John E. Vitalis, Vitalis & Company, LLC My initial reaction is that the decision will not have a significant impact on medical travel, especially in the short term (next two years), since the PPACA does not really “kick in” for adults until 2014. According to the report, The Uninsured: A Primer, Kaiser Family Foundation, 2010, p. 5, “The vast majority of the uninsured are in low- or moderate-income families.” If you examine the following graphic (from same report), it shows that of the approximately 50 million uninsured, approximately 5 million (10 percent) have incomes at or above 400 percent of the federal poverty level (FPL) ($88,000 for a family of four). In the second graphic you see that 5 percent of those at 400 percent of the FPL are classified as uninsured. Four percent are covered by Medicaid/other public programs. The vast majority of uninsured (63 percent) are at or below 250 percent FPL ($55,125). I believe that this is the largest income group impacted by the PPACA (those uninsured and not receiving Medicaid/other public programs). I don’t know that this group of individuals will have the income required to travel for healthcare services. So, my thought, at this time, is that the PPACA will have little or slightly negative impact on the medical travel industry. There may be some reduction in medical travel by those in the higher income category (above 400 percent FPL), due to medical insurance availability through the PPACA and insurance exchanges. However, the majority of those seeking medical travel in the next five years will likely be the same group as today. Wouter Hoeberechts, CEO, WorldMedAssist In my opinion, the ruling is indeed monumental for the country, but the impact on medical travel is reduced to one of timing of some of the discrete consequences, not substance. PPACA does little to curb the rise of costs of the healthcare system for employers, insurers, providers, patients. Initially, we will see a reduction of demand for medical travel from patients as some of the uninsured will opt to get covered. The amount of people making that choice is unknown because it is not clear what happens to people who do not pay the penalty/tax. Will there be a penalty? Over time, the situation will become more defined.. In order to curb costs, reimbursement rates will continue to drop, providers will focus on being more efficient and, with a continued effort from employers to shift costs to their employees, we will see a healthcare model where quality declines with waiting times increasing, combined with patients who are forced to make smarter choices with their money. All of this is bad for the country, but good for medical travel. What’s key is that the Court’s ruling does not impact these major trends other than the timing of them. Now that the Act was upheld, it will take some time for some of these major trends to really manifest, while others will have a more immediate effect. Regardless of the content of the ruling, having a ruling in and of itself is also good for medical travel. Although some employers have already embarked on the medical travel journey, others were waiting for the ruling. Having this clarity is good, although many questions surrounding the Act remain. Nathan Cortez, Southern Methodist University, Dedman School of Law Given that the Court largely upheld the entire law, most of my thoughts in this article still stand:http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1690690. In short, this is great for the un- and underinsured. But we’ll still have roughly 23 million without insurance after 2014, and some of those people will still need low-cost foreign providers. Grace-Marie Turner, Galen Institute Yes, the Supreme Court’s decision to uphold the health overhaul law is disappointing, but the final judgment on the law will be made by the voters in November. The president now must spend the next four months defending a law that the majority of Americans dislike, and the more they learn about it, the more they dislike it. Worse, the part of the law that is the least popular – the individual mandate – has now been declared a tax. That’s double jeopardy for the president: The unpopular mandate stands and now it is called a tax. And this is only one of the 20 new and higher taxes in the law. In its decision, the Supreme Court has determined that Congress can compel otherwise free private citizens to purchase a private product with their own after-tax money – a product that would cost them $20,000 a year for a family – under penalty of federal law. The court decided that only those who refuse to comply with the mandate will be subject to the tax. Importantly, the court did not base its ruling on the Commerce Clause of the Constitution. The government had argued that this provision should be used to compel private citizens to engage in commerce so the federal government could regulate it. The court said no. By calling the mandate a tax, they have actually put new limits on the Commerce Clause’s ever-intrusive rule over our economy. The first job for the American people is to demand that Congress repeal the PPACA in its entirety. The focus of the November elections now will be fixed on healthcare and on the positions of candidates and incumbents on the law. We all know there are problems in our health sector that must be fixed to get more affordable healthcare and coverage to millions more people. But the health overhaul law