For the time being, the United States’ long slog toward universal health insurance coverage remains on track.
The voters could still intervene. A political earthquake in November that puts Republicans in control of the White House and both houses of Congress could overturn Obamacare, a.k.a. the Patient Protection and Affordable Care Act.
But Chief Justice John Roberts’s carefully crafted decision to uphold the reform law’s individual mandate as a legitimate exercise of the federal government’s taxing power affirms an important principle: The national government has the right to intervene in the economy when it serves a social purpose or solves a national problem.
There can be no doubt that the nation’s dysfunctional health insurance and health care delivery systems present pressing national problems that have festered for a long time.
The U.S. provides some of the best health care on earth to most of its citizens most of the time. Yet it does so at tremendous cost and with tremendous waste – $2.7 trillion, 17.9 percent of gross domestic product, $8,953 in 2012 for every man, woman and child. That is far more than any other country on earth by a wide margin.
Despite this huge expense, one in six Americans still does not have easy or affordable access to care because they do not have health insurance. The U.S. is an outlier in that regard, too. Among countries in the Organization of Economic Cooperation and Development – the world’s 30 largest economies – only Chile, Mexico and Turkey insure a smaller proportion of their populations.
For nearly a century, progressives have dreamed of enacting a universal insurance scheme that provides affordable access to health care for all Americans. That’s what led reform advocate Ron Pollack of Families U.S.A. on Thursday to call the Supreme Court decision “a hallelujah moment.”
President Franklin Delano Roosevelt wanted to make it part of his Depression-era New Deal, but realized getting a universal retirement program – Social Security – was a heavy lift on its own. In the immediate post-World War II years, President Harry Truman wanted the U.S. to join when other advanced industrial nations like Great Britain implemented universal coverage. He pushed for a government-run insurance scheme to cover anyone without employer-based coverage, a uniquely American invention that began in the 1930s and expanded rapidly during the war as a way of providing benefits to workers chafing under wartime wage controls. That effort went nowhere, too.
President Lyndon B. Johnson and the Democratic Congress that was elected in the 1964 sweep made a major dent in covering the uninsured by establishing universal coverage for the elderly, the disabled and the poor through government-funded programs. Medicare and Medicaid upheld the primacy of the private market, though. Both programs paid claims to privately- or publicly-employed doctors, clinics and hospitals through the already existing fee-for-service system, which became a major driver of rising costs.
In the early 1970s, President Richard Nixon offered Sen. Ted Kennedy, the liberal standard-bearer from Massachusetts who made universal health care coverage his life’s work, a plan for all Americans that relied on private insurance companies. Kennedy turned him down in what he later admitted was the biggest mistake of his career.
President Bill Clinton tried to revive a version of Nixon’s scheme but failed. The collapse of “Hillary-care” and the election of a Republican Congress in 1994 led to another two decades of stalled progress on achieving universal coverage.
Over the course of those two decades, liberals and conservatives wrestled with the best way to reform what both sides admitted was a dysfunctional system of providing health insurance coverage to people whose employers, often small businesses, failed to provide. Many were low-wage workers who couldn’t afford the high-priced plans offered in the individual insurance market.
It was a conservative think tank – the Heritage Foundation – that came up with the idea of imposing an individual mandate on people, albeit in a deregulated insurance market that would allow companies to sell bare bones policies across state lines. But once you said everyone has to buy insurance, you simultaneously have to guarantee that insurance companies would sell them coverage at rates similar to everyone else no matter what their health status. Only through the individual mandate could insurance companies afford to sell policies to people who had pre-existing medical conditions.
When then-Senator Barack Obama ran for president, he opposed the mandate in debates with, among others, Senator Hillary Clinton, who had pressed the case for health care reform during her husband’s first term. But after his election, as Democrats in Congress wrestled with how to craft a bill that would rely on the private insurance market to achieve near-universal coverage, he, too, came to recognize the wisdom of the conservative idea.
One state that already had the individual mandate served as the model. Massachusetts had crafted a universal coverage law in the mid-2000s under then-Gov. Mitt Romney. A pragmatic problem solver in a liberal-leaning state, Romney became convinced of the mandate’s necessity. Obama and the bill’s architects in Congress followed his lead by including the mandate in the final bill that was signed into law in 2010.
Only when one reviews the entire history of the push for universal coverage over the last half century does one begin to recognize how conservative Obamacare really is. It is not a government takeover of the health care system. It is not a single-payer insurance plan like Medicare for all. It does not even have a public option to compete with private plans in the state-based exchanges where policies will be sold. The legislation relies entirely on private insurance companies to cover the uninsured unless people are so poor that they must be added to the ranks of those covered by Medicaid.
It is also not a takeover of the health care delivery system, although commercials are already running that claim the government will come between people and their doctors, a charge Romney repeated in his statement after the high court decision. Sections of the law do encourage doctors and hospitals to deliver care more efficiently, more effectively and therefore, it is hoped, more affordably using bundled or capped payment models that are already gaining adherence among private insurers and providers.
Romney, standing before the Capitol building after the decision was announced, promised to sign any law that repealed Obamacare. Republicans running for Congress have promised to put that law on his desk. Another symbolic vote in the House repealing the law – it has no chance in the Senate – will take place within the next few weeks.
But what neither Romney nor anti-Obamacare legislators have articulated is an alternative path to universal coverage or even if that is a goal for them. In his statement, the Republican’s presumptive nominee made only one passing reference to the 50 million Americans without insurance. “We also have to assure that we do our very best to help each state in their effort to assure that every American has access to affordable healthcare,” he said. The campaign has yet to offer specifics on how it would help the states or even if he would set that as a goal for states.
The president, meanwhile, in his statement from the White House, dwelled on the benefits that have already accrued to millions of Americans from the reform law. The high court “reaffirmed a fundamental principal: Here in America, the wealthiest nation on earth, no illness or accident should lead to any family’s financial ruin,” the president said. “Today’s decision was a victory for people all over this country whose lives will be more secure because of this law.”
According to polls, a majority of Americans are opposed to his path to that security – the individual mandate, a conservative idea that has become the Democratic Party’s policy. The same polls show they support most of the other provisions in the law.
The choice voters will face in November, then, is between a law they haven’t experienced and whose most prominent feature they oppose, and an alternative that, so far at least, hasn’t been articulated.