PERSPECTIVE
U N R A V E L IN G
The Supreme Court’s decision to hear a case {King v. Burw ell) challenging the legality o f pro viding premium subsidies in fed eral exchanges is crucial to the GOP precisely because the chanc es for legislative repeal of Obamacare are so remote. The Court can seriously damage the ACA in a way that congressional Repub licans cannot. A decision to pro hibit subsidies for helping the uninsured to purchase coverage in the 34 states that have feder ally run exchanges would desta bilize the health insurance mar ketplaces and unravel the A n a u d io in te r v ie w individual and em w i t h D r . O b e r ia n d e r ployer mandates in is a v a ila b le a t N E J M .o r g those states, exac erbating the already large dis parities in insurance coverage among states. It would cause both a sizable increase in the un insured population and sizable losses for the insurance industry and medical care providers as millions of Americans lost their health coverage.4 Such a ruling could, in turn, produce enormous pressures on affected states and
Congress to adopt measures to stave off those outcomes. Yet the ACA’s shaky political foundations would complicate policymakers’ responses, and Obamacare’s op ponents would be emboldened to resist any fixes.5 A ruling against federal subsidies could have a spillover effect, dampening the chances for Medicaid expansion in some states. The 2014 elections altered the ACA’s political environment in a way that could produce changes in the law, but its core will re main in place. Now the question is, once again, whether Obamacare will emerge intact from the Supreme Court. If the Court dramatically narrows the ACA’s scope, the political calculus will change substantially in 2015 and beyond. The law’s recent mo mentum will be reversed, the fight over Obamacare will in tensify, and the future o f health care reform will be highly un certain.
O B A M A C A R E
From the U niversity o f N o rth Carolina, C hap el H ill. This article was pu blish ed on D ec e m b e r 10, 2014, at N EJM .org.
1. Cohn J. This is how the new G O P Senate will try to d ism an tle O b am a c are . N ew Re public.
N o v em b e r
4,
2014
( h ttp ://w w w
.n ew rep u b lic.co m /article/120125/rep u b lican -p lan s-o bam acare-device-tax-m an dates-risk -corridors). 2 . D e p a rtm e n t o f H ea lth and H u m a n Ser vices. H o w
m any individuals m igh t have
m arketplace coverage after the 2015 open en rollm ent period? ASPE Issue Brief. N ovem ber 10, 2014 (http ://aspe.hh s.gov/h ealth /reports/ 2014/T arg e ts /ib _T a rg ets .p d f). 3. C en ter for M e d ic a re and M e d ic a id Ser vices.
M e d ic a id
&
C H IP :
A u g u st
2014
m o n th ly a p p lic atio n s , elig ib ility d e te rm in a tio n s, and e n ro llm e n t re p o rt. O c to b e r 17, 2014
( h ttp ://m e d ic a id .g o v /m e d ic a id -c h ip
-p ro g ra m -in fo rm a tio n /p ro g ra m -in fo rm a tio n / d o w n lo a d s /a u g u s t-2 0 1 4 -e n ro llm e n t-re p o rt .p d f). 4 . Levitt L, C laxton J. T h e p o ten tia l sideeffects o f H albig. M e n lo Park, CA: Kaiser Fam ily Foundation. July 31, 2014 ( h ttp ://k ff .o rg /health-reform /persp ective/the-po ten tial -side-effects-of-halb ig). 5. Jost T. Im p le m e n tin g health reform : Su p rem e C o u rt will review tax credits in federal exchanges. H ea lth A ffairs Blog. N o v em b e r 7, 2014 ( h ttp ://h e a lth a ffa ir s .o r g /b lo g /2 0 1 4 /ll/ 0 7 /im p le m e n tin g -h e a lth -re fo rm -s u p re m e -c o u rt-w ill-re view -tax -c red its -in -fe d e ral -exchanges).
Disclosure forms provided by the author are available with the full text o f this article at NEJM.org.
