Archive for October, 2010

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The Insider: Trick-or-Treat – Top Three Must-Reads of the Week

Thursday, October 28th, 2010

Community Catalyst’s “Insider” is much in demand this week, traveling from one end of the country to the other to provide policy insights on children’s health (at the New England Children’s Health Summit in New Hampshire) and health reform implementation at the state level (at Utah Health Policy Project’s annual conference). While next week Hub readers can expect a robust Insider chock-full of analysis of the implications of the election on the ACA, today we’d like to steer you to some of the Insider’s must-read recommendations:

witch pumpkin

1. Myth-busting around the ACA: Saturday’s New York Times editorial does an excellent job of dispelling many of the myths and untruths about the new health law that have reared their ugly head during this election season.

2. Rebutting a myth in the making: An excellent retort to claims by Tennessee Gov. Phil Bredesen (and others) that the ACA will cause employers to drop coverage, written by Adam Searing, Director of the Health Access Coalition at the North Carolina Health Justice Center. (This is a two-parter; the second blog links to the first.)

3. Beyond the political rhetoric – why the ACA matters to Floridians: An outstanding “what it means on the ground” op-ed from Laura Goodhue, Executive Director of Florida CHAIN.

We encourage readers to share these with partner organizations, post them on websites and disseminate them via social media.

Happy Halloween!

– Kathy Melley, Director of Communications channeling Michael Miller, Policy Director

Photo credit: Empirically Grounded

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Village lessons on the dental access crisis: Alaska’s program a potential model for the lower 48

Tuesday, October 26th, 2010

In late August, I found myself in a small conference room in a sub-regional clinic (SRC) in St. Mary’s, Alaska, a village of 549 Yup’ik residents, listening to Bernadette Charles describe how she is working to meet the village’s oral health needs. Not only was her passion for preventing disease and serving her community admirable, her presence in this small village offers policy professionals a promising approach on how to expand dental care to rural and underserved communities.

Oral health is essential to overall health, yet nearly 50 million Americans lack access to a dentist for routine oral health care. There are 4,000 federally designated dental professional shortage areas in the U.S. Nearly 9,700 new dental practitioners are needed to overcome our nation’s dental care shortage. Therefore many communities around the country struggle to attract and retain dental providers. However, St. Mary’s and other Alaska Native communities are leading the way in developing a robust workforce by training providers from their own communities – a potential model for communities across the country that are grappling with a shortage of dental care.

Charles, an Alaska Native who is St. Mary’s first full-time dental provider in almost a decade, is not a dentist but rather a dental therapist, an alternative provider who extends the reach of dentists by providing basic preventive and restorative care under the general supervision of dentists in locations where dentists are not located.

Dental therapists, first deployed in New Zealand in the 1920s, have a long history of providing dental care in community-based settings in 54 countries throughout the world. However, Charles is one of only thirteen dental therapists practicing in the United States.

Charles was trained as part of a program established by the Alaska Native Tribal Health Consortium (ANTHC) to address the longstanding challenges of maintaining an adequate dentist workforce in harsh, rural Alaska.

The impact Charles and her colleagues are making in reducing barriers to care in underserved Alaska is undeniable – dental therapists are now serving nearly 20,000 people in communities that previously did not have dental care providers.

While the success of the practice of dental therapy was evident during my recent trip and is well-established internationally, concerns about the quality of care have been repeatedly raised by those opposing this model. As their major argument against the dental therapist model, organized dentistry claims dental therapists provide lower-quality care, and have expressed safety concerns.

To address any questions regarding the quality of care provided by dental therapists and to document the model’s potential, RTI International of Research Triangle Park, NC conducted an independent evaluation of the Alaskan dental therapy program. W.K. Kellogg Foundation, the Rasmuson Foundation and the Bethel Community Services Foundation funded the evaluation.

The RTI evaluation released today found that dental therapists with two years of intensive training provide safe, competent, appropriate dental care. Other findings include:

– Dental therapists are technically competent to perform the procedures within their scope of work and are doing so safely and appropriately.

– They are consistently working under the general supervision of dentists (at remote locations).

– They are successfully treating cavities and helping to relieve pain for people who often had to wait months or travel hours to seek treatment.

– Patients were very satisfied with the care they received.

– They are well-accepted in tribal villages.

The study of the Alaska program adds to research of programs that have been in place for decades that shows preventive and basic dental repair services provided by dental therapists are safe, high quality, acceptable to the public, and cost-effective.

