Somber Words from Robert Reich, Marcia Angell MD, and More: Life After the Health Care Ruling
Within the next two weeks, the Supreme Court is expected to hand down its decision on the Affordable Care Act. If they accepted jurisdiction, the justices could uphold the law entirely or strike it all down, or they could zero in to reject the most controversial aspect, the mandate that individuals must have health insurance.
What would the future hold if the individual mandate were struck down?
There are nine brief opinion pieces from a group of very prominent health policy advocates with myriad points of view.
I suppose if there's a consensus it's that the mandate is bad policy.
Dr. Marcia Angell, the former editor in chief of The New England Journal of Medicine, and a big single payer champion writes that the requirement to buy a defective product (for-profit insurance) is bad public policy, which won't begin to solve our immense healthcare crisis.
The point of health reform was to expand coverage while reining in the unsustainable inflation in costs. Yet, in making the insurance industry the linchpin of his reform plan, Obama ensured that health costs would grow even faster. By throwing the industry millions of new customers and billions of federal dollars, the law with its mandate is inherently inflationary. No health reform can work if it's not affordable. As premiums mount, so will deductibles and co-payments, until many Americans will have insurance that they can't afford to use (which is the current situation in Massachusetts).
So if the mandate is struck down, I will not be sorry. We will no longer be tempted to think we've solved the problem of providing universal care. The rest of the law will probably go down with it or unravel (even though there is no reason why the provision to extend Medicaid, which accounts for fully half the additional coverage, couldn't stand alone).
Robert Reich argues that if the mandate falls, but the rest of the law remains, insurers will resist the guaranteed issue and community rating provisions, and might be amenable to a 'grand bargain' which would allow a public option/Medicare buy-in to be re-introduced.
But the requirement to cover pre-existing conditions has proven to be so popular with the public that Congress will be reluctant to scrap it.
This opens the way to a political bargain. Insurers might be let off the hook, for example, if they support allowing every American, including those with pre-existing conditions, to choose Medicare, or something very much like Medicare -- in effect, what was known during the debate over the bill as the “public option.”
So in striking down the least popular part of the law -- the individual mandate -- the court will inevitably bring into question one of its most popular parts -- coverage of pre-existing conditions. And in so doing, such a ruling could open alternative ways to maintain that coverage -- including ideas, like the public option, that were rejected in favor of the mandate.
If health reform is struck down in its entirety, however, not only would the uninsured lose, so would other constituents with health insurance, like the elderly. One of the unsung benefits of the Affordable Care Act is Medicare’s Annual Well Visit exam, which has been offered since 2011. Thanks to these visits, which I perform everyday in my primary care clinic, I have the opportunity to evaluate seniors for their risk of falling, screen for depression and ensure preventive services like vaccines and cancer screening are adhered to. . . .There will be no shortage of political opinion once the Supreme Court’s decision is rendered. Striking down all or part of the Affordable Care Act likely won’t affect these politicians or commentators, who are already secure in their health benefits. Our most vulnerable patients, whose voices you won’t hear, stand to lose the most.
Amen. I urge you to read all this expert commentary, rough days are imminent.