A handful of key issues that emerged or gained speed in 2018 have the potential to transform healthcare delivery in the United States. Here's a look at four of them.
There was no shortage of big stories in healthcare in 2018, but it's still too soon to separate the truly innovative and transformative developments from the mere hyped-up stories that generate a few headlines and disappear.
With that in mind, here are four stories that likely will have a long-lasting impact on U.S. healthcare.
1. Vertical Integration
Arguably no single issue will have a more profound effect on the way care is delivered than the vertical integration that is occurring among commercial health insurers and pharmacy benefits managers and their retail subsidiaries.
But the biggest reason why this trend is so transformative is because it will force traditional healthcare providers to rethink their business models, and hustle in areas where they've preferred to be laggards because they haven't had any competition; in particular, with pricing transparency and consumer convenience.
2. Horizontal Mergers
This is hardly a new trend in 2018, but there were several noteworthy health system consolidations in the past 12 months, including the megamerger between Advocate HealthCare and Aurora Health Care.
Hospital folks like to say there are a number of reasons why these consolidations are occurring, including the creation of synergies and economies of scale, and the reduction of redundant services, all of which they say will result in lower costs for consumers, a claim that is widely disputed by a number of studies.
Of course, the real reason why hospitals merge is because the larger system can maximize an advantage of size to extract better deals from commercial payers, and because hospitals need a larger footprint as the nation transitions to risk-based compensation.
As long as that transition continues, there is nothing to indicate that this trend is going to slow down anytime in the coming year.
3. Amazon
It's hard to gauge exactly how much Amazon changed healthcare delivery in 2018 but it sure generated a lot of talk. Perhaps, in looking back five years from now, we will see that Amazon used 2018 as a transition period on a number of key fronts.
In January, a loosely formed partnership between Amazon, JPMorgan Chase, and Berkshire Hathaway to form some sort of healthcare entity got a lot of media play, and it generated a lot of speculation. They named healthcare policy rock star Atul Gawandeas CEO. But, that's about it.
Other Amazon initiatives that garnered less media attention have the potential to be more impactful.
For example, Amazon this fall began selling software that mines patient medical records for information physicians and hospitals could use to improve care and cut costs.
In June, signaling its intent to enter the pharmacy benefits space, Amazon acquired PillPack, a relatively small company with only 40,000 customers that ships pills directly to consumers and also makes daily individual packets.
Amazon's core competencies inlogistics and distribution, and its existing B2B ecommerce platform, will allow it to easily expand into hospital and provider supply, disrupting the traditional group purchasing organization contract model.
Amazon is also attempting to integrate its Alexa voice assistant into the health and wellness space, targeting people with chronic diseases with initiatives as simple as reminding patients to take their daily medications.
While many believe that Amazon's ventures into healthcare have the potential to disrupt traditional markets, especially pharmacy, pharmacy benefits, and supply chain, the Byzantine nature of the nation's $3.3 trillion healthcare sector will also determine the pace of that disruption.
4. Government
If nothing else, the Department of Health and Human Services under President Donald Trump has been predictably unpredictable in 2018.
On the one hand, the Centers for Medicare & Medicaid Services pushes doctrinaire conservative healthcare policy initiatives such as work requirements for Medicaid recipients.
On the other hand, HHS Secretary Alex Azar, a fervent free-market champion, sounded more like a Democratic Socialist this fall when he called for tethering Medicare Part B rates to the prices paid by other developed nations.
To its credit, CMS has also pushed for greater pricing transparency to help consumers understand irrational hospital prices.
In August, CMS unveiled a final rule to improve patient access to hospital price information.
In November, CMS launched an online tool that allows consumers to compare Medicare payments for surgical procedures in hospital outpatient departments and ambulatory surgical centers.
On other fronts, the Trump administration wasn't able to muster enough support in Congress to repeal the Affordable Care Act, so they're attempting to kneecap the legislation using HHS's broad regulatory authority. This includes the creation of cheaper, short-term health plans that are light on coverage, and which will be attractive to healthier people, leaving sicker populations in the more expensive, more comprehensive ACA plans.
Nearly $2 billion in penalties have been imposed on hospitals since the Hospital Readmissions Reduction Program began in 2012, but a growing number of researchers believe the program is doing more harm than good.
Using financial penalties to reduce hospital readmissions has been linked to a significant rise in post-discharge mortality for patients with heart failure and pneumonia, a new, large-scale study shows.