D O I: 10.1056/NEJMpl413992 C o p y r ig h t ©
2 0 1 4 M a s s a c h u s e t t s M e d i c a l S o c ie t y .
Very Complicated M ath — Reconfiguring Organ Allocation Daniela Lamas, M.D., and Lisa Rosenbaum, M.D.
t has long been recognized that there are geographic dis parities within the United States in the allocation of organs for transplantation. In an attempt to address the inequities, the De partment of Health and Human Services issued a “final rule” in 1998 stating that organs “ought to be distributed on the basis of objective priority criteria and not on the basis o f accidents of
I
N
geography.”1 But though tweaks have since been made to the al location systems for various or gans, disparities persist. The underlying problem is that transplantable organs are scarce, so any redistribution risks re placing old inequities with new ones. Is there any solution that would help us more effectively use our limited resources to achieve greater good?
ENGLJ
MED
37U 26
N E JM .O R G
DECEMBER 25,
The current allocation system for deceased-donor organs divides the United States into 58 districts called donation service areas (DSAs) that are grouped into 11 regions; the regional boundaries were drawn decades ago, without specific attention to geographic variation in need for or supply of transplantable organs. Organs are first offered to patients within the DSA where they’re obtained,
2014
2447
PERSPECTIVE
R E C O N F IG U R IN G
O R G A N A L LO C A T IO N
N ew H a m p s h ire
W a s hington
V e rm o n t M o n tan a
N o rth Dakota
\
M innesota M a ssa ch u se tts Wisconsin
South Dakota M ichigan
W yom ing
Rhode Island Pennsylvania
N e w Jersey
Nebraska
N evada
Connecticut
Illinois
Indiana
Delaw are W est
Colorado
Virginia V jrginia M issouri
Kansas
M a ryla n d W a s h in g to n , D.C
Kentucky N o rth Carolina
O klahom a
H a w a ii
S outh
Arkansas
^
Carolina!
'Mississippi Louisiana
M e d ia n M E LD score at tra n s p la n ta tio n 2011
! ■
>29
mm 25-28 I
I 23-24
I _
I
U N R A V E L IN G
The Supreme Court’s decision to hear a case {King v. Burw ell) challenging the legality o f pro viding premium subsidies in fed eral exchanges is crucial to the GOP precisely because the chanc es for legislative repeal of Obamacare are so remote. The Court can seriously damage the ACA in a way that congressional Repub licans cannot. A decision to pro hibit subsidies for helping the uninsured to purchase coverage in the 34 states that have feder ally run exchanges would desta bilize the health insurance mar ketplaces and unravel the A n a u d io in te r v ie w individual and em w i t h D r . O b e r ia n d e r ployer mandates in is a v a ila b le a t N E J M .o r g those states, exac erbating the already large dis parities in insurance coverage among states. It would cause both a sizable increase in the un insured population and sizable losses for the insurance industry and medical care providers as millions of Americans lost their health coverage.4 Such a ruling could, in turn, produce enormous pressures on affected states and
Congress to adopt measures to stave off those outcomes. Yet the ACA’s shaky political foundations would complicate policymakers’ responses, and Obamacare’s op ponents would be emboldened to resist any fixes.5 A ruling against federal subsidies could have a spillover effect, dampening the chances for Medicaid expansion in some states. The 2014 elections altered the ACA’s political environment in a way that could produce changes in the law, but its core will re main in place. Now the question is, once again, whether Obamacare will emerge intact from the Supreme Court. If the Court dramatically narrows the ACA’s scope, the political calculus will change substantially in 2015 and beyond. The law’s recent mo mentum will be reversed, the fight over Obamacare will in tensify, and the future o f health care reform will be highly un certain.
O B A M A C A R E
From the U niversity o f N o rth Carolina, C hap el H ill. This article was pu blish ed on D ec e m b e r 10, 2014, at N EJM .org.
