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 3:12 PM EST, Thu November 20, 2014
The plan by President Obama to provide legal status to millions of undocumented adults living in the U.S. leaves Republicans in a political quandary.
updated 2:04 PM EST, Thu November 20, 2014
Despite criticism from those on the right, Obama's expected immigration plans won't make much difference to deportation numbers, says Ruben Navarette.
updated 8:21 PM EST, Thu November 20, 2014
As new information and accusers against Bill Cosby are brought to light, we are reminded of an unshakable feature of American life: rape culture.
updated 5:56 PM EST, Thu November 20, 2014
When black people protest against police violence in Ferguson, Missouri, they're thought of as a "mob."
updated 3:11 PM EST, Wed November 19, 2014
Lost in much of the coverage of ISIS brutality is how successful the group has been at attracting other groups, says Peter Bergen.
updated 8:45 AM EST, Wed November 19, 2014
Do recent developments mean that full legalization of pot is inevitable? Not necessarily, but one would hope so, says Jeffrey Miron.
updated 8:19 AM EST, Wed November 19, 2014
We don't know what Bill Cosby did or did not do, but these allegations should not be easily dismissed, says Leslie Morgan Steiner.
updated 10:19 AM EST, Wed November 19, 2014
Does Palestinian leader Mahmoud Abbas have the influence to bring stability to Jerusalem?
updated 12:59 PM EST, Wed November 19, 2014
Even though there are far fewer people being stopped, does continued use of "broken windows" strategy mean minorities are still the target of undue police enforcement?
updated 9:58 PM EST, Mon November 17, 2014
The truth is, we ran away from the best progressive persuasion voice in our times because the ghost of our country's original sin still haunts us, writes Cornell Belcher.
updated 4:41 PM EST, Tue November 18, 2014
Children living in the Syrian city of Aleppo watch the sky. Not for signs of winter's approach, although the cold winds are already blowing, but for barrel bombs.
updated 8:21 AM EST, Mon November 17, 2014
We're stuck in a kind of Middle East Bermuda Triangle where messy outcomes are more likely than neat solutions, says Aaron David Miller.
updated 7:16 AM EST, Mon November 17, 2014
In the midst of the fight against Islamist rebels seeking to turn the clock back, a Kurdish region in Syria has approved a law ordering equality for women. Take that, ISIS!
updated 11:07 PM EST, Sun November 16, 2014
Ruben Navarrette says President Obama would be justified in acting on his own to limit deportations
updated 8:21 AM EST, Mon November 17, 2014
America will have its hands full in the Middle East for years to come, writes Aaron David Miller.
updated 11:17 AM EST, Sat November 15, 2014
Gene Seymour says it's part of our pioneering makeup to keep exploring the universe
updated 12:42 PM EST, Fri November 14, 2014
Sally Kohn says the U.S.-China agreement to cut carbon emissions is a big deal, and Republicans should take note.
updated 4:29 PM EST, Sat November 15, 2014
S.E. Cupp says the Obamacare advisor who repeatedly disses the electorate in a series of videotaped remarks reveals arrogance and cluelessnes.
updated 5:00 PM EST, Fri November 14, 2014
Reggie Littlejohn says gendercide is a human rights abuse against women, with bad consequences for nations.
updated 11:57 AM EST, Thu November 13, 2014
The massing of Russian forces near Ukraine only reinforces the impression that Moscow has no interest in reconciliation with the West, writes Michael Kofman.
updated 9:55 AM EST, Wed November 12, 2014
It takes a real man to make the moves on the wife of the most powerful man in the biggest country. Especially when the wife is a civilian major general.
updated 8:47 AM EST, Wed November 12, 2014
Proponents of marriage equality LGBT persons have been on quite a winning streak -- 32 states and the District of Columbia now allow same-sex marriage.
updated 8:58 AM EST, Thu November 13, 2014
It has been an eventful few weeks for space news.
updated 3:14 PM EST, Wed November 12, 2014
It's too early to write the U.S. off, and China's leaderships knows that better than anyone, argues Kerry Brown.
updated 1:21 PM EST, Wed November 12, 2014
"How can Jon Stewart hire you to be 'The Daily Show''s senior Muslim correspondent when you don't even know how to pronounce Salaam Al-aikum?!"
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT