Today, in a 5 to 4 decision Chief Justice John Roberts joined the four traditionally more liberal members of the court to uphold the key individual mandate provision of the Patient Protection and Affordable Care Act.
The majority found only one Constitutional problem with the law - they said that the federal government could not withdraw existing Medicaid funding from states that did not wish to participate in the Medicaid expansion envisaged under the law. It is unlikely that the federal government ever planned to do this - so this part of the ruling is not of much practical significance.
John Roberts wrote that the individual mandate to purchase health insurance was not authorized under the Commerce clause of the Constitution which enables the federal government to regulate interstate commerce, but it was authorized under the federal government's taxing authority. The fact that the bill mandated no punishment for an individual who does not purchase health insurance other than requiring him or her to pay money to the IRS was sufficient to qualify this penalty as a tax for Constitutional purposes.
Now that the Supreme Court has ruled, a great short-term uncertainty has been removed from the US health care landscape. However, the Patient Protection and Affordable Care Act does not solve the nation's health care problems by a long shot. The law does not effectively control escalating health care costs because it does not force budgetary choices to be made. For example, Medicare is still not allowed to consider costs when deciding which procedures and services are to be covered.
I favor a system of basic universal health care coverage subject to an overall budget cap. Such a system would cover everyone and eliminate the need for such programs as Medicare, Medicaid and the VA health care system. Such a system would also end the current US system of employer-based health insurance - a system that impedes economic growth and reduces employment because it greatly increases the marginal cost to employers of hiring new employees. Employer-based health insurance makes losing one's job a health crisis as well as an economic crisis. And, as we have seen, employer based health insurance odiously may enable employers to impose their religious views on their employees medical care.
I favor testing alternative approaches to achieving the goal of basic universal health care (e.g., single payer, voucher system, etc.) in different localities. For services not covered by the basic package of benefits, individuals would be free to purchase private supplementary insurance. I hypothesize that a well designed and fully funded voucher system may work best for providing basic universal health care coverage. Such a system would involve every citizen receiving a voucher which he/she could use to purchase a private insurance plan which covers, at a minimum, a prescribed set of required benefits. Such a system would harness competitive forces to both attract patients and put pressure on providers to hold down costs. However, hypotheses - including mine - need to be tested.
The action of the Supreme Court preserves health insurance coverage for millions of Americans, but it does not solve the health care problem in the US. That challenge is far from met.
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