This month includes two dates significant in the field of American health care.
The first date is March 23rd. That datewill mark the two year anniversary since President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. This groundbreaking law, along with the Health Care and Education Reconciliation Act of 2010) provides the main source of health care reform legislation in the United States today. This legislation reforms certain aspects of insurance programs, increases insurance coverage of pre-existing conditions, expands access to insurance to over 30 million Americans, and lowers projected Medicare spending through improvements in efficiency.
During the last couple of years, it seems there has been one attempt after another to defeat this new law, even though most of its provisions have yet to be implemented. But after this week, we can now say good-bye to the terrible twos for the Affordable Care Act.
The first two years of health care in the United States remind me of something Mark Twain once said: “Rumours of my death have been greatly exaggerated.”
After fierce wrangling in Congress for a year and even bigger hurdles for the better part of a century, progress was finally made toward extending health care for all Americans, a goal of most presidents since Teddy Roosevelt. We still have a long way to go until that important threshold is reached, but PPACA is big step forward.
As the cost of health care has soared and access has disappeared for millions of Americans, this law helps to lessen that trend. In addition to expanded access, cost containment and the elimination of preexisting conditions as a basis of denial are among the new benefits to millions of Americans.
Currently, the U.S. spends more per capita on health care than any other nation and gets less, at $2.4 trillion dollars, and 18 percent of our GDP. As the baby boomers age, this trend was destined to increase prior to the passage of PPACA.
To be sure, many details have yet to be ironed out and most of the benefits of this law will not take effect until 2014. As new steps in implementation take place, we’ve witnessed many administrative hurdles.
A recent point of contention has focused on a “forced” mandate of the Catholic Church to provide no-copay coverage that includes contraception services through their insurance companies for employees of large Catholic affiliated employers such as hospitals. The latest development being that The Obama administration has offered to expand the number of faith-based groups that can be exempt from the contraception mandate, and proposing that third-party companies administer coverage for self-insured faith-based groups at no cost. It remains to be seen whether the Church will officially agree.
The total cost does seem to be a moving target. The Congressional Budget Office has just updated its cost estimates for the second time since last year when it estimated that the gross cost of coverage expansion from 2012 through 2021 would be $1.445 trillion. The new estimate is $1.496 trillion. This is due in part to new projections for economic growth. The law’s supporters would argue that extension of this basic human right is worth the cost.
Many proponents believe the law falls far short of the original mandate to provide a single payer or even universal coverage. But for all its perceived imperfections and seemingly endless adjustments, proponents believe it’s a huge step in the right direction.
The other significant date this month is March 26.
On that date, the Supreme Court will begin its review of this law. After unsuccessful repeal efforts in Congress, two of four federal appellate courts have upheld it, a third has declared the individual mandate unconstitutional, and a fourth has ruled that the federal Tax Anti-Injunction Act prevents the issue from being decided until taxpayers are assessed penalties in 2015. The Supreme Court has now put it on the docket for March 26th through the 28th. A final decision is due by the end of June.
Much of this controversy hinges on an interpretation of the individual mandate and the Commerce Clause. The Obama administration believes that the decision to go without health insurance has an effect on the national economy by raising other people’s insurance rates. This in turn forces hospitals to pick up the bill for the emergency care of those who cannot afford it.
Even more basic to this contested issue is the belief (or disbelief) that access to health care is a basic human right. Among those who would say yes are President Obama, Senator Bernie Sanders of Vermont and others in Congress who voted for passage, Pope Benedict and hundreds of millions of people throughout civilized nations around the world. The day after passage, the head of the U.N. World Health Organization praised the move. As a sidebar, it’s puzzling how the Vatican will reconcile advocacy for universal health care while American bishops have vehemently protested insurance coverage for contraception.
On the other side of the debate, it’s safe to say that those voting against this legislation don’t believe health care is a basic human right. Joining these ranks are the adherents of Ayn Rand, other libertarians, 21st century nouveau Christians of the Rick Santorum variety and most folks right of center along the ideological spectrum including the Republicans who voted against the measure in 2010 and all those opposing it since the time of Teddy Roosevelt.
The projected outcome to the impending judicial review is uncertain. But what is certain is that if this law is struck down, we have no viable alternative currently on the table to bend down the upward curve of health care costs as America’s population grows in number and age but also maintain accessibility at the same time.
At the time of this writing, House Republicans have presented a 2013 budget proposing to cut the national debt by dramatically redefining Medicare and cutting deeply into Medicaid, food stamps and other programs for the poor, while reshuffling the tax code to sharply lower rates. This is clearly regressing in the opposite direction. The proposal for premium subsidies made several months ago falls short in a similar way. Among its shortcomings is a failure to keep pace with a projected rate of inflation.
Perhaps more than any other issue during the past couple of years, the fight over health care in this country has crystallized into a holy war of ideology and culture, with one side recoiling from an intrusion on personal freedom and the other side claiming a denial of personal right from the law’s absence prior to 2010.
As one of only three nations among the Organization for Cooperation and Development, the United States is now moving toward the more egalitarian societies of the other 30 developed nations that already provide universal health care. To the extent that we continue to lag behind or, worse, strike down this law even before its full 2014 implementation in order to assess its full benefits, would demonstrate an American Exceptionalism that’s nothing to be proud of.
Health care reform as embodied in PPACA represents economic as well as social progress. As consenting members of an American society who vote and participate in a range of democratic processes, we have agreed to a social contract. That contract is one that codifies justice as fairness as the American philosopher John Rawls once wrote. In 21st century America where liberty and justice for all are the prevailing principles, the provision of health care is part of that original truth and is our moral responsibility to provide.
Happy two year anniversary to the Patient Protection and Affordable Care Act. Good riddance terrible twos. See you next year in full vindication, the Roberts Court notwithstanding.