In an article published this week in JAMA, researchers at Beth Israel Deaconess Medical Center examined the unintended consequences of the Hospital Readmissions Reduction Program, a component of the Affordable Care Act that began in 2012.
Under the HRRP, hospitals have faced financial penalties for higher-than-expected 30-day readmissions for heart failure, pneumonia, and heart attack. Nearly $2 billion in penalties have been imposed on hospitals by the HRRP since 2012.
"Policy makers had observed that hospital readmissions for these conditions were high and that many of these readmissions were potentially avoidable," study first author Rishi Wadhera, MD, said in comments accompanying the study.
To one extent, HRRP worked. Hospitals made changes to avoid readmissions rates among Medicare beneficiaries and readmissions rates for those three conditions fell. However, a growing chorus of researchers and physicians have raised concerns that the drop in readmissions has led to increased mortality.
"Some policy makers have declared the HRRP a success because they believe that reductions in readmissions solely reflect improvements in quality of care," Wadhera said. "But the financial penalties imposed by HRRP may have also inadvertently pushed some physicians to avoid readmitting patients who needed hospital care, or potentially diverted hospital resources and efforts away from other quality improvement initiatives."
The researchers examined more than 8 million Medicare fee-for-service hospitalizations from 2005 to 2015. They evaluated mortality among Medicare patients who were hospitalized for heart failure, a heart attack or pneumonia before the establishment of HRRP in 2012.
Then, they compared those trends to determine if there was a significant change in mortality after the HRRP was announced in 2010 and then after the policy was implemented in 2012.
"Even though 30-day post-discharge mortality was increasing among patients hospitalized for heart failure in the years before HRRP was established, we found that the rise accelerated after the policy was implemented," said co-corresponding author Changyu Shen, PhD, senior biostatistician in the Smith Center for Outcomes Research in Cardiology at BIDMC.
The team also found mortality rates among patients with pneumonia were stable prior to HRRP, but began increasing after the HRRP. "Whether the HRRP is responsible for this increase in mortality requires further research, but if it is, our data suggest that the policy may have resulted in an additional 10,000 deaths among patients with heart failure and pneumonia during the five-year period after the HRRP announcement," Shen said.
Readmissions has become a controversial topic among physicians and researchers, with some studies indicating that it leads to a rise in mortality, and other studies indicating that HRRP has improved care delivery.
The primary implication of the research is that health systems and hospitals have made broad improvements to quality of care rather than changes aimed only at Medicare beneficiaries treated for the conditions targeted by HRRP.
Interveners want U.S. District Judge Reed O'Connor to clarify his December 14 ruling that the Affordable Care Act was unconsitutional, and they want him to certify the ruling so they can appeal it immediately.
Attorneys general from 17 states who've intervened in defense of the Affordable Care Act are again asking a federal judge who ruled the law was unconstitutional to expedite an appeal by January 1.
Their motion is similar to a request filed on December 17, which also asked O'Connor to certify the opinion so that it can be appealed to the Fifth Circuit Court of Appeals immediately.
The suit challenging the constitutionality of the ACA was filed by Republican state leaders in 20 states, who had successfully argued that the entire law was rendered invalid by Congress zeroing out the penalty tied to its individual mandate.
The Democratic AGs want O'Connor to clarify before January 1 that the ACA remains the law of the land during the appeals process. Ending the ACA, the interveners say, would cause incalculable harm to the U.S. healthcare system, states that rely on Medicaid expansion funding, and millions of Americans.
"It's hard to imagine a world in which millions of Americans could lose healthcare, but these are the stakes right now in federal court," Becerra said in prepared remarks.
"Every American could be affected by this case's outcome: children, seniors, workers covered by employers or through the Marketplace, and the hundreds of millions of people with a pre-existing condition," Becerra said. "This shouldn't be a debate: the ACA is the law of the land, and we will continue to challenge this dangerous attempt to undermine Americans' health."
Here's the timeline on the various motions filed since the December 14 ruling:
On December 17, the 17 Democratic AGs first filed for an expedited motion to clarify the status quo of the ACA and ask O'Connor to grant an immediate stay on his ruling, or to certify it so that it could be appeal immediately.
On December 18, O'Connor issued an order, requesting the federal government and plaintiff states respond to the request filed by the Democratic AGs, and additionally weigh in on whether they believe the court needs to resolve any pending claims that were not addressed in the December 14 ruling. The plaintiffs and the federal government were ordered to reply by December 21. The Democratic AGs were to respond by December 26.
