This week's Supreme Court decision on the Affordable Care Act has many rejoicing and other fuming. Chief Justice Roberts is heading off to an "impregnable island fortress" (i.e. a teaching gig in Malta), Obama and Romney are refocusing their health care ads, and Americans are still mostly ignoring some very important issues.
Three important pluses came out of the decision. First, people that need health care will have a slightly easier time receiving it at a slightly lower cost to society at large. Those are the goals of the legislation, and progress will be made toward them.
Second, the Chief Justice showed us that the Supreme Court can make an important decision based on law and not politics. In an environment when extreme political stands are the norm (and some very political folks inhabit both wings of the court), Justice Roberts showed that we can put politics aside and do our jobs. Without delving too deeply into legal matters beyond my competency, I can't believe the government can force any number of expensive choices concerning building codes, auto insurance or other matters paid to third parties and yet would be unable to tell us to buy health insurance so that we don't force our local emergency rooms to charge everyone else in town to cover the cost of our care.
Third, this decision showed us that as a country we can make important decisions that try to change our common life for the better. Given the increased use of Senate filibusters, the quickening resort to litigation, and a diminished respect for the "common good", our legislators are less and less able to accomplish anything of real value. In a complex society, only the government is able to regulate, to set standards, and to protect the vulnerable in ways that have the potential to be effective and affordable. We don't always succeed. But we dare not fall into the cynicism that claims that open legislative processes of a free society are less trustworthy than the private decisions of individuals in any business or industry who are (rightly) concerned with their own profit and corporate future. Businesses have a primary responsibility to their shareholders. Good businessmen and women work with others in government to make sure the rules of the game are fair and that work is done together that no one could or would do individually. Health care has become one of those public areas of the commonweal. Even if the Affordable Care Act isn't perfect, the government's ability to pass and implement legislation in this arena is essential for the health of our democracy.
While the above are all reasons to celebrate small steps forward, I can't help but feel they are no more than baby steps. At least three issues still remain.
The first problem is that the provision of the legislation requiring states to expand Medicaid was struck down. If 16 million uninsured are still wandering into emergency rooms for expensive treatments to problems that could have been dealt with through a quick immunization or routine preventative care, many of the needed cost savings will probably not materialize. This leads us to the second problem.
The second problem is that the entire Affordable Care Act is an attempt to improve with the health care system we currently have, but that system is seriously broken. Almost all the money goes through insurance companies, and inordinate amount of resources are used to pay for aspects of health care financing instead of medical care. Instead of going to a doctor and receiving care, we go through an insurance company that has someone on staff to talk to the doctor's office, which has to hire someone just to deal with insurance companies. (This is oversimplified, but not by much.) Until we put almost all of our health care resources into care, we aren't going to be able to afford the health care we need. The Affordable Care Act is a step in that direction, but until we are using some kind of modified single payer plan, our premiums will continue to go up, health care for retirees will continue to cripple public budgets, and health care costs will make American industries less competitive.
Even with all the changes that would be made in an ideal world, health care in the United States will never work until we decide to all accept the health care we need instead of the health care we want. We want
never to die or to have our loved ones die. American medicine can go far along those paths, if we spend tens of thousands of dollars in the last months of life to keep someone alive. How much is one last birthday party worth to someone in their late 80's? Good question, and I'm sure it will be worth a lot more to me in forty years. But when someone spends weeks in the hospital getting that last birthday party while their grandchildren go without health insurance, we are not making good choices as a society and we are not providing the structure necessary to loved ones to make good choices at very difficult times in their lives. In a similar vein, we cannot expect society to pay unlimited amounts of money to correct individual bad lifestyle choices. Certainly we have to help people, especially people in need, but unless our health care budget it unlimited (which is what our current insurance premiums seem to imply), we need to be able to make choices as a society about what to cover, and provide the resources for people to live into those choices.
Obviously, these issues are thorny. They won't be successfully discussed in sound bites or tweets. But eventually we will have to deal with them, at least for everyone except the very rich. America is still capable of tackling such hard work when we want to. The Supreme Court decision upheld the framework for us to do such work. For that we can be grateful.