The Supreme Court of the United States of America is scheduled soon to return its verdict on the Patient Protection and Affordable Care Act, derisively called Obamacare by some.
There are win, lose and draw judicial scenarios that are being bounced around. With a win for the administration there will be nearly universal coverage of health insurance in the last developed country to have it. There will also be a tab that may cost more than we can afford.
If there is a rejection of the total law, we will be — not back to where we started — in a deeper hole than ever with a population of over 300 million. The number of people without health insurance will climb; families losing everything to medical bankruptcy will become more of a black mark of national shame than ever before; the rich will be fine, but the middle class will be taxed by the medical insurance industry and incomes will further stagnate.
In the meantime, obesity will expand as a health threat. Diabetes will kill kidneys, cause blind eyes, stop hearts and cut off limbs. Tobacco will poison the young, and drugs will fill our emergency departments. Mental health will be ignored, under-diagnosed and more often undertreated.
Lest you think I exaggerate this apocalyptic scene of waste and pain, it already exists. The status quo is fragmentation, duplication, over- and under-regulated segments in a perverted system of financing where doing more makes the big bucks.
This does not say that the ACA if approved in tote is medical nirvana. It has so many pages of law that will only multiply logarithmically the number of rules so that the paperwork itself will clog up all scrub sinks in every hospital in the country.
If the Court approves some parts and not others that also could be a crapshoot. Will insurance companies be required to have a limit to their administrative costs to payment of claims? Will dependent children up to 26 years of age be cut from parental insurance? Is it going to rule against the part about employer obligation to provide insurance or perhaps the most onerous prevision, the federal law to mandate individual coverage or else?
The majority of the nine Supreme Court judges who gave the famous Citizens United ruling of limitless unidentified political contributions have a reputation of conservative thought. So conservative that some feel they interpret the Constitution according to its original meaning in 1789.
The problem is no human wants to return to the medical practice of the Revolution, though it would definitely be simpler: Eat plant bark and die.
So how does our representative democracy, including the courts, fix the marasmus of modern American health care? If the law is deemed unconstitutional, there will be no incentive for Congress to do anything different. Correcting the mess and making universal health care available will not be as important as being re-elected.
If the market is the only means left, money will trump human suffering. The pricing of services will continue to be somewhat arbitrary with procedures and surgeries demanding the majority of the service dollars. Drugs will remain prohibitively expensive for some or in short supply for conditions other than erectile dysfunction.
Medicaid will not be expanded, and states will cut as much as they can to stay solvent.
It would be nice regardless of the decision up, down or sideways to have reasonable and wise people come together to correct the over exuberance of the current law without gutting the intent of improved universal coverage. They would fix the payment system while focusing on quality of care.
If the voting members of Congress messed up, it is unlikely nine Supreme Court justices can do better. You can bet on that.
Joseph Cramer, M.D., is a fellow of the American Academy of Pediatrics, practicing pediatrician for 30 years, and an adjunct professor of pediatrics at the University of Utah. He can be reached at [email protected].