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 6:42 PM EDT, Tue August 26, 2014
Former ambassador to Syria Robert Ford says the West should be helping moderates in the Syrian armed opposition end the al-Assad regime and form a government to focus on driving ISIS out
updated 9:21 AM EDT, Wed August 27, 2014
Ruben Navarrette says a great country does not deport thousands of vulnerable, unaccompanied minors who fled in fear for their lives
updated 9:19 AM EDT, Wed August 27, 2014
Robert McIntyre says Congress is the culprit for letting Burger King pay lower taxes after merging with Tim Hortons.
updated 7:35 PM EDT, Tue August 26, 2014
Wesley Clark says the U.S. can offer support to its Islamic friends in the region most threatened by ISIS, but it can't fight their war
updated 7:26 AM EDT, Wed August 27, 2014
Jeff Yang says the tech sector's diversity numbers are embarrassing and the big players need to do more.
updated 4:53 PM EDT, Tue August 26, 2014
America's painful struggle with racism has often brought great satisfaction to the country's rivals, critics, and foes. The killing of Michael Brown and its tumultuous aftermath has been a bonanza.
updated 4:19 PM EDT, Tue August 26, 2014
Ed Bark says in this Emmy year, broadcasters CBS, ABC and PBS can all say they matched or exceeded HBO. These days that's no small feat
updated 3:19 PM EDT, Tue August 26, 2014
Rick Martin says the death of Robin Williams brought back memories of his own battle facing down depression as a young man
updated 11:58 AM EDT, Tue August 26, 2014
David Perry asks: What's the best way for police officers to handle people with psychiatric disabilities?
updated 3:50 PM EDT, Mon August 25, 2014
Julian Zelizer says it's not crazy to think Mitt Romney would be able to end up at the top of the GOP ticket in 2016
updated 4:52 PM EDT, Mon August 25, 2014
Roxanne Jones and her girlfriends would cheer from the sidelines for the boys playing Little League. But they really wanted to play. Now Mo'ne Davis shows the world that girls really can throw.
updated 12:29 PM EDT, Mon August 25, 2014
Peter Bergen and Emily Schneider say a YouTube video apparently posted by ISIS seems to show that the group has a surveillance drone, highlighting a new reality: Terrorist groups have technology once only used by states
updated 5:04 PM EDT, Mon August 25, 2014
Kimberly Norwood is a black mom who lives in an affluent neighborhood not far from Ferguson, but she has the same fears for her children as people in that troubled town do
updated 5:45 PM EDT, Fri August 22, 2014
It apparently has worked for France, say Peter Bergen and Emily Schneider, but carries uncomfortable risks. When it comes to kidnappings, nations face grim options.
updated 1:27 PM EDT, Tue August 26, 2014
John Bare says the Ice Bucket Challenge signals a new kind of activism and peer-to-peer fund-raising.
updated 8:31 AM EDT, Fri August 22, 2014
James Dawes says calling ISIS evil over and over again could very well make it harder to stop them.
updated 9:05 PM EDT, Sat August 23, 2014
As the inquiry into the shooting of Michael Brown continues, critics question the prosecutor's impartiality.
updated 6:47 PM EDT, Fri August 22, 2014
Newt Gingrich says it's troubling that a vicious group like ISIS can recruit so many young men from Britain.
updated 10:50 AM EDT, Thu August 21, 2014
David Weinberger says Twitter and other social networks have been vested with a responsibility, and a trust, they did not ask for.
updated 7:03 AM EDT, Fri August 22, 2014
John Inazu says the slogan "We are Ferguson" is meant to express empathy and solidarity. It's not true: Not all of us live in those circumstances. But we all made them.
updated 8:23 AM EDT, Fri August 22, 2014
Retired Lt. Gen. Mark Hertling says he learned that the territory ISIS wants to control is amazingly complex.
updated 3:51 PM EDT, Wed August 20, 2014
Cerue Garlo says Liberia is desperate for help amid a Ebola outbreak that has touched every aspect of life.
updated 1:42 PM EDT, Thu August 21, 2014
Eric Liu says Republicans who want to restrict voting may win now, but the party will suffer in the long term.
updated 11:38 AM EDT, Thu August 21, 2014
Jay Parini: Jesus, Pope and now researchers agree: Wealth decreases our ability to sympathize with the poor.
updated 8:00 AM EDT, Thu August 21, 2014
Judy Melinek offers a medical examiner's perspective on what happens when police kill people like Michael Brown.
updated 6:03 PM EDT, Tue August 19, 2014
It used to be billy clubs, fire hoses and snarling German shepherds. Now it's armored personnel carriers and flash-bang grenades, writes Kara Dansky.
updated 1:27 PM EDT, Wed August 20, 2014
Maria Haberfeld: People who are unfamiliar with police work can reasonably ask, why was an unarmed man shot so many times, and why was deadly force used at all?
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT