It’s about time

Court’s rul­ing caps a cen­tury of re­form strug­gle and pol­icy twists

Modern Healthcare - - OPINIONS EDITORIALS -

If you find your­self near Oys­ter Bay in New York and hear a sound like the purring of a con­tented griz­zly bear, it’s prob­a­bly the ghost of Theodore Roo­sevelt. Ex­actly 100 years ago, Roo­sevelt broke from the Re­pub­li­can Party, which he thought had aban­doned his re­forms. He ran for pres­i­dent on the Pro­gres­sive Party ticket and en­dorsed a na­tional health­care plan. Since then, more than half a dozen pres­i­dents have tried, with lim­ited suc­cess, to ex­pand cov­er­age (See chronol­ogy, pp. 14-19).

Now, the U.S. Supreme Court has up­held Pres­i­dent Barack Obama’s re­form law in a con­vo­luted de­ci­sion au­thored by the chief jus­tice and clearly aimed at de­fus­ing al­le­ga­tions of ex­treme par­ti­san­ship against the court. And it’s worth re­flect­ing on how we ar­rived at this place in his­tory.

Decades af­ter Roo­sevelt’s cam­paign, dis­sat­is­fac­tion with the na­tion’s crazy-quilt health­care “sys­tem” grew. In the 1990s, con­ser­va­tive an­a­lysts de­vised their own re­form plans. That think­ing co­a­lesced around a sys­tem of pri­vate in­surance plans. It’s out­lined in a 1991 Health Af­fairs ar­ti­cle ti­tled “A Plan for Re­spon­si­ble Na­tional Health In­surance.” Here are two key points from that pa­per: “(3) All cit­i­zens should be re­quired to ob­tain a ba­sic level of health in­surance,” and “(4) The obli­ga­tion to ob­tain ba­sic health in­surance should be placed on the in­di­vid­ual, not the em­ployer.”

More than 20 prominent Re­pub­li­can law­mak­ers spon­sored in­surance-mar­ket leg­is­la­tion with an in­di­vid­ual man­date. It was an al­ter­na­tive to Pres­i­dent Bill Clin­ton’s pro­posal.

But af­ter Obama won in 2008, Repub­li­cans and con­ser­va­tives re­jected any Demo­cratic pro­posal, and the Democrats even­tu­ally passed the Pa­tient Pro­tec­tion and Af­ford­able Care Act out of po­lit­i­cal des­per­a­tion. Repub­li­cans de­nounced the con­ser­va­tive plan as un­con­sti­tu­tional so­cial­ism.

Most le­gal ex­perts dis­missed the con­sti­tu­tional ob­jec­tions as du­bi­ous at best. One of them, Charles Fried, solic­i­tor gen­eral un­der Pres­i­dent Ron­ald Rea­gan, vowed to eat his kan­ga­roo-skin hat if the Supreme Court struck down the law. None­the­less, con­ser­va­tive le­gal groups pushed to have the law scrapped (June 25, p. 8).

Dur­ing the Supreme Court’s March oral ar­gu­ments, Fried in a Wash­ing­ton Post in­ter­view lamented what he saw as the rea­son for the con­ser­va­tive an­tipa­thy to the ACA: “Pol­i­tics, pol­i­tics, pol­i­tics … I don’t un­der­stand what’s got­ten into peo­ple. Well, I do I’m afraid, but it’s pol­i­tics, not anything else.”

In­deed. To­day, pub­lic pol­icy no longer mat­ters, even if it’s your own pol­icy. If your po­lit­i­cal op­po­nent en­dorses a mea­sure, it must be re­jected.

Here are other things to chew on be­sides hats: About the time of the Clin­ton plan de­bate, de­cid­edly cap­i­tal­is­tic Switzer­land con­tem­plated an over­haul of its mal­func­tion­ing health­care sys­tem. It adopted a plan sim­i­lar to the con­ser­va­tive pro­pos­als in its re­liance on pri­vate in­surance and a re­quire­ment that ev­ery­one buy in­surance.

Switzer­land and other coun­tries that have adopted health in­surance have viewed their moves as moral and prac­ti­cal im­per­a­tives. On the prac­ti­cal side, as health­care ex­perts have noted, a coun­try that cov­ers ev­ery­one has a pow­er­ful in­cen­tive to keep peo­ple healthy and not waste re­sources. The moral de­bate is usu­ally avoided in the U.S. in fa­vor of eco­nomic con­sid­er­a­tions. None­the­less, a coun­try that guar­an­tees its peo­ple the means to life’s ne­ces­si­ties em­braces hu­man de­cency and na­tional unity. In her ACA opinion, Jus­tice Ruth Bader Gins­burg quoted from a 1785 let­ter from Ge­orge Wash­ing­ton to James Madi­son: “We are ei­ther a united peo­ple, or we are not. If the for­mer, let us, in all mat­ters of gen­eral con­cern act as a na­tion, which have na­tional ob­jects to pro­mote, and a na­tional char­ac­ter to sup­port …”

And at this mo­ment in his­tory, we could use more na­tional unity and less po­lit­i­cal games­man­ship.

NEIL MCLAUGH­LIN Manag­ing Edi­tor

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