On December 21, The Trump Administration and Republican AGs agreed that O'Connor's December 14 decision does not change the status quo of the ACA. They also agreed that O'Connor should certify his decision for appeal and issue a stay of proceedings pending appeal.
However, because O'Connor's decision was not final, the Trump Administration said it would ask the judge to clarify his decision and confirm that it doesn't require immediate compliance. The Republican plaintiffs said they won't enforce O'Connor's decision while the case is on appeal.
On December 26, the Democratic AGs reiterated their call for clarity in an expedited and certified ruling.
However, critics note the survey of hospital executives does not necessarily show that savings generated by mergers are passed on to healthcare consumers.
As state and federal regulators take a harder look at hospital mergers, an American Hospital Association-sponsored study suggests that in-market consolidations decrease costs and expand patient services.
The report comes as the AHA levelled criticism against the Federal Trade Commission for a hospital merger review process that AHA said was "overbroad" and "does not properly credit the many pro-consumer benefits of hospital transactions, and ignores key realities of the marketplace."
The newly extended survey—conducted by Charles River Associates—found that mergers of hospitals within 30 miles of each other generated savings of more than $6.6 million in annual operating expenses at acquired hospitals.
"These findings are important because antitrust authorities and some researchers have suggested that mergers involving hospitals in closer proximity can raise particular competitive issues," the survey found.
"Data demonstrating that there are somewhat greater cost savings from such mergers, no increase in revenues and some evidence of quality improvements underscore the procompetitive potential of such mergers and their likely benefits for patients," the survey said.
Matt Schmitt, an assistant professor of strategy at UCLA, whose research was cited in the Charles River report, says the findings are true, to an extent.
"My own research and that of CRA suggests that the average hospital merger reduces costs. That said, there is likely substantial heterogeneity across mergers," Schmitt said in an email to HealthLeaders.
"Some mergers likely reduce costs by quite a bit, whereas others have no effect (or even increase costs). I believe that it is unwise to apply the results of these aggregate studies to individual mergers: in my view, case-by-case analysis is necessary," he said.
Schmitt says it's "much less apparent" if merger savings trickle down to consumers in the form of lower healthcare prices.
"There are two steps here. First, whether those savings trickle down to insurers in the form of lower negotiated rates," he said. "Second, whether those lower negotiated rates trickle down to consumers in the form of lower premiums and/or more generous benefits."
Schmitt said the CRA report's attempt to examine revenue per admission "is very rough."
"For example, it includes Medicare and Medicaid, when negotiated rates between hospitals and commercial insurers is what we really want to see," he said. "Unfortunately, given the proprietary nature of hospital/insurer negotiations, it is not easy to get access to good data on those rates."
Schmitt said one study published in May found higher post-merger prices when the merging hospitals are geographically close.
"Overall, the jury remains out with respect to whether hospital mergers benefit consumers, both financially and perhaps more importantly with respect to the quality of care," Schmitt said.
The federal government collected $2.8 billion in False Claims Act settlements across all sectors of the economy in 2018, but the bulk of it came from the healthcare sector.
Healthcare fraud accounted for $2.5 billion in fraud recoveries for the federal government in 2018, and it came from a variety of sources within the healthcare sector, including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories, and physicians, DOJ said.
It's the ninth straight year that DOJ's civil healthcare fraud settlements and judgments have exceeded $2 billion. The recoveries reflect only federal losses but additional millions of dollars for state Medicaid programs. Recoveries since 1986, when Congress substantially strengthened the civil False Claims Act, now total more than $59 billion, DOJ said.
"Every year, the submission of false claims to the government cheats the American taxpayer out of billions of dollars," Principal Deputy Associate Attorney General Jesse Panuccio said in media release.
"In some cases, unscrupulous actors undermine federal healthcare programs or circumvent safeguards meant to protect the public health. Such fraud will not be tolerated by the Department of Justice," Panuccio said. "The nearly three billion dollars recovered by the Civil Division represents the Department’s continued commitment to fighting fraudsters and cheats on behalf of the American taxpayer."
Here are five of the big settlements in 2018:
AmerisourceBergen Corp. and some subsidiaries paid $625 million to resolve civil claims that the drug wholesaler improperly repackaged cancer drugs into pre-filled syringes and sent them to physicians treating cancer patients. Federal prosecutors said the drug wholesaling giant profiteered by skimming drug "overfill" contained in the original FDA-approved sterile vials and creating pre-filled syringes through a subsidiary, the now-shuttered Medical Initiatives Inc., that ABC claimed was a pharmacy.
