This week, the U.S. Supreme Court is hearing arguments about the constitutionality of the Obama administrations 2010 health care reform plan.
Thats all. The court wont rule on whether its a good idea, whether its well designed, or whether its cost-effective for the government or affordable for individuals. It wont rule on whether the free market could do a better job, or whether that market has failed abysmally. It wont rule on whether the presidents program is a top-secret plot to force Americans to eat broccoli or use contraception. All those points are in question (although some shouldnt be), but they arent before the Supreme Court this week. The issue is not health care, but governments relationship with its constituents.
The centerpiece of the case is the requirement that Americans either obtain insurance, through any of a variety of means. Justices also will determine whether the federal government can withhold Medicaid funding from states that do not expand their programs to cover people slightly less poor, at 133 percent of the federal poverty level, than the current Medicaid cutoff. While the court sorts through the legality of those mandates, and while supporters and opponents of the law debate, often bitterly, the need for it, everyone should remember that whatever the Supreme Court decides in this case, the ruling will not, and cannot, completely divorce government from health care.
When medical care is provided, costs are incurred, to be paid by the patient or that persons family, through private insurance mechanisms, by a federal or state program (which are, of course, government,) or not to be paid in any way very closely related to the provision of care. When the latter happens, the costs dont disappear. Often theyre spread among other recipients of health care, especially private-pay patients without an insurance company or a government agency to negotiate their costs.
Without Medicare and Medicaid, several possibilities emerge. One is that costs might rise to a level at which a sharply decreasing number of patients could afford either care or insurance coverage. Another is that providers, unable to cover their costs, would flee the market, resulting in diminished availability of care in many markets and a near void in others, especially rural areas. Innovation could decrease as its potential rewards shrank.
Without government mandates to provide emergency care as well as basic care to certain populations, including children, the overall level of health in this country could drop, increasing both risks and costs for those who can still afford health care. And so on.
Opponents of government programs could argue persuasively that if such programs never had been instituted, a different system would have emerged. No doubt that is true, nor can there be much doubt that one would emerge if the government gradually withdrew from health care finance or that the system currently in place will evolve, because there is simply too much money in health care to imagine that the market will be allowed to wither.
But those arent the issues before the Supreme Court, which is not being asked to design a fair, affordable system of health care. The third branch of the federal government will rule on whether the other two branches have a right to force individuals to attempt, at least, to cover their own health care costs, and whether it can force the states to follow rules the federal government sets up for Medicaid.
Those are very specific questions, and the answers will determine a great deal of the future of health care in this country. They carry enough weight. Neither the public and the states, nor the administration and Congress, nor the court itself should freight them with any more.