The Supreme Court Upholds the Affordable Health Care Act, A Counterpoint

I have only recently found the time to properly respond to Paige P.'s recent post published here at Boomtown Review, and I wanted to take the time to give my own comments on her claims, and offer a few facts on the Affordable Care Act.



First we start with a very, ah, bold assertion about the constitutionality of the Affordable Care Act;

What I see is when the side that believes the mandate is constitutional, they believe that the entire bill is constitutional, and in my opinion, it is not. No, I do not believe that the government should be able to "technically" force healthcare on any citizen, but the truth is we have millions of Americans that do not have coverage. (emphasis mine - JMG)

I respect and cherish differences of opinion, but this is getting tiresome. The Affordable Care Act as run the gauntlet of the American judicial system, and has consistently been upheld as constitutional; the latest being none other than the highest ranking justice on the nation's Supreme Court. The time to litigate the ACA's constitutionality has expired—finally—now after over two full years after it was signed into law.



Next, the author makes a kind of confused assertion about the mechanics of the bill:

Unfortunately, the "affordable" part of this pitch lies on the backs of the Americans that currently have health insurance. (emphasis mine - JMG)

I am sorry if I lose my composure a bit, but this is just silly. The only credible reason one can make the claim that the Affordable Care Act is built on "the backs of Americans that currently have health insurance" is because our entire health healthcare system is built up on the backs of the insured. That's how American heath healthcare works! If you don't have insurance, there are very few options available if you need any kind of preventative care, aside from being so destitute that you qualify for your state's Medicaid program.



There's a lot of talk in conservative circles about how 'you can always go to an emergency room,' which is a really awful health policy plan —from both a public health and fiscal health perspective. It's quite bad for the hospital, which has to inflate it's billing prices across the board to cover the uncompensated cost of emergency room care; and it's terrible for the patients who have chronic issues, yet can't access preventative care. By almost every metric, US health outcomes are really bad; we spend more money on healthcare goods and services than any other nation on the globe, both per capita and as percentage of GDP, but our public health outcomes are mediocre, which is underscored by the fact that nations who spend far less money consistently have better public health outcomes. As the Commonwealth Fund bluntly states "The U.S. health system is the most expensive in the world, but comparative analyses consistently show the United States underperforms relative to other countries on most dimensions of performance."



Conversely, Paige brings up some interesting, if somewhat muddled point about the ACA's 'Cadillac-plan' tax provision. Pagie's explains that

For those of you that do not know what this [Cadillac-tax] is, it is a provision that adds an additional tax on healthcare plans that exceed a certain dollar threshold for individual care and family care. The theory behind this is that companies will work harder to find better deals for their employees, a bunch of garbage if you ask me.

I wanted to make two points on this; first, I am not sure how market forces could be characterized as a "bunch of garbage." Cost sensitivity is one of the most important elements of consumer behavior, and lack of cost-sensitivity is one of the major problems with the Unites States' health insurance market. Next, provisions like the 'Cadillac-tax' are sadly necessary because how how entrenched the dysfunctional elements of American health care has become. As Matthew Yglesias explains:

[...] the key thing about it is that the definition of what counts as a "Cadillac" plan is pegged to the overall rate of Consumer Price Index inflation. That means that over time more and more plans will be subject to the excise tax, offsetting the impact of the deduction for employer-provided plans. They put this in the bill to get something the CBO would score as reducing system-wide health expenditures, and the CBO scores it that way because they think it's equivalent to phasing out the deduction.

Yglesias continues:

Saying you think Obamacare's increase in taxation of investment income should be rolled back and replaced with more aggressive implementation of the excise tax is a far cry from positing a deep-seated philosophical disagreement with the overall approach. At some point, everyone had to look at the overall legislative package and decide if they were "for" or "against" it, and ever since that moment the debate about the specific elements of the progam has gotten extremely fuzzy and overly polarized.

Lastly, I wanted to bring up a more general point about the Affordable Care Act and how Paige characterizes it. She closes her arguments against the Affordable Care Act by reviving the usual boogymen tropes about socialism:

There is a reason that the world's longest reigning communist dictator, Fidel Castro, applauded Obama for this system. Hitler, Lennon [sic], and Castro have all used socialized medicine as ways to subjugate their people.

This is really beyond pale for me. Actual socialists hate the Affordable Care Act. They (hyperbolically) allege the law that the bill is a 'huge giveaway' for the pharmaceutical industry. I find these kind of criticisms to be simplistic and reductive, not to mention completely ignorant of the fact that the Affordable Care Act is not an entitlement program. The ACA is an attempt to correct the market failures of the US’s current health insurance market, with specific provisions such as exchange market regulations, state-level grants and waivers, and a raft of other possible policy solutions to our rampant healthcare cost inflation trends.



The entire point of the Affordable Care Act is to bring everyone into the health insurance market, just like property taxes are designed to being everyone into the public education market, and gas taxes bring everyone into the public roads market. There's nothing 'socialistic' about that, beyond the general collective compromise one needs to make to live (healthily) in a mature industrialized democracy.

The Supreme Court Upholds the Affordable Care Act

The opinion is available here. The vote was 5-4, with Chief Justices John Roberts "deliver[ing] the opinion of the Court with respect to Part III–C, concluding that the individual mandate may be upheld as within Congress’s power under the Taxing Clause". Anthony Kennedy was a part of the dissent, along with Antonin Scalia, Clarence Thomas, and Samuel Alito. Amy Howe of SCOTUSblog writes:

In Plain English: The Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. There were not five votes to uphold it on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power. That is all that matters. Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose new funds if they didn't comply with the new requirements, rather than all of their funding.

I am quite taken by the fact that Roberts was the deciding vote of affirmation. A pet theory that was bouncing around on Intrade just before the ruling was that Justice Roberts would be, at the very least, cognizant of the historic nature of the ruling, and how it might influence historical evaluations of the Roberts Court. I think historical concerns or not, the Court has affirmed a quite clearly constitutional law, and today's ruling is a positive step towards keeping the United States on the right track to controlling healthcare costs and improving national heath outcomes.