From the day in 2010 that President Obama signed the Patient Protection and Affordable Care Act, a legal fever gripped much of the country. Was the "individual mandate" — the requirement to buy insurance if you weren't already covered, a key pillar of the law — constitutional? Would a Supreme Court dominated by Republican appointees toss it out, no matter what?
You know how that fever finally broke. In a 5-4 decision that surprised both sides, Chief Justice John Roberts ditched his fellow conservatives to conclude that Congress and the President acted within their authority, not under the Commerce Clause, but because the penalty for violating the mandate was permissible as a tax. Within hours, the body politic was gripped again, this time with a fever bound to last till Election Day — or well beyond — over a role Roberts disowned: weighing the law's "wisdom or fairness."
It's sometimes hard to remember amid all the spin, but that's what lies beyond: real questions from people with genuine concerns about their health, their finances, and, yes, their taxes — and, for many, in a country that values individualism, concerns about the fairness of any program that offers government support to anyone else.
If it survives the feverish debate ahead, the law almost everybody now calls Obamacare will change key elements of our health-care system. In a moment, I'll tell you about five sets of people who stand to benefit from the law, and how we all may benefit if their access to health care improves. But first, a comment about the strange moment we're in, when politics and ideology seem have totally eclipsed problem-solving.
Roberts may have done so briefly, and to the country's benefit, but on this topic, it's nearly impossible to straddle the partisan divide. So I'll just come clean. Like the Democrats in Congress who ultimately passed Obamacare without a single GOP vote, I've long believed our health-care system was broken and needed fixing. Sadly, I seem to have believed so more urgently than Republicans who'd voiced similar concerns in response, say, to Census Bureau data showing 45 million people uninsured even before the Great Recession, or stories of sick people denied lifesaving treatment, or of families bankrupted by costly care.
Our long economic slump has only widened the ideological chasm — a divide reflected in a June blog post by libertarian economist Tyler Cowen, who argued for the rejection of what he calls "health-care egalitarianism" and wrote: "We need to accept the principle that sometimes poor people will die just because they are poor."
Give Cowen credit. He's a clearheaded advocate for his viewpoint and was gamely trying to address a question raised by many who disagree: Since the individual mandate was born as a Republican idea, what kind of mandate — what kind of market intervention — could he stomach?
It's hard to dispute what followed Cowen's remark about death and the poor: "Some of you don't like the sound of that," he wrote, "but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree."
Of course, some of us consider that more a bug than a feature — especially in a society with growing disparities in income and wealth and a class of increasingly powerful plutocrats.
But Cowen is fighting a straw party. Obamacare won't deliver "health care egalitarianism" — far from it. Nothing will stop the well-off from buying more or better care, as they do now through services such as "concierge medicine." Nearly half the 33 million people it promises to add to the insurance roles would get there via Medicaid, the safety-net insurance system for the poor — including those who get there after exhausting all their resources in nursing homes.
Roberts' ruling — siding this time with the court's four other conservatives — threw a monkey wrench into that plan, by allowing states to opt out of the Medicaid expansion. But for now, the rest of the law survives. Here are five groups whose lives stand to change as a result:
• Families with ailing children. You may have heard that the law already bars insurers from refusing to cover children with preexisting conditions, as it will for adults in 2014. Maybe you even have such a child, and are unconcerned because you have good group coverage. But consider this: Even if your child is safely protected now by your plan, the new rules will also offer security as he or she grows up. No longer will a parent's career advice have to start with, "Above all, choose a career at a large employer that offers health insurance.
• Women and their families. The law aims to improve health by requiring new plans to offer a range of preventive services without co-pays or other cost-sharing, and both women and children will be particular beneficiaries. Kaiser Family Foundation says the services will include childhood immunizations and screenings for diseases and developmental disorders. As adults, women will be eligible for services such as annual well-patient visits, breast-feeding support, and screening for domestic violence.
• Entrepreneurs. Finding affordable insurance has always been problematic for the self-employed and people at start-ups. Sometimes, it's the tail wagging the dog, a factor that keeps people clinging to ill-fitting jobs, or discourages them from taking entrepreneurial risks, because someone in the family needs the protection of group insurance. It's tough to measure, but once the exchanges are running in 2014, similar coverage will be available to everybody, with subsidies for people earning up to four times the federal poverty level — support akin to the tax-deductibility of employer-sponsored plans.
• Young adults. You may know that Obamacare enables children to stay on family policies until age 26, and that some states, such as Pennsylvania, authorize extended coverage even further in certain circumstances. The new rules have helped millions of young adults in the economic slump.
• Insurance customers. Yes, that's all of us who don't have Medicare, veterans' coverage, or another government plan. The new law already requires large-group insurers to spend at least 85 percent of premiums on medical care, and those serving the individual and small-group market to spend at least 80 percent. As of last month, 12.8 million Americans, including 576,000 in Pennsylvania, were due to get $1.1 billion in rebates averaging $151 per family.
There's a price for all this. The Congressional Budget Office puts the net expense at $110 billion in 2015. And the numbers are wrapped up in the larger necessity — partly addressed by innovations built into Obamacare — of having to “bend the cost curve" for medical care.
But doesn't a humane society have value, too?