Skip to main content

A health care victory that's only a start

By Aaron Carroll, Special to CNN
updated 1:41 PM EDT, Thu June 28, 2012
A protester holds an American flag during a demonstration in front of the U.S. Supreme Court,.
A protester holds an American flag during a demonstration in front of the U.S. Supreme Court,.
STORY HIGHLIGHTS
  • Aaron Carroll: Court gave Obama, Congress what they couldn't ask for: Mandate as tax
  • He says some may see Medicaid ruling as victory for states, but most will likely take money
  • U.S. lags developed nations in many areas on health care, Carroll says
  • Carroll: Upholding ACA is only a start; issue of quality of care and costs remains

Editor's note: Dr. Aaron E. Carroll is an associate professor and vice chair of health policy and outcomes research in the department of pediatrics at the Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

(CNN) -- Chief Justice Roberts, in a move that likely surprised many, joined the four more liberal justices in declaring that the mandate could survive, but as a tax. (For those of you following along, I made that argument here at CNN.com a number of months ago.)

News: What the health care ruling means to you

In some ways, politically, this may have been what the president and Congress wanted, but couldn't get. They feared making the mandate a tax back when they were passing health care reform. That was because "tax" is a four-letter word in American discourse. So instead, they made it a penalty. But the court decided it was a tax anyway, meaning that Democrats got their desired outcome without having to make an undesirable argument.

Supporters of the health care legislation celebrate after the Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act in a 5-4 ruling Thursday, June 28. Supporters of the health care legislation celebrate after the Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act in a 5-4 ruling Thursday, June 28.
Health care and the high court
HIDE CAPTION
<<
<
1
2
3
4
5
6
7
8
9
10
11
12
>
>>
Photos: Health care and the high court Photos: Health care and the high court

Since the mandate is constitutional under taxing power, the other arguments related to it went away. The court did not have to rule on the regulations, and that means the other parts of the ACA that deal with insurance and the exchanges were left untouched. The "doughnut hole" remains, the cost-control measures remain, and so does everything else.

Read the court ruling (.PDF)

Aaron Carroll
Aaron Carroll

The other notable news had to do with the Medicaid expansion. As part of insuring millions of Americans, the ACA declared that everyone in the US up to 133% of the poverty line, regardless of marital or parental status, would now qualify for Medicaid. This is an enormous increase in the Medicaid population, and is expected to cover about half of the newly insured in 2014.

Originally, the ACA stated that if states refused to comply with the expansion, they would lose all Medicaid funding, even that which they already had. Those fighting the expansion argued that was coercive. The Supreme Court partially agreed today. It ruled that the federal government can offer states money for the expansion. It can refuse them the extra money if they deny the expansion. But it can't take back the old funding if they don't comply.

News: Breaking down the court's decision

Obama: This is a victory for the people
Romney: I'll do what justices didn't
Ruling on individual mandate explained
How will the court's ruling affect you?

Some will see this as a partial victory for the states. But I think few states in the end will opt not to take the money. The federal government is picking up the entire tab for the expansion for a number of years. It will be very hard for governors to turn to their constituents and explain that they are refusing free money from the feds to give them health care insurance.

News: What Justices wrote, how they voted

I'd caution you, however, to take all of this with some equanimity. Health care reform is far from over.

Regardless of your political persuasion, there are many reasons not to celebrate. The truth of the matter is that our health care system is still a mess. At last count, there were about 50 million Americans who lacked insurance for all of last year. More than 7 million of them are children. Millions more lacked insurance for part of the year. Millions more are underinsured, meaning that illness could still ruin them financially, if they can afford treatment at all. Yes, the ACA will reduce that number, but not to zero. More than 20 million Americans will likely remain uninsured.

Even if you have insurance, access is still terrible. Almost 20% of people in the United States report having to wait six days or more if they are sick. Fewer people in the United States think that their doctor spends enough time with than any comparable country. Fewer people think their doctor knows important information about them as well.

Our information systems are abysmal. As of last year, only one-third of physicians reported that they have a functioning electronic medical record system that met the criteria for a "basic" system.

The United States still has the highest infant mortality of any nation we'd want to compare ourselves to. If you think infant mortality is rigged, then you still have to acknowledge that we have the highest maternal mortality. That's right -- more mothers die in childbirth every year in the United States than any other comparable country. The mortality rates for a host of diseases are shockingly high.

We have fewer doctors per population than any other comparable country. We have fewer hospital beds per population than any other comparable country.

News: Ruling plays into campaign narrative for both sides?