tries to do too much, too fast, and a strong majority of Americans have concluded it will limit their choices, lower the quality of care, increase health costs and raise their taxes. While the Supreme Court has declared the law to be constitutional, Americans still overwhelmingly object to the approach that the Obama administration has taken with its law to put one-sixth of our economy under government control. As an analogy, it may be constitutional to raise income tax rates to 100 percent, but that doesn’t mean it is right, and the voters will issue their final verdict at the ballot box in November. The healthcare law must be repealed so Congress can get a fresh start in addressing the problems the American people want fixed: protecting the most vulnerable, help for the uninsured, lower costs, more choices and portability of insurance. Once the healthcare law is repealed, the work can begin in forging targeted bills with bi-partisan support to build toward these objectives. Editor’s Note: Grace-Marie Turner recently appeared on Fox Business where she offered additional insight into the cash versus insurance cost of care and her concerns on how the PPACA will impact costs. To view the clip click here. Ruben Toral, Founder, Medeguides Holding Company Ltd. Philosophically speaking, the PPACA is the right thing to do, and I am happy to see that the Supreme Court left the legislation largely intact. America simply cannot have 50 million people living without access to affordable medical care. That said, the PPACA does not solve the other big issues like how America will manage the rising cost of healthcare or meet the growing demand of healthcare driven by aging and chronic disease. America is getting older, fatter and sicker, and that’s the elephant dancing in the background. Practically speaking, the PPACA has triggered consolidation in the healthcare market, particularly amongst hospitals. Hospitals now employ 65 percent of all the doctors in America, which makes them a much more formidable power, and PPACA will drive more patients through their doors. Insurers have millions of more lives to cover (but take on added risk as a result), and it will be a couple of years before they get the product mix right. US hospitals are going to focus on profitability through better cost-management and efficiencies, and a more efficient US hospital is a more competitive hospital. Think manufacturing. As for medical tourism, the ‘medical tourism industry’ never ever really knew the size, scope and opportunity of the US market, so the impact of the PPACA on the industry is largely academic. As an outbound market, the US still seems ripe for aesthetic surgery, anti-aging and non-Food and Drug Administration-approved treatments (look younger, live longer, feel better). My sense tells me there is still an opportunity to develop products and partnerships with US insurers, who may need or want global options as part of their portfolio. As an inbound market, I think US hospitals will become more cost-competitive and more interested in the international cash-paying patient over the next five years. Editor’s Note: Ruben Toral’s opinion piece How Consumerism, Globalization and the Internet are Changing Health Care appears in the most recent issue of Strategic Review. It can be viewed by clickinghere. Fred Hunt, Active Past President, Society of Professional Benefit Administrators (SPBA) The White House is declaring that the Supreme Court decision now gives everyone certainty. I disagree. I think there is realigned, but continued, uncertainty. First, the decision has galvanized opposition forces to win elections in November and try to repeal the law and come up with a “replacement.” (Reality check: The talk of “first day” and other simple repeals is easier said than done.) Second, it is not clear that some of the segments of the law, such as State Exchanges and the expanded role of Medicaid, will evolve and survive as planned. hird there are half a dozen small specialized lawsuits being brought against the law, such as contraception, doctor-owned hospitals, Medicare, etc. What will impact medical travel? If there is a Republican electoral sweep, and they do indeed try to repeal the PPACA, what then? First, about a dozen of the new features of the PPACA are so popular that they will become permanent fixtures in American health coverage. They have overwhelming popularity among Republicans, Democrats and Independents. So, count on the following in any “replacement:” Insurance pools of some kind; subsidies for people in the pools; mandatory coverage from employers with more than 50 workers; children up to age 26 (maybe even older); banning insurers from canceling policies; and, perhaps, keeping the no-limit on lifetime health costs, which removes incentives from seeking cost-effectiveness in health care. On the other hand, Mitt Romney and the Republicans seem to be returning to the concept floated by Ronald Reagan, George Bush, George W. Bush and McCain to strongly move away from employer-based health coverage and to individual insurance policies. Will insurers be open and enthusiastic about medical travel? Will independent patients have medical travel in the forefront of their mind, and will they actually take an overseas trip at the moment when their ailment is dominating their thinking? The biggest question for medical travel is the role of state exchanges and/or federal exchanges under