While the study provides evidence of the efficacy of dental therapists in Alaska, I saw firsthand the impact Bernadette Charles had on her village. She brought regular dental care to St. Mary’s as well as three other villages — Mountain Village (where she grew up), Pilot Station, and Pitka’s Point — all areas in remote Alaska that previously had no care. Before dental therapists like Charles were able to work with their supervising dentists to extend care to remote, rural communities, residents depended on an annual visit from a dentist and irregular itinerant care, or they had to round up residents to fly hundreds of miles to the nearest dental care facility.

Before dental therapists, dental care for Alaskan natives was inefficient and costly. The addition of dental therapists to the dental team meant professionals who received rigorous training in providing a specific set of preventive and basic services, including cleaning, filling and routine extractions could work in the community to prevent disease and treat patients to the highest level of their training. Dental therapists allowed dentists like Dr.Dezbaa Damon, who supervises Bernadette Charles, to maximize their training and treat only the highest need patients, thereby extending their reach and improving access to care for thousands of Alaska Natives.

In Alaska, the addition of dental therapists to the dental team has improved the state’s ability to deliver quality, coordinated, and cost-effective care. As we struggle to address dental workforce shortages and improve the delivery of care in the lower 48, we could learn a lot from Alaska.

– David Jordan, Director of the Dental Access Project

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Cross Post: Insurance Commissioners Respond to Consumer Concerns

Friday, October 22nd, 2010

This blog was originally posted on Say Ahhh! A Children’s Health Policy Blog

By now many of you have probably heard about the big news coming out of the NAIC meeting this week in Orlando. After seven months of intense debate and negotiation, the NAIC voted in favor of a regulation defining the ACA’s required “medical loss ratio” (MLR). They rejected several amendments that were heavily pushed by insurance companies and brokers, scoring a big win for consumers who deserve better value for their health care dollar.

What hasn’t been reported so widely is all the other work NAIC did this past week, from advancing model state laws on major consumer protections required by the ACA, developing a model law on state insurance exchanges, and defining how an insurer must justify an “unreasonable” rate increase. Here are a few highlights:

– A key NAIC task force adopted model state laws implementing three market reform provisions of the ACA: rescissions, young adult coverage up to age 26, and choice of health professional. These now will be reported up to the NAIC’s “B” Committee, which is the umbrella committee for health issues. The same task force is also developing model laws on: lifetime/annual limits, elimination of pre-existing condition exclusions for children under 19, access to preventive benefits, and grievances and appeals, all of which are ACA provisions that went into effect on September 23, 2010.

– Consumer representatives are urging changes to the model law on the kids’ “pre-ex” provision to encourage states to prevent “child only” health plans from withdrawing from the marketplace. We also made formal presentations applauding Commissioner Sevingy from New Hampshire and Commissioner Kreidler from Washington for their leadership and toughness in requiring their states’ insurers to offer coverage to kids.

The consumer reps also pushed for better notice requirements for health plans that have received a waiver from the ACA’s restrictions on annual benefit limits, so that consumers know that the plan doesn’t provide the full range of consumer protections promised under the health reform law. The NAIC’s working group on state insurance exchanges also met in Orlando. They’ve received a whopping 200+ pages of comments on their first draft of a model state law and sometime within the next two weeks they’ll schedule a conference call to receive oral comments. A few issues were raised in the meeting that are worth watching:

– Coordination with Medicaid. My impression is that the model law will probably not delve into the tricky issues of how the exchanges will coordinate with state Medicaid agencies. When one of the Commissioners asked about this, the chair of the work group, Commissioner McRaith from Illinois, said that they have not been working with Medicaid Directors, and emphasized that it would be a “NAIC Model” and therefore would focus on insurance-related issues.

– Dual regulation. The members of the work group were very concerned about exchanges potentially usurping their traditional role regulating health insurance through rate review, market conduct exams and grievances. They’ll probably add new language to the model that will have a more clear delineation of regulatory roles between state insurance departments and the exchange.

– Pediatric dental. The current draft model doesn’t have any language reflecting the ACA’s provision allowing the inclusion of stand-alone dental plans that offer pediatric dental benefits in the exchange. A representative from Delta Dental pointed that out to the group and Commissioner McRaith asked him to submit legislative language. The consumer reps will keep an eye on this issue as it develops.

