By Marcia Angell
Room for Debate, The New York Times, June 17, 2012
If the Supreme Court strikes down the Affordable Care Act’s mandate to buy insurance, it will have done the right thing for the wrong reason. The court’s Republican majority will have used the Constitution as an excuse to undermine President Obama. (Anyone who still thinks the Supreme Court is not a political body hasn’t been paying attention.)
But the mandate is a terrible idea. It requires people to buy a commercial product from investor-owned businesses at whatever price the companies set. The point of health reform was to expand coverage while reining in the unsustainable inflation in costs. Yet, in making the insurance industry the linchpin of his reform plan, Obama ensured that health costs would grow even faster. By throwing the industry millions of new customers and billions of federal dollars, the law with its mandate is inherently inflationary. No health reform can work if it’s not affordable. As premiums mount, so will deductibles and co-payments, until many Americans will have insurance that they can’t afford to use (which is the current situation in Massachusetts).
So if the mandate is struck down, I will not be sorry. We will no longer be tempted to think we’ve solved the problem of providing universal care. The rest of the law will probably go down with it or unravel (even though there is no reason why the provision to extend Medicaid, which accounts for fully half the additional coverage, couldn’t stand alone).
We should see this as an opportunity to undertake real health reform. The only way to provide health care to all Americans at an affordable cost is by instituting some form of publicly administered nonprofit system like those in other advanced countries. After all, they manage to provide universal care at less than half the cost. I favor expanding Medicare (our single-payer subsystem) gradually by lowering the eligibility age one decade at a time, while phasing out for-profit health facilities.
Just as it is irresponsible for Republicans to oppose the Affordable Care Act to weaken the president, it is irresponsible for Democrats to support it for short-term political reasons. We need to evaluate it on its merits, and I believe it fails.
Marcia Angell, M.D., is a senior lecturer in social medicine at Harvard Medical School. She is the former editor in chief of The New England Journal of Medicine.