First things first: Everyone exhale. The Supreme Court handed a stunning victory to President Obama in upholding his signature health care reform, but it was also a victory for the American people. The ruling, fair and defensible, does not mark the death of the Constitution, as some alarmists have declared, apparently with straight faces. Nor, however, does it mark an end of the political, financial and medical wrangling. Health reform was urgent before the Affordable Care Act was passed and it remains urgent in the aftermath of the court's ruling. We are by no means done yet.
Americans are split over this law in multiple ways. For our part, we have long believed that reform was necessary in a country with the developed world's highest health care costs but only middling results – a nation where millions of citizens lacked insurance, where pre-existing conditions usually weren't covered, where your insurer might abandon you if you got too sick and where the No. 1 cause of bankruptcy was impoverishment because of illness. It simply wasn't tolerable.
But we also believe that the reform, as passed by Congress, failed in what should have been a primary and urgent goal: containing costs. As long as medical costs are growing faster than inflation, and with health care consuming nearly 20 percent of gross domestic product, our system of health care – reformed or not – is simply not sustainable.
The ruling favoring the individual mandate was unexpected by most people, especially so from a court that has often seemed imprisoned by ideology. Yet, twice this week, the court has defied those expectations, first throwing out most of Arizona's egregious immigration law, and now upholding the health care law. In both cases, Chief Justice John Roberts, an unabashed conservative, sided with the majority.
The principal dispute over the health care law was the individual mandate, which forces all Americans, including the young and healthy, to buy insurance or pay a penalty. That produces the money needed to fund expansions of health insurance and other aspects of the law that many Americans like. The constitutional objection was that Congress exceeded its authority by invoking its right to impose the mandate under the Commerce Clause. And, indeed, the court also came to that conclusion, but also ruled, 5-4, that the mandate is constitutional because it is merely a tax, which Congress undeniably has the right to impose.
You can like that or not, and reasonable people can disagree over the wisdom of it, just not the constitutionality.
The more common public objection was that government had no right to compel Americans to purchase something they didn't want, but the argument falls on its face out of the gate. We are compelled to buy car insurance, to pay for police and fire protection and to fund education, even if you don't have children.
Consider transportation. Americans who don't drive still pay taxes that fund the construction and maintenance of roads. Similarly, Americans who don't fly nonetheless subsidize the construction of airports. Why? Because those services benefit society as a whole.
So it is with the nation's ability to be healthy. What is more, unlike the New Yorker who doesn't drive or the Pennsylvanian who doesn't fly, everyone uses the health care system. The only questions are where – too often in hospital emergency rooms – and at what cost. A tax that attends to those problems may cause legitimate political and fiscal dispute, but it is not a solution with which Americans are unfamiliar.
The politics will continue. The Republican House is expected to vote once again to repeal the law, but it is nothing more than a showpiece to keep the party's base energized. Nothing more is likely to happen between now and Election Day.
What happens then depends upon what happens in November. If Republicans gain control of both chambers of Congress and the White House, the law will likely be repealed, even though reform is urgent. If not, the law will likely stand and it will be up to Congress to return to the critical task of controlling the costs of health care, which are, in fact, disincentives to economic development.
Washington's greatest influence will be on Medicare and Medicaid, which are huge portions of the federal budget. In the private sectors, doctors, insurers and patients are likely to have the greater influence on quality and cost issues.
Other issues remain. An increase in the number of insured will require more doctors. The impact on the deficit, if the Congressional Budget Office is correct, will be high.
That means Congress eventually has to stop the mindless sniping and get serious. That, really, is the message from the Supreme Court.
You asked for this, you got it. There are important matters to deal with. So do it, and do it right.