This week, the Supreme Court will hear oral arguments in perhaps one of the most hotly debated cases in recent memory -- whether or not the 2010 Patient Protection and Affordable Care Act ("ACA") – which effectively provides universal health care -- is constitutional.
The law, also referred to frequently by its critics as “Obama Care,” is a major national legislative effort to provide health insurance to more Americans. At the most basic level, it aims to extend insurance coverage to millions Americans through an expansion of Medicaid and by subsidizing the purchase of private coverage. Americans would also face a new requirement in 2014 -- to have health insurance coverage of some kind, or face a penalty.
There are two sides to this epic debate. On one hand, supporters of the ACA argue that affordable health care is something all Americans will need at some point in their lives and that requiring citizens to obtain insurance is as fundamental as paying taxes. Experts estimate that there are currently 50 million people in the US who don't have health insurance. The ACA would help to extend coverage to an estimated 30 to 32 million of those people.
On the other hand, some have argued that it is not an economic fact that all people require health care and that Congress exceeded its authority by requiring Americans to maintain health insurance or risk a penalty in the form of a tax.
David Grande, MD, MPA, assistant professor of Medicine at the Perelman School of Medicine and a senior fellow in the Leonard Davis Institute of Health Economics, helps break down this complex case and where the legislation stands now.
Q. What is the Supreme Court considering in relation to the ACA?
A. There are a few key questions. The one that is getting the most attention is whether the government can require people to purchase insurance. If it can’t, then the second question is what parts of the health reform law would fall and what parts would remain if any.
There of course is another major question – and that is whether the court can actually rule on the case now since nobody has technically been impacted by the coverage requirement yet.
Q. What are the arguments that the law is unconstitutional?
A. The argument against the law is that the government can’t require people to purchase something or enter into a private contract.
The argument for the law is that everyone will use health care at some point in their lives and that any one person’s decision to not buy insurance ultimately impacts everyone else. It impacts all of us because in the end, we all pay for the care uninsured people receive.
Q.What would it mean if the court ruled against the law?
A. You have to understand the 3 legs of the stool that the law stands on.
Leg 1 is the most popular. It says that insurance companies can’t deny you coverage or charge you more if you have a preexisting condition. Almost everyone supports this part.
Leg 2 is the controversial part. It says that you have to have coverage. This part is important because if you don’t require coverage and insurance companies aren’t allowed to charge more money to people with a preexisting condition, everyone would just wait to buy insurance until they are sick. It would be like buying car insurance on the side of the road for an accident you just go into.
Leg 3 makes sure people get financial help to afford insurance.
So you really need all 3 of these things to make this all work. Taking away the coverage requirement will make insurance more expensive. So if you want the most popular part to remain in place, you have to be willing to go along with something like a mandate that gets people to participate in health insurance.
Q. Could the entire law be repealed?
A. There are parts which could clearly stand on their own even if there were not a requirement to have coverage. The government could certainly expand Medicaid and give people financial help to buy private coverage and that part would work just fine without a mandate.
But the coverage requirement clearly goes along with the ban on insurance companies denying coverage or charging more for preexisting conditions. Those two parts of the law go hand in hand and it’s hard to see how you keep one without the other.
Q. What would it mean if the whole law was thrown out?
A. It means we would stick with our current system, which is not working for millions of people. It would mean a whole lot of people are not going to have financial protection from an illness.
It would mean that the options to fix health care and cover more people will get really limited. The Supreme Court would have taken away one of the last ways to cover all Americans while preserving our system of private insurance. At that point, you either let more and more people get priced out of health care and lose coverage or you consider a Medicare for all type model.