Obamacare and the high court

Focus of the Supreme Court case is on scope of the law

This week, the U.S. Supreme Court is hearing arguments about the constitutionality of the Obama administration’s 2010 health-care reform plan.

That is all. The court will not rule on whether it is a good idea, whether it is well-designed or whether it is cost-effective for the government or affordable for individuals. It will not rule on whether the free market could do a better job, or whether that market has failed abysmally. It will not rule on whether the president’s program is a top-secret plot to force Americans to eat broccoli or use contraception. All those points are in question (although some should not be), but they are not before the Supreme Court this week. The issue is not health care, but government’s relationship with its constituents.

The centerpiece of the case is the requirement that Americans either obtain insurance, through any of a variety of means, or pay a penalty. 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 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 person’s 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 do not disappear. Often, they are 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 less available 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. 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. There is simply too much money in health care to imagine that the market will be allowed to wither.

But the Supreme Court is not being asked to design a fair, affordable system of health care. It 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 federal rules for Medicaid.

Those are specific questions, and the answers will determine much of the future of health care in this country. They carry enough weight. Neither the public nor the administration and Congress nor the court itself should freight them with any more.