Actelion Pharmaceuticals US, Inc. paid $360 million to resolve claims that it illegally paid the copays of thousands of Medicare patients who used the drug maker's hypertension drugs. Prosecutors said the San Francisco-based Actelion usedCaring Voice Coalition Inc., a tax-exempt patient financial assistance charity as an illegal conduit to pay the copays for a number of expensive pulmonary arterial hypertension drugs, including Tracleer, Ventavis, Veletri, and Opsumit.
A DaVita Inc. subsidiary paid $270 million to resolve claims it provided inaccurate information about patients that caused Medicare Advantage plans to get inflated payments from the government.
Health Management Associates paid more than $260 million to settle fraud charges that included paying kickbacks to physicians and ripping off Medicare and other federal healthcare programs. Prosecutors said HMA, which was acquired by the for-profit hospital Community Health Systems in 2014, paid physicians in exchange for patient referrals and submitted inflated claims for emergency department fees to federal health insurance programs, prosecutors said.
Detroit-based William Beaumont Hospital paid $84.5 million to resolve kickback allegations levelled by four former employees in whistleblower lawsuits. Prosecutors alleged that, between 2004 and 2012, Beaumont hospitals in Royal Oak, Troy, and Grosse Pointe compensated eight physicians with free or substantially discounted office space and employees in exchange for patient referrals, violating the Anti-Kickback Statute and Stark Law.
Also-rans includemedical device maker Alere Inc. paid $33.2 million to settle False Claims Act allegations that it knowingly sold "materially unreliable point-of-care diagnostic testing devices" to hospitals. Federal prosecutors allege that, from 2006 through 2012, Alere sold hospitals its Triage devices, which are used in emergency departments for the diagnosis of acute coronary syndromes, heart failure, drug overdose, and other serious condition.
Pfizer paid approximately$23.85 million to resolve claims that it used a foundation as a conduit to pay the co-pays of Medicare patients taking Pfizer drugs. The government alleged that Pfizer raised the price of one of those drugs by 40% in just three months.
No specific reason was given for the delay, but CommonSpirit Health is expected to be operational on January 31, 2019.
Dignity Health and Catholic Health Initiatives bumped back the closing date for the creation of their merged CommonSpirit Health, from December 31, 2018 to January 31, 2019, Dignity Health said in a media release.
"We continue to finalize the last steps to bring our operations together and to combine our ministries, including the completion of licenses, certifications and other administrative items," Dignity said. "We are looking forward to completing our alignment, and we also want to make sure this is seamless for those we serve."
CommonSpirit Health will include hospitals, outpatient centers, home health agencies, assisted living and retirement communities, and community-based health programs.
The organization will be led by CEOs Kevin E. Lofton, currently CEO of CHI, and Lloyd H. Dean, currently President/CEO of Dignity Health. They will oversee a health system that will include more than 700 care sites and 139 hospitals, approximately 159,000 employees and more than 25,000 physicians and other advanced practice clinicians.
The name CommonSpirit Health was chosen in November from among more than 1,200 possible names. The health systems said they settled on that name because it represents a shared sense of missional service and because it resonates with the diverse populations being served, the organizations said.
The merger becomes official on January 1, 2019, and both health systems vow to invest heavily in healthcare services for underserved areas in southern Georgia.
Atrium Health and Navicent Health have signed the definitive agreement for their "strategic combination," the two health systems announced jointly.
The merger, which takes effect on Jan. 1, 2019, will make Macon, Georgia-based Navicent Health a hub for Atrium Health for central and southern Georgia.
"This important milestone demonstrates our continued commitment to creating a personalized care experience for each and every patient and community we serve," said Atrium CEO and President Eugene A. Woods.
"By the joining of two well-respected healthcare organizations, we will have the privilege to provide even greater access and care for existing and new communities throughout central and south Georgia, while we continue to live our mission to improve health, elevate hope, and advance healing – for all," Woods said.
Under the merger:
Navicent Health will be the central and south Georgia hub for the Atrium Health network, led by the Navicent Health President and CEO Ninfa M. Saunders.
Atrium Health and Navicent Health will invest $400 million for routine expenditures and strategic expenditures to be funded from Navicent Health, $250 million for additional strategic expenditures to be funded by Atrium Health; $175 million for discretionary expenditures to be funded by Atrium Health and $175 million to be funded by Navicent Health.