1. Cohn J. This is how the new G O P Senate will try to d ism an tle O b am a c are . N ew Re public.
N o v em b e r
4,
2014
( h ttp ://w w w
.n ew rep u b lic.co m /article/120125/rep u b lican -p lan s-o bam acare-device-tax-m an dates-risk -corridors). 2 . D e p a rtm e n t o f H ea lth and H u m a n Ser vices. H o w
m any individuals m igh t have
m arketplace coverage after the 2015 open en rollm ent period? ASPE Issue Brief. N ovem ber 10, 2014 (http ://aspe.hh s.gov/h ealth /reports/ 2014/T arg e ts /ib _T a rg ets .p d f). 3. C en ter for M e d ic a re and M e d ic a id Ser vices.
M e d ic a id
&
C H IP :
A u g u st
2014
m o n th ly a p p lic atio n s , elig ib ility d e te rm in a tio n s, and e n ro llm e n t re p o rt. O c to b e r 17, 2014
( h ttp ://m e d ic a id .g o v /m e d ic a id -c h ip
-p ro g ra m -in fo rm a tio n /p ro g ra m -in fo rm a tio n / d o w n lo a d s /a u g u s t-2 0 1 4 -e n ro llm e n t-re p o rt .p d f). 4 . Levitt L, C laxton J. T h e p o ten tia l sideeffects o f H albig. M e n lo Park, CA: Kaiser Fam ily Foundation. July 31, 2014 ( h ttp ://k ff .o rg /health-reform /persp ective/the-po ten tial -side-effects-of-halb ig). 5. Jost T. Im p le m e n tin g health reform : Su p rem e C o u rt will review tax credits in federal exchanges. H ea lth A ffairs Blog. N o v em b e r 7, 2014 ( h ttp ://h e a lth a ffa ir s .o r g /b lo g /2 0 1 4 /ll/ 0 7 /im p le m e n tin g -h e a lth -re fo rm -s u p re m e -c o u rt-w ill-re view -tax -c red its -in -fe d e ral -exchanges).
Disclosure forms provided by the author are available with the full text o f this article at NEJM.org.
D O I: 10.1056/NEJMpl413992 C o p y r ig h t ©
2 0 1 4 M a s s a c h u s e t t s M e d i c a l S o c ie t y .
Very Complicated M ath — Reconfiguring Organ Allocation Daniela Lamas, M.D., and Lisa Rosenbaum, M.D.
t has long been recognized that there are geographic dis parities within the United States in the allocation of organs for transplantation. In an attempt to address the inequities, the De partment of Health and Human Services issued a “final rule” in 1998 stating that organs “ought to be distributed on the basis of objective priority criteria and not on the basis o f accidents of
I
N
geography.”1 But though tweaks have since been made to the al location systems for various or gans, disparities persist. The underlying problem is that transplantable organs are scarce, so any redistribution risks re placing old inequities with new ones. Is there any solution that would help us more effectively use our limited resources to achieve greater good?
ENGLJ
MED
37U 26
N E JM .O R G
DECEMBER 25,
The current allocation system for deceased-donor organs divides the United States into 58 districts called donation service areas (DSAs) that are grouped into 11 regions; the regional boundaries were drawn decades ago, without specific attention to geographic variation in need for or supply of transplantable organs. Organs are first offered to patients within the DSA where they’re obtained,
2014
2447
PERSPECTIVE
R E C O N F IG U R IN G
O R G A N A L LO C A T IO N
N ew H a m p s h ire
W a s hington
V e rm o n t M o n tan a
N o rth Dakota
\
M innesota M a ssa ch u se tts Wisconsin
South Dakota M ichigan
W yom ing
Rhode Island Pennsylvania
N e w Jersey
Nebraska
N evada
Connecticut
Illinois
Indiana
Delaw are W est
Colorado
Virginia V jrginia M issouri
Kansas
M a ryla n d W a s h in g to n , D.C
Kentucky N o rth Carolina
O klahom a
H a w a ii
S outh
Arkansas
^
Carolina!
'Mississippi Louisiana
M e d ia n M E LD score at tra n s p la n ta tio n 2011
! ■
>29
mm 25-28 I
I 23-24
I _
I