– Another key NAIC task force has been working for many months to develop the form that insurance companies will have to fill out if they are proposing an “unreasonable” rate increase. This form will provide unprecedented transparency on rate increases, and will include essential information for consumers and employers to better understand the factors driving proposed increases. The task force finalized the form this week and reported it to the “B” Committee, in spite of last-minute opposition from America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association. Even in the face of many hours of open and inclusive conference calls and meetings, both trade associations claimed that the form had been developed without sufficient industry input.

– Last but not least, the NAIC has created a new working group to tackle the issue of limited benefit plans, or “mini-meds.” A joint effort of the “B” Committee and an anti-fraud committee, the group will investigate whether plans are making misrepresentations about their products and whether they are being sold by unlicensed brokers. Because many of these plans provide little or no real coverage if someone actually gets sick, the group will also be looking into the “utility” of these products for consumers.

– Sabrina Corlette, Georgetown Health Policy Institute

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The Insider: ACA Implementation: Partly sunny with a (Supreme) chance of rain

Thursday, October 21st, 2010

This week brought some important developments in ACA implementation. First and foremost is the major win by consumer advocates in the prolonged and multi-pronged struggle to shape NAIC recommendations on Medical Loss Ratios. At the NAIC meeting in Orlando today, consumer advocates beat back attempts by brokers to exclude commissions from the definition of medical expenses, blocked insurers from using high-loss ratios in one state to paper over a failure to meet standards in another, and created a reasonable standard of certainty to establish whether an insurer’s failure to meet the loss ratio was due to under-spending on medical care or unforeseeable random events.

These decisive wins are a case example of the one-two punch that advocates will need in order to influence the numerous federal and state decisions ahead. The consumer victory resulted from the combination of persistent policy advocacy, especially by the NAIC consumer representatives, coupled with a national effort by consumers to reach out to their insurance commissioners and let them know that people were watching (illustrating one of the important axioms of grassroots advocacy: decision makers make different — and better — decisions when they are being watched).

The second key development, while less positive, also contains within it an important strategic dimension. Last week, the Florida District Court issued a decision allowing the case against the individual responsibility clause of the ACA to go forward. Specifically, the Florida court will hear arguments about whether the individual responsibility requirement is legal under the Commerce Clause. The court also will hear arguments about whether the Medicaid expansion under the ACA exceeds Congress’ authority, although Judge Vinson’s decision makes it clear that he considers this argument to be much weaker than the individual responsibility claim. Because Judge Vinson rejected the federal government’s argument that the penalty for not having health insurance constitutes a tax, the focus of the Florida case is squarely on the Commerce Clause argument. Just a week earlier, a District Court in Michigan ruled that the individual responsibility requirement was Constitutional. Whether Florida (and Virginia) ultimately agree with the Michigan ruling, the issue is likely heading for the Supreme Court, which should be enough to give anyone concerned about the sustainability of the ACA a few sleepless nights (especially since the wife of one Justice is actively campaigning for repeal).

But while legal scholars slug it out and try to second guess the next round of rulings, it is important for advocates not to lose sight of the intertwining of the political and legal issues since most advocates will not be able to intervene directly in the legal proceeding.

First, the court cases keep public attention focused on the individual responsibility requirement, which is one of the least popular provisions of the law. The lawsuits also encourage doubt over whether the law will actually be implemented in its current form and potentially give cover for foot-dragging by state administrations inclined to oppose implementation.

The court actions not only affect the political debate, they are also affected by it. The political backdrop against which the Supreme Court makes its final decision is extremely important. To the extent that the law is considered unpopular and there is an active movement for roll back, it will create a context in which a negative legal outcome is considered more palatable.

The key takeaway for supporters of reform is that whether we are looking at how the court cases affect the political debate or how the political debate affects the courts, the response of advocates must be to keep working to create a context of support for the law and expectation that it should and will move forward.

Overall, the events of the past week underscore both the need for and the potential of sustained consumer engagement.

— Michael Miller, Policy Director

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Consumers Win on MLRs!

Thursday, October 21st, 2010

In the final showdown at the NAIC meeting, Insurance Commissioners listened to consumer advocates and took a firm stand on medical loss ratios (MLRs). After a furious week of lobbying by both the insurance industry and consumer advocates, the MLR definition passed without any amendments. This is a critical win that underscores the importance and influence of consumer advocacy on implementation decisions.

The amendments were filed on two issues — national aggregation (filed by Florida) and broker fees (by Ohio) — but were withdrawn after discussion among the Commissioners. An amendment on the most contested issue of late, credibility adjustments (also filed by Ohio), failed to pass by a vote of 34 to 19 (with one abstention).

