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Collateral Damage

By Dr. Sachin D. Shah

Predicting how the Supreme Court is going to rule on the constitutionality of the individual mandate, which may decide the overall fate of the Affordable Care Act (ACA), is tricky business.  Of course, that hasn’t stopped anyone from speculating.  And while there’s plenty of postgame political spinning from both sides of the aisle as we await a final decision in June, the conclusions of many reasonable analyses suggest the ACA may be in danger.


The votes of the Justices have been cast, and a preliminary decision has already been made on the central questions that were argued.  The majority and dissenting opinions are now being drafted.  And while Justices have been known to change their minds as they review the drafts of the opinions, there is cautious optimism on the part of the opponents of the ACA and real consternation on the part of those who support it.


During the three days of oral arguments, the case received an extraordinary amount of coverage in the media.  It’s not surprising: this is an election year and the case will determine the fate of the signature legislative achievement of President Obama’s first term. 


What was utterly disappointing, though, was how the attention was framed in almost exclusively political terms.  How much will the ruling benefit the Republican Party and hurt the Democratic Party?  How will it impact the Presidential Election in November?


This is a sad testament to our complicity in the embarrassing spectacle our political system has become.  We’ve become so engrossed in the hyperpolarized partisan infighting, we’ve forgotten the fundamental objective of health care reform: improving access to health care.


Regardless of your position on the political spectrum, it’s clear that the ACA, if allowed to stand, is poised to dramatically improve access to health care for tens of millions of Americans.  If the ACA is overturned, sure, it’s bad for President Obama and the Democratic party.  Perhaps in the bigger picture it’s bad for Republicans, too, since in the eyes of many the ACA (with its reliance on the individual mandate) represents the only viable avenue for a private health insurance system to succeed in the U.S.


More importantly, though, it’s bad for the over 50 million Americans without health insurance, 30 million of whom are expected to be covered under the ACA. The arguments over whether or not the individual mandate is constitutional, indisputably colored as they are by politics, are intriguing, and I’ve followed them with great interest.  But they are academic. 


What’s far more salient is the fate of the ever growing millions of vulnerable, disenfranchised Americans without access to health care because we cannot come up with a sustainable system to address this crisis.  If this monumental effort (the ACA) is struck down or repealed, conventional wisdom suggests it will be decades before we see another far reaching attempt to reform our health care system (see Clinton Health plan, circa 1993).  The political capital required will be prohibitive, and the deeply entrenched and antagonistic nature of our current two party system will make another endeavor of this magnitude nearly impossible for the foreseeable future.  Oppose the ACA if you must, but it represents an earnest effort to improve access to health care for millions of people without a voice in this debate.


If the ACA is struck down, the ranks of the uninsured in America will undoubtedly grow, well beyond the 50 million people we currently count as part of an appalling indictment of our values as a nation.  As if some people don’t deserve health care.


Perhaps we’ll eventually find a way to expand coverage through Medicare, Medicaid, and the Children’s Health Insurance Program.  Perhaps we’ll eventually realize that a single payer system (financed by a decidedly constitutional payroll tax, which is how Medicare is currently funded) is the only sustainable solution to achieving quality and cost-effective care for all Americans, since expanding coverage via the private insurance system without an individual mandate will be impossible.


Maybe someday we will get there.  In the interim -- potentially another generation -- there will be an unconscionable amount of (additional) unnecessary suffering.  How either political party is affected by the SCOTUS decision in June should be a distant, secondary concern in this discussion. More people will die because of lack of access to health insurance, which is the real impact if the ACA is struck down. That should not be celebrated as a victory for anyone.

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