Navicent and Atrium will continue to invest in underserved communities in central Georgia.
Atrium will maintain and expand Navicent's core services, including its Level I trauma center, tertiary services and teaching hospital.
Navicent will have two members nominated to the system-wide Atrium Health Board of Commissioners or Board of Advisors.
Navicent will have a locally controlled board which will include two members from Atrium.
Former executives at Cleveland Clinic Innovations set up a shell company and submitted inflated bills to the health system for software design and development.
A former executive at Cleveland Clinic was sentenced to 30 months in prison for his role in a conspiracy to defraud the renowned health system out of more than $2.7 million, the Department of Justiceannounced.
Gary Fingerhut, 58, had already pleaded guilty to one count of conspiracy to commit wire fraud and honest services wire fraud and one count of making false statements. He was also ordered to pay back the $2.7 million he stole, DOJ said.
Fingerhut worked at Cleveland Clinic Innovations from 2010 until he was fired in 2015. As general manager of information technologies, and later executive director, he helped doctors and other Clinic personnel with inventing and marketing medical products.
In 2012, Cleveland Clinic Innovations formed a subsidiary called Interactive Visual Health Records, to develop a visual medical charting concept of certain Clinic physicians into a functioning product. Fingerhut hired Wisam Rizk as a consultant and then chief technology officer at IVHR to develop the product, DOJ said.
Fingerhut and Rizk both knew they were prohibited from receiving financial benefit or having any personal or familial financial interests in companies the Clinic did business with, DOJ said.
Rizk created a shell company known as iStarFZE, set up a website, email addresses, and a mailing address in New York City. Once operational, ISTAR submitted a bid to the Clinic to develop and design IVHR's software and to increase the price the Clinic paid for the software design and development, without disclosing his financial stake in ISTAR, DOJ said.
Rizk paid Fingerhut about $469,000 in "referral" fees from 2012 through late 2014. In return for Fingerhut not disclosing the fraud scheme. The fraudsters diverted more than $2.7 million from the Clinic.
Rizk has already pleaded guilty to his role in the conspiracy and is awaiting sentencing, DOJ said.
Federal regulators are asking for public comment and cite 'disparity rates' between state audits and AO reviews of healthcare facilities.
The Centers for Medicare & Medicaid Services is asking questions about potential conflicts of interest between Medicare accrediting organizations and the healthcare facilities they monitor.
"We are concerned that the practice of offering both accrediting and consulting services–and the financial relationships involved in this work–may undermine the integrity of accrediting organizations and erode the public’s trust," CMS Administrator Seema Verma said in a media release.
"Our data shows that state-level audits of healthcare facilities are uncovering serious issues that AOs have missed, leading to high 'disparity rates' between the two reviews," Verma said.
"We are taking action across-the-board to ensure the quality and safety of patient care through strengthened CMS oversight of AOs, and today's RFI is a critical component of that effort."
The query likely will include an examination of The Joint Commission, the nation's largest hospital accrediting organization. In a media statement, The Joint Commission said it is reviewing CMS's requests for comment, but said it is confident in the integrity of the "firewall" between its consulting and accrediting divisions.
"The Joint Commission recognizes the importance of assuring the integrity of the accreditation process, which we accomplish by prohibiting any sharing of information about consulting services for individual organizations with anyone involved in accreditation," the statement read.
"The Joint Commission as an accrediting organization and Joint Commission Resources, Inc. as a provider of education and consulting services are two separate organizations. The Joint Commission enterprise has long-standing firewall policies, practices and procedures in place that assure that this goal is achieved," the statement read.
Analysts believe Friday's ruling declaring the ACA to be unconstitutional will get tossed out on appeal. Until then, however, the ACA's precarious status will sow uncertainty across the healthcare sector.
A federal judge's ruling that the Affordable Care Act is unconstitutional could be bad news for states, healthcare providers, and health insurers, financial analysts say.
Moody's Investors Service, Fitch Ratings, and S&P Global Ratings this week issued near-identical predictions of rough times ahead if U.S. District Judge Reed O'Connor's ruling late Friday is not reversed on appeal.
"If the entire law is found to be unconstitutional, federal funding for Medicaid expansion and subsidies to individuals purchasing insurance on the health exchanges would end—an outcome that would be significant for all affected sectors," Moody's said.
