Protesters debate healthcare reform Thursday outside the U.S. Supreme… (Kris Connor, Getty Images )
The Supreme Court's lengthy decision upholding healthcare reform contains enough intricate twists and turns to fuel reams of law review analyses. But the majority opinion by Chief Justice John Roberts upholding the law's core provision, the mandate that individuals pay a tax if they lack a health policy, should clear away one major obstacle to public acceptance of the reform: doubt about its constitutionality.
There's still a lot of hard work to be done to communicate the benefits of the 2010 law, as well as how much still needs to be done to make the American way of healthcare less dysfunctional.
The core dysfunction addressed by the healthcare reform act is that tens of millions of Americans couldn't or wouldn't buy health insurance but could access the nation's healthcare system anyway. They did so less efficiently or effectively than if they had owned coverage, and by passing on their expenses to government and those who pay insurance premiums.
Opponents of the law, and the conservative minority in Thursday's ruling, chose to treat those non-buyers as non-participants in the healthcare market who were being forced to buy a product they didn't want. But they're not exempt from that market — they just didn't pay for their care in advance, or ever.
Indeed, government statistics cited by justice Ruth Bader Ginsburg in her separate opinion, concurring in part and dissenting in part from Roberts', show that 60% of those without insurance visit a doctor or hospital every year, and that 90% would do so within five years. There's no point pretending that anyone can avoid medical treatment indefinitely, Ginsburg added: "A healthy young person may be a day away from needing healthcare ... though scarcely expecting to do so."
The biggest obstacle to public acceptance of the reform law has been ignorance about what was in it. A Kaiser Family Foundation poll in March 2011 — a full year after enactment — found that 52% of Americans said they still didn't know enough about the law to judge its effects on them personally. The gap was filled in by political propaganda, with the result that by last month, polling by Kaiser showed that the public's view of the bill tilted unfavorable (44%) over favorable (37%). The remaining one-fifth didn't know or refused to answer.
How do we know that the negative opinion was swayed by propaganda? Simple: Polling also consistently found that solid majorities of voters favored individual provisions of the law, when they were asked about them in isolation. But when asked about the bill as a whole, they turned thumbs-down. One could envision encounters between pollsters and respondents like this:
"How do you feel about prohibiting insurance exclusions for preexisting conditions?"
"Reducing drug costs for seniors on Medicare?"
"Requiring insurers to spend at least 80% of premiums on actual medical care?"
"Restricting their ability to jack up rates?"
"How do you feel about Obamacare?"
Sadly, blame for this morbid condition belongs to the Democrats who passed the measure and promptly ran away from their own achievement as though they had invented a virus, not a vaccine. President Obama took a belated step in the right direction Thursday in his brief White House remarks following the court decision when he cited the reform act's prohibition of exclusions for preexisting conditions, the coverage of dependents under 26, the limitations on premium increases and the requirement for free preventive care (among other provisions).
For all that, the reform bill as passed still left huge tasks undone in the effort to make healthcare work for everyone in America. The tax provision enforcing the individual mandate may be too meager to drive all holdouts into the insurance pool. A taxpayer without coverage would have to pay $695 a year or 2.5% of his or her income, whichever is higher, and a family of four earning $50,000 would pay a total family penalty of $2,085. Meanwhile, the cost of a family policy is estimated by the Kaiser Family Foundation to be about $14,000 for a family headed by a 45-year-old. How will behavior be affected by those calculations and the available government subsidies? It may be impossible to know until the law is fully implemented.
The law's cost-cutting provisions are another question mark. The ability of insurance companies to raise premiums will be constrained by regulation, but that's not the same as fighting medical inflation. Most of the law's efforts in that vein apply to Medicare, and those tend to hold down costs by pressing down on the reimbursements paid to doctors and hospitals. That's not fair and it may not be the most effective way of wringing costs out of the system. Still, soaring medical inflation has been an intractable problem for decades, so changing the American system wouldn't happen overnight even under the best circumstances.