Blog | Tuesday, July 3, 2012

The intriguing Supreme Court decision (and what should come next)


I have favored the individual mandate throughout the process. Like most observers, I had no clue whether it would pass constitutional muster. So having the Supreme Court affirm the right of Congress to create an individual mandate and "tax" those who do not participate becomes a victory.

Of course the victory is intriguing. Having read many editorials, I have found no consensus on what the ruling really means. One should not fall prey to bashfulness on such an issue, so I will proffer my take, borrowing much from other pundits.

To remind readers, I favor the individual mandate because we already have established that physicians and hospitals cannot refuse to provide care, regardless of ability to pay. As an academic hospitalist, I take care of just the patients who will benefit from the individual mandate. Moreover, we must remember that those of us who have insurance are currently subsidizing the hospital care of these uninsured patients.

Chief Justice Roberts defined the penalty as a tax. Every pundit has an open on why he did that. The best reason that I have read is that he has a strong belief that the judiciary should respect the legislative branch. He seems to want to avoid striking down laws, and seems to look for ways to support the legislature. But then my opinion has as much value as any other.

The Medicaid decision strikes a blow for states' rights. The Court removed a penalty that they considered draconian. Now states can choose to expand Medicaid (with great financial help from the federal government) or refuse to expand, depending on their local calculations. No longer does the entire Medicaid program in a state depend on accepting this expansion.

Both sides won in this decision. Clearly upholding the individual mandate allows the U.S. to approach universal health care. Universal health care is such a worthy goal, that we must applaud this victory.

At the same time the Court cautioned Congress that they can no longer use the Commerce Clause to tell states what they should do. George Will: Supreme Court gives conservatives a consolation prize.

The big challenge now becomes implementation. We should all challenge Congress to address the other major issues of health care that they ignored in this bill:

--malpractice and tort reform
--our payment structure, starting with the Sustainable Growth Rate,
--increasing primary care, and
--making high-value, cost-conscious care the norm rather than the exception.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.