The Supreme Court's ACA Decision: A Step Away From Chaos

In a landmark moment in US history, the Supreme Court on Thursday upheld the Patient Protection and Affordable Care Act against a challenge that its provisions exceeded Congress's constitutional powers. While it rejected the idea advanced by the Obama administration that the ACA was authorized under Congress's power under the Commerce Clause, the Court, in an opinion by Chief Justice John Roberts, held that the ACA was a valid exercise of its power to tax for the general welfare.

There is a mountain of commentary dissecting why the Court handled the case as it did, and what it means for the future. But now that implementation of the ACA will go ahead as planned, we wanted to check in with Thomas Lee to find out what it will mean for actual care. Lee is network president of Partners Health Care and coauthor (with the late James Mongan) of Chaos and Organization in Health Care, which laid out a plan for a more less fragmented, more efficient health care delivery system. His thoughts are below.

So far, much of the discussion of the implications of the Supreme Court decision on the Affordable Care Act has focused on the individual mandate and standards for health insurance policies. I think that in the long run, the most important impact will be on the organization of health care delivery. In short, I think the U.S. took a large step back away from a fragmented, disorganized health care system, and toward one in which health care organizations must actually get organized - so that they can deliver better, more efficient care.

The imperative for movement toward a more organized health care system is enormous.  In Chaos and Organization in Health Care James Mongan and I described how the driving force behind our cost and quality challenges in medicine was progress itself. Because of research advances, untreatable diseases have become treatable, which is wonderful news for many patients - but the delivery of state of the science care requires many more people who are not always working as well-oiled machines. The result is chaos - too much to do, too many people involved, and no one with all the knowledge or all the responsibility.

The imperative to cover virtually all Americans will necessarily force payment system changes that reward physicians and other providers who can organize themselves into groups that can provide higher value care - and punish those providers who cannot. This means that, inevitably, 1-2 physician practices will fade even faster from the scene, and be replaced by organizations in which teams of clinicians (including non-physicians) use information technology and other systems to work with each other and with patients to avoid hospitalizations and keep patients healthy. Some of the intimacy and pride of the small physician practices will probably be lost. But, since no one physician can meet all the needs of most patients today, the result just might be better care that is affordable for a much larger number of Americans.