The final vote to support the MLR definition was unanimous — thanks in large part to the hard work of consumer representatives on the NAIC and advocates around the country who supported them and reached out to their Commissioners on these issues.

Congratulations to all who worked to ensure this victory. It is a great example of how a concerted effort by consumers can have great impact! Next step: HHS approval!

– Christine Barber, Senior Policy Analyst

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MLRs — Going South?

Wednesday, October 20th, 2010

Our sources at the National Association of Insurance Commissioners (NAIC) meeting in sunny Orlando sent an update on the storm brewing over the medical loss ratio (MLR) definition. For those of you new to MLRs, it’s been a long seven months for all of the folks embroiled in the efforts by the NAIC to define what are medical expenses versus profits or administrative expenses. Up until now, the NAIC has carefully worked to adhere to federal law and balance the interests of industry and consumers. But in Florida, those calm skies are growing cloudier as the final vote nears tomorrow morning.

The insurance industry has been pulling out all the stops the past few weeks to undermine the carefully woven fabric of the MLR regulation crafted by the NAIC sub-committees. Their threat to Commissioners: We will pull out of your insurance market and leave your residents without any options – a low blow considering the industry agreed to the compromises made on these very issues just months ago.

Insurance Commissioners are mostly non-committal as they prepare to file amendments to the MLR tomorrow and then have another commissioner-only discussion. The whole definition is up for a vote on Thursday. What should be clear to all is that if the amendments pass, the entire MLR will be meaningless and consumers will not benefit from the potential changes.

First up is national aggregation: Some national insurers are seeking aggregation, or pooling all of their MLRs across state lines for certain insurance markets. This would mean that if an insurer is in a state with a low MLR and another state with a higher MLR – the two numbers would be averaged – leaving consumers in the dark about how much of their premium dollars are spent on health care. This change not only goes against the definition of health insurance ‘issuer’ in the federal law but could also end up making national carriers look better than their local competition.

Second are credibility adjustments for small insurers. Insurers must hit the MLR percentage the required by ACA (85% in large group and 80% in small group and individual markets), or provide rebates to policyholders. There has been much discussion at NAIC about how to protect smaller insurers that may not meet the MLR standard because they only cover 1,000 people and random events (like few filed claims) affect their MLR, rather than their spending on administration and profit.

Previously, everyone agreed to the solution to adjust the MLR of these small carriers – like a handicap in golf – called a credibility adjustment. This is done through actuarial calculations based on a “confidence level.” Basically, the confidence level is the amount of certainty that insurers tried to meet the MLR in good faith, but that random events prevent them from meeting the MLR target. The bottom line is that a higher confidence level means a much weaker MLR standard. The draft regulation crafted by NAIC workgroups allowed a 50 percent confidence level. The issue was heavily debated, and the actuaries agreed that 50 percent made the most sense mathematically and from a policy perspective.

However, there is now a last-minute push to move the confidence level up to 80 percent, and to expand its reach to insurers that cover up to 75,000 people. As an example of how this would play out, every health plan in New York would qualify for a credibility adjustment and would gain between 10 and 25 percentage points on their MLR without actually streamlining anything but maintaining the status quo. Insurers will have a much easier time meeting ACA’s target for MLR, without reducing administration and profit.

Third, counting broker fees in the MLR calculation. There is a move afoot to take broker commissions out of both the premium and the administrative expense component of the MLR. This could be damaging to consumers. Broker fees need to be counted toward administrative expenses and profits.

Right now the NAIC has an opportunity to do something transformative for consumers. Let’s give them the support they need to do so. The vote is tomorrow morning. Take five minutes and call your Insurance Commissioner today. See our latest alert for talking points and more information.

— Christine Barber, Senior Policy Analyst

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Consumer Assistance Programs grants, an important victory

Wednesday, October 20th, 2010

Yesterday marked an important victory for health consumers and consumer advocates as the Department of Health and Human Services (HHS) announced nearly $30 million in grants to consumer assistance programs (CAPs) in 35 states, four territories and the District of Columbia.

Community Catalyst has, throughout our history, championed consumer involvement in health care. CAPs are critical to making consumer involvement effective, and as such was one of the primary features of health care reform that we worked hard to see succeed.

The federal funds to create CAPs will establish a range of essential services for consumers to educate them about the new law, aide them with enrollment in health care plans and help them navigate their care options. CAPs are also required to provide feedback to policymakers about any problems with existing laws and regulations. For these reasons, Community Catalyst sees CAPs as a way of linking consumers to the health care system and a vital ingredient to the success of the Affordable Care Act.

