While reading the Supreme Court’s decision on King vs. Burwell, I realized that I was not surprised by the ruling. It fits the pattern that has developed over the last several years. The letter of the law has not applied to The Affordable Care Act, this was true when it was upheld as a tax instead of an abrogation of the Commerce clause, and now the ruling has massaged the meaning of subsidies that apply to state run exchanges to apply to everyone.

The other thing that has not changed is the fact that patients will continue to find access limited by rising out of pocket expenses in the form of rising deductibles, co-insurance and premiums that are expected to continue to increase further. We can continue to look forward to patients using emergency rooms as primary care centers because they can’t afford to see a physician and independent physicians closing their practices or becoming hospital employees further exacerbating the doctor shortage. The ruling does nothing to change the reality that having health insurance in the age of Obamacare does not equal access to quality healthcare.

Finally, the winners have been rewarded. When the stock value of health related companies such as corporate hospitals rise on the news of the decision, doctors and patients should take pause. The insurance companies and hospitals have clearly figured out that business as usual can continue. In fact, it will become business as usual on steroids.  Insurance companies will be empowered to further limit their physician panels, they will continue to decrease the medications that they will cover, they will continue to decrease what they cover as medically unnecessary and experimental to limit access to physician directed care while they increase their premiums increasing their profits in the bargain. Hospitals will continue to get larger taking over the market and setting prices without pressure from honest competition from independent physicians, ambulatory surgery centers, labs and radiology centers that would encourage cost control.

The King vs. Burwell decision has answered the question of who stands to gain in the age of Obamacare. Justice Roberts in his opinion said it best “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”  With this decision medical insurance companies, hospitals and other pieces of the corporate healthcare delivery system now have the scale clearly tipped in their favor at the expense of doctors the patients – the mission has been accomplished.