the current law, and insurance pools expected under any replacement law. How turf-protective will these entities and their political sponsors be? Will they allow patients to go overseas or outside whatever medical network/pool the participating insurers have? What will be the cost and other factors? A significant percent of state exchange/pool enrollees will be getting subsidies for their coverage. Imagine the political reaction to the emotional charge that “American subsidy dollars are going overseas to pay foreign doctors and hospitals instead of right here in America.” Will the US healthcare system undergo a phenomenal revolution of price transparency and Accountable Care Organization-like perfect cooperation and efficiency, or will the bad trends we’ve been seeing continue? So, these are the questions that lead me to disagree with President Obama and say that the Supreme Court case certainly does not provide a sense of “certainty.” Josef Woodman, CEO, Patients Beyond Borders No sound bites here. The answers are “yes,” “no” and “unchanged.” Regarding international medical travel, currently some 70 percent of medical travelers seek treatment not normally covered by any insurance (whether private, government, or as a result of healthcare reform). Such treatments include restorative and cosmetic dentistry, cosmetic and plastic surgery, in vitro fertilization (IVF)/fertility, bariatrics (most health plans do not cover bariatrics except in emergent situations), IVF/fertility, elective testing (MRIs, CT scans, and so on), hearing and vision examinations, second opinions and comprehensive health screenings. Thus, nearly three-quarters of all current medical travel will remain unchanged by healthcare reform. Near-term, if healthcare reform is upheld (i.e. not repealed in whole or part), we’ll see some 16 million Americans becoming covered with health plans. Undoubtedly, given the choice, most in this group will choose not to travel for care that will now be covered under healthcare reform, resulting in a short-term decline in outbound US medical travel. Longer-term, as our already broken healthcare systems struggles to absorb millions of new claims, I expect to see the kinds of burdens placed on the US system as we’ve seen in other economies deploying universal care, such as Canada and the UK. We’ll likely see demand outstripping supply, creating shortages of physicians, nurses and specialists, and resulting in longer waits for diagnosis and treatment, particularly specialty care (e.g. orthopedics, cardiac, oncology). As in countries such as Canada and the UK, we’ll see medical travel increase not so much due to cost-savings opportunities, but in patients seeking global options for more immediate care. In brief, I believe we’ll see international medical travel take a dip in growth over the next couple of years, then pick up again as global options become more attractive, and as cost, quality and patient experience data become increasingly accessible to healthcare consumers. Large shifts in domestic medical travel depend on how employers, insurers and patients react to the establishment of state-run exchanges mandated by the PPACA. Trude Bennett, University of North Carolina School of Public Health The US Supreme Court decision to uphold the PPACA, while allowing states to curtail Medicaid benefits and expansions, will eliminate segments of the uninsured without guaranteeing universal coverage or equitable quality of care for the US population. Though it is impossible to predict the twists and turns of the continuing debate and all of its potential outcomes, one certainty is clear: many residents of the US will remain uninsured. In addition, the failure to regulate or limit rampant profit-making and inefficiencies in the private insurance sector will result in continued growth of deductibles, co-payments and benefit ceilings. Where will the greatest need for affordable services persist? As always, the disadvantaged will be at highest risk of Medicaid opt-outs and service cuts in certain states; undocumented immigrants will be left out of the system entirely; and recent immigrants will still have to endure five-year waiting periods. Some immigrants may return to their home countries for medical care, risking deportation or arrest if and when they seek to come back to their lives and responsibilities in the US. The poor are not a constituency for medical travel, either within or outside the US. It seems unlikely that transnational medical travel would either decrease or increase significantly as a consequence of the PPACA, even if the legislation is implemented to the full intent. Some observers believe that even partial support for the PPACA will leave an opening for more comprehensive reform, and specifically for the establishment of a single payer system in the US. Single payer would allow the possibility of international options for various treatments, based on cost, specialization, and availability of services. At this point the US is quite far from a health system or public decision-making process that would truly prioritize “Health for All” rather than profit and stigmatization of anything besides “personal responsibility.” Perhaps medical tourism has helped to create greater awareness of different models of care and options for treatment in other countries that could arouse the US public to demand greater entitlement to equitable and high quality health services.