While the grants are awarded to states, many will partner with non-profit organizations to provide this assistance, and we continue to urge states to work with consumer advocacy organizations, even in an advisory and oversight role. Community Catalyst has seen the proven consumer assistance work of organizations like Community Service Society of New York and Maine Consumers for Affordable Health Care (CAHC) guide thousands of consumers through the health care process, and know how vital this assistance is to consumers.

In fact, Joe Ditré, executive director of Maine CAHC and a Community Catalyst board member, was recognized by HHS and was one of the featured speakers at yesterday’s press conference announcing the grant awards. He spoke about how CAPs can help all sectors of a community from consumers to health care providers, businesses and insurers. Maine CAHC will contract through their state grant to strengthen its current consumer assistance program.

As many consumers remain confused about how the ACA will affect them, CAPs are one tool to clear up this confusion and educate individuals about changes in health care. The support these programs provide, from outreach to the newly insured to help filling out paperwork, is vital to the success of health reform. And, importantly, the actual impact of these grants will be felt on the ground where individuals and their families will get real help.

— Christine Lindberg, Communications Associate

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Florida ruling swings pendulum toward Supreme Court

Friday, October 15th, 2010

Yesterday, the federal judge in Florida, Roger Vinson, allowed the lawsuit against the new health law to go forward. In his ruling, the Judge maintained that there were constitutional issues in play and formal hearings would begin mid-December. Specifically, the Judge discounted the Justice Department’s claim that 1) the individual mandate was a natural extension of the commerce clause – or the federal government’s ability to regulate interstate commerce; and 2) the penalty imposed by the individual mandate was equivalent to a tax.

However, Judge Vinson dismissed several claims made by the plaintiffs – 20 attorneys general, led by the Florida AG, Bill McCollum – including arguments related to state sovereignty. Nevertheless, he sided with the AGs that the use of the commerce clause was unprecedented and deserved a weighing of whether or not that exercise in federal power is constitutional. Vinson also went to great pains to dismiss the Justice Department’s argument that the penalty associated with the individual mandate was simply a tax. Interestingly, he honed in on the political discussions that occurred during the passage of the legislation when many promoting reform argued that the penalty was not a tax. Shouldn’t the semantics of taxation during political theater be irrelevant in the courtroom? I guess not.

As reported by the Volkh Conspiracy here, there is little discussion by Vinson regarding the Necessary and Proper clause – which is the strongest argument for the new health law. Millions of uninsured doesn’t translate into “necessary?” In U.S. District Court in Michigan, however, Judge Steeh maintained that the insurance mandate is constitutional and the overwhelming national crisis supersedes the concerns expressed by health reform foes: “The costs of caring for the uninsured who prove unable to pay are shifted to health care providers, to the insured population in the form of higher premiums, to governments, and to taxpayers… These decisions, viewed in the aggregate, have clear and direct impacts on health care providers, taxpayers and the insured population who ultimately pay for the care provided to those who go without insurance.”

The Florida ruling is important because, alongside the Virginia ruling expected on Monday, it narrows the path for defendants and plaintiffs alike in how they argue the case. Clearly, the commerce clause will be the central constitutional question going forward. Should not purchasing health insurance be viewed as an active choice that may be regulated? We will hear many competing theories in the coming months – which theoretical frame will the Supreme Court choose? How will the pendulum swing? Stay tuned.

– Eva Marie Stahl, Policy Consultant

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Cross-Post: Consumer Rep Previews the National Association of Insurance Commissioners National Meeting

Friday, October 15th, 2010

This blog was originally posted on Say Ahhhh! A Children’s Health Policy Blog.

Hard to believe it’s come around again but that National Associatin of Insurance Commissioners (NAIC) is gearing up for a big national meeting – this time in Orlando, Florida from October 18-21. I and my fellow consumer representatives will be packing our Mickey Mouse ears and fanning out at the big regulator-industry confab to share our views on how to make the Affordable Care Act implementation work for consumers and families. The NAIC has a lot of work packed into just a few days. Here’s a preview of what they’ll be doing and how it might impact children and families:

* Helping states implement the September 23 patient protections. NAIC’s “Regulatory Framework Task Force”, chaired by South Dakota’s Director of Insurance, Merle Scheiber, has been drafting model laws to help states implement many of the “Patients’ Bill of Rights” protections in the ACA, such as the prohibition on pre-existing condition exclusions for children under 19, required coverage for young adults up to age 26, preventive benefits, restrictions on annual limits and the ban on lifetime limits, internal and external appeals, and the prohibition on rescissions. The Task Force has almost completed its efforts, and is expected to take up final edits and changes during its meeting in Orlando on October 18. State advocates can expect that many states will use these models to craft the necessary legislation to enforce these new consumer protections. We’ll also be talking to the regulators about strategies to keep child-only plans in the market and make kids’ coverage more affordable.

