Earlier today, the Supreme Court finally ruled on the Affordable Care Act (ACA), upholding the vast majority of the law. The landmark 5-4 decision affirms the Affordable Care Act, President Obama's signature domestic act, with Chief Justice John Roberts wrote the majority opinion. The individual mandate for the purchase of health insurance was affirmed not under the Commerce Clause of the U.S. Constitution, but in the form of a tax, as the court ruled that the federal government cannot use the Commerce Clause to justify the individual mandate because the government cannot force people to purchase services. However, it sustained the mandate under the concept of its being a tax, as there is no criminal or civil penalty for not purachsing health insurance under the ACA. The court also ruled that the Medicaid expansion provided for in the ACA is constitutional, but that it would be unconstitutional for the federal government to withhold Medicaid funding for noncompliance with the expansion provisions.
While many groups have issued statements today on their opinions of the court's ruling, the effects of the decision will most certainly unfold over the coming months and years. As we've discussed in HEALTHCARE DESIGN several times over the last few years, many health systems have been in a holding pattern in the wake of healthcare reform, unwilling to commit to expensive large-scale building projects in a future that remained cloudy. According to McGraw-Hill Construction’s Dodge Project Center (as quoted by Architectural Record), healthcare construction starts have declined in recent years. After peaking at $30 billion in nationwide starts in 2008, the amount dipped to $24.4 billion in 2010 and $23.0 billion last year. Through May of this year, total starts (in square footage terms) were down 24 percent.
Sheila Cahnman, Group Vice President/Regional Healthcare Leader, HOK, Chicago, certainly thinks that trend is nearing an end, but not as soon as everyone would like. "The healthcare industry can now move ahead with far more certainty with one less 'ball in the air'," says Cahnman. "Health systems are still unsure of their projected revenues, but have already established that they are going to continue to decline, regardless of this ruling. In the short term, they will continue to push for improvements to lean operations to increase their bottom line. Hopefully with some more stability in financial outlook, they will start to address more infrastructure improvement issues including aging chassis that do not support lean operations or improved patient satisfaction. Long term, we will continue to see more development of ambulatory care facilities that support an accountable care mission of reaching patients early and easily. Public hospitals will need to improve their facilities to become more competitive in the market place. The new market realities will continue to require healthcare designers to do more with less, just like our clients."
David Allison, FAIA, FACHA, Professor of Architecture and the Director of Graduate Studies in Architecture + Health, Clemson University, still sees some big question marks on the horizon, however. "In the long run, it will hopefully be better for healthcare than the status quo, which was certainly unsustainable," says Allison. "I am unclear how this ruling impacts the healthcare design community in the short term beyond creating some stability for the context under which healthcare providers will operate, allowing them to move forward on capital investments that have been on hold due to uncertainty. That may not materialize though given the politicalization of healthcare and the upcoming elections."