Hospitals
"This scenario would be credit negative for hospitals, especially those in Medicaid expansion states," Moody's said, "because it would increase the number of uninsured patients, resulting in higher bad debt and uncompensated care."
S&P said tax-exempt hospitals and healthcare systems—which provide the bulk of U.S. healthcare—"will see a broad diminution in credit quality over time in our view as the growth in both bad-debt expenses and charity care costs would directly lower operating margins."
That concern was already raised this week by Bruce Siegel, MD, president and CEO of America's Essential Hospitals, who said safety nets would suffer the most if O'Connor's ruling is upheld.
"The crushing rise in the number of uninsured patients likely to follow this decision, absent a higher court's reversal, would push these hospitals to the breaking point," Siegel said. "Communities across the country are in jeopardy."
Fitch Ratings agreed that any reductions to the ACA will be detrimental for the not-for-profit healthcare sector, particularly in states that have expanded Medicaid.
"Those that currently receive healthcare insurance under expanded Medicaid would likely become bad debt or charity for provider organizations," Fitch said.
S&P said for-profit hospitals will also see rising numbers of uninsured patients, bringing higher levels of uncompensated care and pressuring margins, "but most likely not as bad as tax-exempt hospitals because they typically operate in markets that tend to have a more commercially focused payer mix."
Hospitals and companies that provide healthcare with mandated coverage under the ACA such as emergency services, mental health, and substance abuse treatment, could also be adversely affected, S&P said.
Health Insurers
For insurers, Moody's predicts that the end of federal funding would be a credit negative because it would eliminate the Medicaid expansion, which accounted for most of the net gain in the insurance rolls.
Ending the ACA would also eliminate subsidies on the health exchanges, making insurance unaffordable for many of the nine million people now getting assistance, Moody's said.
S&P said eliminating the ACA would mean lower revenues and membership from payers' individual and Medicaid businesses.
The elimination of the ACA would allow insurance companies to deny coverage for people with pre-existing conditions, S&P said, and it could also spur interest in short-term, or minimum benefit plans that could help insurers offset the loss of business from the individual markets.
"To the extent these types of policies replace more comprehensive policies, greater bad debt expense for inpatient providers can be expected given the coverage limitations inherent in these policies," S&P said. "Preventative services to the newly uninsured would decline with an expectation that more expensive emergency room care and inpatient care would have to be provided."
Ultimately, S&P said, eliminating the ACA would make health insurance more expensive for the people with chronic conditions, which could result in more medical-expense driven personal bankruptcies.
Historically, uninsured care costs were taken on by state governments using risk pools and cost-shifting to commercial plans, but S&P says those days are over.
"Employers, in our opinion, are increasingly unwilling to pay those costs," S&P said. "The current array of insurance products already requires consumers to pay more for their healthcare, which reflects a combination of rising costs for employer-based health insurance and employers' desire to pay less."
"This is not a new trend, but we believe it would be exacerbated by elimination of the ACA," S&P said.
State & Local Government
States that expanded Medicaid under the ACA would likely revert to prior eligibility levels and eliminate ACA-related spending, Moody's said.
"Although many states have 'poison pill' language in their Medicaid expansion laws that would eliminate expanded state coverage if the federal law is struck down, they nonetheless would face political pressure to help their expansion populations," Moody's said.
S&P noted that the loss to states of billions of federal dollars for Medicaid expansion would represent a significant cost increase for states hoping to maintain coverage for the expansion population.
"Furthermore, we expect the withdrawal of federal funding flows would have an incrementally negative impact on regional economies, which are already poised to see economic deceleration as the effects of the fiscal stimulus from the tax cuts begins to fade," S&P said.
Longer-Term Outlook
The three bond rating agencies all believe that O'Connor's ruling will be overturned on appeal, either in the 5th Circuit Court in New Orleans, or in the U.S. Supreme Court, which upheld the constitutionality of the ACA in 2012 and 2015.
"Ultimately, we believe the ACA will survive through the appeals process as it has survived other challenges in the Supreme Court," Fitch said. "However, renewed debate on the ACA will generate further uncertainty for healthcare providers and the general public alike."
Longer term, if the ruling is upheld, S&P said it has "the potential to change the direction of the current efforts to reform the U.S. healthcare delivery system fundamentally."
"Given the makeup of the incoming Congress, we think it is highly unlikely bi-partisan compromise could be reached on such a large subject, one that amounts to one-sixth of the U.S. economy," S&P said. "In our view, the demise of the ACA would become the number one issue in the 2020 presidential election."