I haven't even gotten to the cost yet.

We spent about $2.7 trillion on health care last year. That's almost 18% of GDP. That's more than $8,600 for every person in the United States. And since we know there are lots of people who get little to no care, that means that the rest of us are spending an insane amount. While it makes sense that we should spend more money than other countries, as we're richer than almost all of them, we're still spending way more than you'd expect given our "wealth".

It's likely that the Affordable Care Act will help with many of these problems. It won't, however, solve them entirely. In many ways, getting more people insurance was the easiest part of fixing the health care system. Getting costs down will be much harder. Improving quality even more so. But we have to do it.

It's time we got started.

News: Timeline of the health care law

Follow us on Twitter @CNNOpinion.

Join us on Facebook/CNNOpinion.

The opinions expressed in this commentary are solely those of Aaron Carroll.

ADVERTISEMENT
Part of complete coverage on
updated 2:31 PM EDT, Mon July 28, 2014
Megan McCracken and Jennifer Moreno say it's unacceptable for states to experiment with new execution procedures without full disclosure
updated 12:35 PM EDT, Mon July 28, 2014
Jeff Yang says it's great to see the comics make an effort at diversifying the halls of justice
updated 11:55 AM EDT, Sat July 26, 2014
Rick Francona says the reported artillery firing from Russian territory is a sign Vladimir Putin has escalated the Ukraine battle
updated 2:22 PM EDT, Sun July 27, 2014
Paul Callan says the fact that appeals delay the death penalty doesn't make it an unconstitutional punishment, as one judge ruled
updated 6:25 PM EDT, Thu July 24, 2014
Pilot Robert Mark says it's been tough for the airline industry after the plane crashes in Ukraine and Taiwan.
updated 11:10 AM EDT, Fri July 25, 2014
Jennifer DeVoe laments efforts to end subsidies that allow working Americans to finally afford health insurance.
updated 11:33 AM EDT, Sat July 26, 2014
Ruti Teitel says assigning a costly and humiliating "collective guilt" to Germany after WWI would end up teaching the global community hard lessons about who to blame for war crimes
updated 8:45 AM EDT, Fri July 25, 2014
John Sutter responds to criticism of his column on the ethics of eating dog.
updated 9:02 AM EDT, Fri July 25, 2014
Frida Ghitis says it's tempting to ignore North Korea's antics as bluster but the cruel regime is dangerous.
updated 2:50 PM EDT, Fri July 25, 2014
To the question "Is Putin evil?" Alexander Motyl says he is evil enough for condemnation by people of good will.
updated 2:03 PM EDT, Thu July 24, 2014
Laurie Garrett: Poor governance, ignorance, hysteria worsen the Ebola epidemic in Sierra Leone, Guinea, Liberia.
updated 9:49 AM EDT, Thu July 24, 2014
Patrick Cronin and Kelley Sayler say the world is seeing nonstate groups such as Ukraine's rebels wielding more power to do harm than ever before
updated 6:05 PM EDT, Wed July 23, 2014
Ukraine ambassador Olexander Motsyk places blame for the MH17 tragedy squarely at the door of Russia
updated 7:42 AM EDT, Thu July 24, 2014
Mark Kramer says Russia and its proxies have a history of shooting down civilian aircraft, often with few repercussions
updated 2:53 PM EDT, Thu July 24, 2014
Les Abend says, with rockets flying over Tel Aviv and missiles shooting down MH17 over Ukraine, a commercial pilot's pre-flight checklist just got much more complicated
updated 9:17 AM EDT, Thu July 24, 2014
Mark Kramer says Russia and its proxies have a history of shooting down civilian aircraft, often with few repercussions
updated 12:37 PM EDT, Thu July 24, 2014
Gerard Jacobs says grieving families and nations need the comfort of traditional rituals to honor the remains of loved ones, particularly in a mass disaster
updated 10:13 AM EDT, Thu July 24, 2014
The idea is difficult to stomach, but John Sutter writes that eating dog is morally equivalent to eating pig, another intelligent animal. If Americans oppose it, they should question their own eating habits as well.
updated 12:30 PM EDT, Wed July 23, 2014
Bill van Esveld says under the laws of war, civilians who do not join in the fight are always to be protected. An International Criminal Court could rule on whether Israeli airstrikes and Hamas rocketing are war crimes.
updated 10:08 AM EDT, Wed July 23, 2014
Gordon Brown says the kidnapped Nigerian girls have been in captivity for 100 days, but the world has not forgotten them.
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT