By: Greg Vigdor/WHF President & CEOIt occurred to me that I should share some observations about the impact of the Supreme Court ruling on the Affordable Care Act. After all, we have been engaged in health policy and advocacy as a big part of our Foundation’s change model for much of the past 20 years. And - we were a very active voice for health reform in the state and nation. In fact, we spoke out regularly on the need for comprehensive reform well before just about anyone else in our state from the late 1990s until health reform became “popular” in 2009. Including our own statewide leadership efforts to explore the values of Washingtonians - and give them voice - regarding the future of health care in 2003.
As a reminder to all, we actively supported national health reform and this legislation in its early form, and developed a full position paper on its many facets. Providing access to coverage and care for all was part of our policy position. Partly for moral reasons under our view of the world, based on our day to day understanding of the consequences of people in need being left out of the coverage and care system. But also because the fundamental unfairness of who was in and out of the system made fixing the broken health system virtually impossible without first doing this. That the individual mandate and medicaid expansions can go forward today remains something that we support, given that this was the only option really presented for achieving universality of inclusion. So, we should feel good about today’s ruling.
Our discomfort with the ruling relates to our fundamental disagreement with what else happened - or more accurately didn’t happen - in the reform Act. That is, the Administration chose to move forward by leaving the “system” essentially as it has been, with all of its many defects. Especially those that relate to how people interact with the system. While the Administration and other advocates now speak regularly to things in the Act that might “transform health care”, these ideas are slow moving, incremental tests of ideas that have, in most cases, already been tried. Some of them would work- but need the leadership act of moving them forward aggressively, not with the permission of insurers and providers and government bureaucrats first, who are all more inclined to take care of their own needs than those of people and patients.
The legal logic of the ruling supports our take on all of this. That is, the argument that the federal government could impose a mandate under the interstate commerce provisions of the Commerce Clause was not accepted. So, presumably there is not enough in the Act that is regulating the commerce of the health care system. Rather, it is the taxing power of the federal government that constitutionally justifies the Act. That is largely what is going on with this law so far. Yes, many uninsured will be covered. But realize that some number of them are folks for whom health insurance is not something that they feel they need and for whom actuarial tables would say cost very little. Now, they will be required to buy and will soon find out that the rating approach within the law will have younger healthier people subsidizing even more the rates for older and sicker people.
Again, we support the universality of inclusion. But just creating this shift in cost is only perpetuating one of the principal defects that has plagued the health care system for the past 50 years. It is one of the fundamental reasons why health care costs have continued to escalate beyond all reason, leaving many with a deep sense that the system is fundamentally “unfair”. The incredibly growing share of our economy now going to health care also makes it hard to invest in other things that we know have a far greater impact on creating “health” than just continuing to invest in an ever-growing medical care system. This we know well from our innovative work through the Healthiest State in the Nation Campaign. And, yes, while there were some useful advances around a “health” reform agenda in the Affordable Care Act, many that we actively supported, these provisions of the Act also depend far too much on “government” being the entity that will change our health behaviors, rather than ourselves or our communities.
All to say that what we have done and are doing to fundamentally change the health system so that it works for people is of only greater importance now that we know the Affordable Care Act is moving forward to full implementation. The true empowering notion of Health HoMEs for all, the value of our Personal Health Advocates to help people customize their own solutions to their health needs, and our newly-inspired dream to create a full and functioning “Center for People’s Health” within the Washington Health Foundation are our building blocks to attain health change that fundamentally works for people and America.
Thanks for all you are doing to achieve these things- they may ultimately prove to be of far more value to changing the health system for the better than government, provider and insurer efforts to manage incremental change. And there is no doubt that the immediate help we are providing to many across our state is of vital value to their health now, while health reformers, lawyers and judges figure out what else they can do to fix a broken health system beyond income transfers. Keep the Faith.