Supreme Court asked to decide future of US health care

Abstract

The twists and turns of the journey of the new US health-care policy through the US legal system reached its expected end destination when in September, 2011, the Justice Department asked the Supreme Court to review the government's health-care law. The Affordable Care Act, signed into law on March 23, 2010, called for a number of changes that are focused around a central tenet mandating that most Americans must be insured from 2014, or face a tax penalty. This is expected to increase the number of Americans with health insurance by 32 million. However, an individual mandate is vehemently opposed by some, most notably the Republican party, who argue it is unconstitutional, and the law has been repeatedly challenged (but mainly upheld) in the courts over the past 18 months—with the requirement for individual insurance the main point of contention. In August, 2011, the 11th circuit appeals court in Atlanta declared the mandate exceeded Congress's powers prompting the government's subsequent referral and appeal to the Supreme Court. And in a further twist, the 26 states that originally filed the Atlanta suit have also lodged an appeal in the Supreme Court claiming that without this individual mandate the health-care legislation will be unworkable. The government is confident that the mandate will not be struck from the law and argue that it does not exceed its powers of commerce but will save money by preventing cost-shifting—in which the costs of emergency treatment of uninsured individuals are covered by increases in the premiums of those with insurance. This shift is estimated to cost the average insured American family US$1000 every year, with uncompensated care costing $43 billion in 2008. So why is there such opposition? No Republican voted for the bill and several state legislatures have since tried to block its implementation. Opponents say that enactment of the law will cost money, leading to raised taxes, and overburden health-care systems that will be unable to cope with the additional patients. Certainly allowing more patients access to the system through insurance is only a first step on the care pathway, with delivery of services an equally important, and perhaps the biggest, challenge for the reforms. Compulsory insurance—with penalties for those who can afford it but fail to comply—divides opinion according to political leanings, and will win or lose votes accordingly. In 2006, the state of Massachusetts required residents to obtain insurance or face penalties. As a result of the subsequent community reaction and premium costs, questions remain about the Obama administration's mandate on future insurance costs and on the capacity of the current health-care system. Furthermore, businesses must also offer coverage under the reforms, with only those companies with fewer than 50 employees being exempt, and this has understandably sparked resistance within the business community. Nevertheless, these uncertainties and squabbles aside, there are several notable and important aspects of the Act, such as coverage for dependents up to 26 years of age and the removal of caps on insurance, that highlight why the legislation must not be overturned or gutted. A large proportion of health-care costs derive from a small group of the very sick, often with pre-existing conditions. Previously insurers were able to deny this group coverage in a bid to increase their profits whereas the new law ensures temporary coverage for people with pre-existing conditions until the mandate is activated in 2014. However, does not all this legal wrangling and discussion of cost rather miss the point and fundamental philosophy behind the law? Who has not experienced a sudden, serious, and chronic illness in a family member or friend? The law is trying to change a reactive health-care system to a proactive one, with improved access to care for all. Without the individual mandate and proposals to remove caps, many will simply remain uninsured or underinsured. Furthermore, in the current austere times, without a penalty, many will choose to test their luck. Surprisingly, no alternative proposals to replace Obama's law have been suggested by detractors, with Republicans simply calling for it to be repealed, despite many health experts calling the existing system broken. So should universal health-care be a human right, and do those who oppose the law lack a moral compass, or is this a naive and rose-tinted view in the current financial climate? One thing is certain. If the law is repealed, or the individual mandate is removed—and if November, 2012, sees a change of guard at the top—a whole generation will rue a missed opportunity.