea that the ACA will actually accomplish this. What we know for sure is that the ACA jump started a nation-wide initiative to improve quality and lower cost, whether through the adoption of Accountable Care Organization (ACO) models, or through a variety of quality and care coordination initiatives that span across the health care continuum. Some were motivated by the desire to achieve clinical excellence — others by the threat of reduced reimbursements from government payers. And the writing is on the wall as it relates to reimbursement: “Do more with less.”

This was the case when the ACA was scored by the Congressional Budget Office (CBO) as a net deficit reducer. Recently, things got really interesting when the CBO provided updated numbers showing that the true ten-year costs of ACA implementation are significantly higher than previously estimated. This puts the ACA in a difficult position as it was sold as a means to provide access to high quality care for the uninsured, while simultaneously reducing the deficit. But this may be the least of the ACA’s worries.

The United States Supreme Court recently heard arguments challenging the constitutionality of the ACA, specifically the individual mandate to purchase insurance. The challengers contend that Congress overstepped its authority by compelling citizens to enter the insurance market. If the individual mandate is found to be unconstitutional, the Supreme Court then has to consider severability, or the ability to sever the individual mandate from the law and what, if any, of the remainder should stand.

Prior to the court hearing, the administration was the odds on favorite to win the case (if you actually listen to political and legal pundits). However, the hearing did not go very well for the Solicitor General who represented the administration, which created a flurry of second guessing as to where the Supreme Court will come down on these issues. The question we must now face is this: If the individual mandate — or the entire ACA — is struck down by the court, will we continue our national movement towards better quality? That is, if the incentives or disincentives are not there, will we be as motivated to achieve significant quality improvement in the delivery of health care?

I believe that the health care paradigm has shifted to the point where nothing — not even Supreme Court opinion — can stop many of the ACA’s initiatives. Our vision of the future in health care has been keenly focused as the result of this legislation and, regardless of whether or not part or all of it stands, we will benefit from this renewed attention on the need for better clinical outcomes and efficiency. No matter where you fall on the ideological spectrum as it relates to healthcare, the ACA, or the role of government in the health care market, this should be something that we can all agree upon.


Aaron Byzak, MBA
Director, Government and Community Affairs
UC San Diego Health System