* Developing an Exchange model law. The NAIC has created a new workgroup, co-chaired by Commissioner McRaith from Illinois and Commissioner Praeger from Kansas, to develop a model law for states to establish an insurance exchange. This group will be meeting on October 20th to review the draft model law and discuss possible recommendations to HHS on issues like governance, exchange functions, network adequacy, marketing standards and quality ratings. During their summer meeting in Seattle, the workgroup also agreed to create a high-level liaison group to state Medicaid directors, led by Commissioner Praeger. We’ll be eager to hear about that group’s efforts to date, particularly on how they intend to address the “no wrong door” goals of the ACA and coordination of care for low-income families that may be cycling between Medicaid and commercial insurance.

* Medical Loss Ratios. NAIC’s draft regulation to define the medical loss ratio (MLR) under the ACA was posted on October 5. It’s likely to be voted on by NAIC’s Excecutive Committee and Plenary during their final meeting in Orlando on October 21st. We’re expecting some fireworks as the insurance industry pushes back hard against some of the tougher requirements. In particular, insurance agents are asking that they be left out of the equation. The bottom line for families purchasing insurance: the MLR standard is a measure of how much a health plan devotes to actual medical care as opposed to overhead and profits. We’ll be urging the NAIC to stay strong against industry pressure to weaken the standard.

* Consumer Information. One of the most important yet least publicized consumer protections in the ACA is the requirement for more transparency in the information provided to consumers about health plan benefits, exclusions, premiums and cost-sharing. NAIC has been charged with developing the standardized definitions and summary of benefits form that all qualified health plans must provide to consumers making purchasing decisions. The NAIC’s Consumer Information workgroup, co-chaired by Superintendant Kofman from Maine and Commissioner Miller from Oregon, has been working diligently all summer on the summary form and is now awaiting the results of focus group testing. Once the focus group results are back, the group will meet in Orlando to finalize the summary of benefits form. HHS will likely then include it in a regulation expected in March of 2011. The consumer reps on this group are working hard to make sure that consumers get the information they need to make purchasing decisions that are right for their situation, without having to worry about hidden contract language that leaves them financially vulnerable when they need care.

The NAIC meetings are open to registered participants, but the travel, hotel and fees are a significant expense. Advocates for children and families are welcome to contact any of the NAIC’s consumer reps to ask questions or share any comments.

– Sabrina Corlette, Georgetown Health Policy Institute

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MI judge’s ruling swings the pendulum in favor of the individual mandate

Friday, October 8th, 2010

A judge that upholds the legality of the individual mandate does exist! Yesterday, U.S. District Judge George Steeh dismissed the Thomas More Law Center’s central arguments against the Affordable Care Act’s individual mandate and denied a requested injunction that would have stalled health reform implementation. In an effort to dismantle health reform, anti-reform groups are pursuing a legal avenue that would invalidate a central pillar of health reform — the requirement that all Americans purchase health insurance. Despite the federal judge’s ruling in Michigan, however, the individual mandate remains under scrutiny in Florida and Virginia.

Steeh, a Clinton appointee, maintains that Congress did not overstep its authority in requiring individuals to purchase health insurance and doing so is within their power; he cites numerous Supreme Court rulings to support his assertions. Steeh writes: “Because the ‘penalty’ is incidental to these purposes, plaintiffs’ challenge to the constitutionality of the penalty as an improperly apportioned direct tax is without merit.” When translated, this means that Congress may use the individual mandate and associated penalties to achieve the greater goal of insuring all Americans. This is great news for supporters of ACA, mostly because it’s a win for moving health reform implementation forward.

The More Center lawsuit is similarly aligned with the suit brought by the 20 attorneys general nationwide, currently being heard in a Florida U.S. district court. The AG suit is assumed to move forward; Judge Roger Vinson of the Florida US district court hinted in an earlier ruling that some major points would progress to trial in December.

The Michigan ruling illustrates the pendulum on which the individual mandate resides. For the citizenry there is little to do but watch it swing. It is likely that the Supreme Court will be the only hand that can stop it.

– Eva Marie Stahl, Policy Consultant

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