As I contemplate the tragically flawed Affordable Care Act, I feel neither the glee of its opponents nor the defensiveness of its proponents. I feel sorrow. A rare moment in history, an opportunity, has been squandered. To whom do I ascribe blame? Mostly, of course, to those who resisted at every turn the effort to extend health care to everyone who lives within the borders of the U.S. I blame them, but I understand they were true to their hard-hearted ideology. I judge more severely those who compromised on core principle. By doing so they not only offered a neutered hybrid of health reform, but likely poisoned the well so that future attempts to fix health care in the US will be doomed for years to come.
Pragmatism is supposed to be about dealing with reality. What transpired with the passage of the ACA was not pragmatism but capitulation. The misbegotten offspring of the insurance/government alliance offered neither universal coverage nor uniformly affordable coverage.
Either health care is a basic human right or it is not. If it is, then it correctly falls to the government to provide its citizens with access. And government services are funded by taxes. Sometimes the tax is dedicated, like Social Security and Medicare, and sometimes it’s a tax that comes out of general funds, like national defense.
When Justice Roberts endorsed the constitutionality of the Affordable Care Act, he did so with what some considered tortured reasoning. He looked to the Welfare Clause of the Constitution (Article I, Section 8), which bestows upon Congress the “…Power to lay and collect Taxes…(to) provide for the general Welfare of the United States…”. In order to arrive at his decision, Justice Roberts decided that the penalty incorporated into the ACA constitutes a tax; if the penalty is a tax, then the tax is authorized by the Welfare Clause.
However, if the ACA had not become an unviable hodgepodge of incompatible ideologies, if it had remained true to the principle of health care reform, then the whole program would have been funded by a tax. In that case, Justice Roberts would not have been obliged to twist himself into a judicial pretzel in order to support the law. That law, if it had come before the Court, would clearly have fallen under the authority of the Welfare Clause. Another provision of the Welfare Clause, that a tax for the general welfare be uniform in effect, would also have been satisfied in this instance. True universal health care would have applied to every person living in the country–as Medicare applies to everyone over the age of 65.
There’s a kind of natural analog to what happened to health care reform. When different species attempt to mate, the result is usually unviable offspring. Intrinsic mechanisms within the cells of these misbegotten offspring simply cannot coordinate; nuclei–which send out messages–and mitonchondria–which interpret and carry out function, cannot work together. Neither can a law work if it is intended to provide for the general welfare but must go through a profit-incentived market apparatus to do so. The ultimate goal of health care reform–to provide universal heath care as a basic right–gets lost in the gears of a mechanism intended to generate money, not public good.
I still hold out hope that somehow the ACA will turn out to be the first step toward universal health care. However, I do not underestimate the determination of opponents. And I perceive both incompetence and a dearth of commitment in those who are supposed to advance reform.
I fear that enactment of true universal health care legislation may be dead for years to come. I fear that even if the ACA survives its current challenges, it will be so severely handicapped as to result, for many, in no health care at all.