The Supreme Court largely let stand the Affordable Care Act.
The court case had centered on the so-called individual mandate, a requirement that all Americans obtain health insurance or pay a fine. Republicans challenged it as an unconstitutional expansion of federal power. The Obama administration argued that it was needed to fix basic flaws in the insurance market and that it was crucial to provisions like the requirement that insurers accept all comers without regard to pre-existing health conditions. This prohibits insurers from denying coverage on the basis of pre-existing conditions. To reduce the soaring cost of Medicare, it creates a panel of experts to limit government reimbursement to only those treatments shown to be effective, and creates incentives for providers to “bundle’’ services rather than charge by individual procedure.
The law will cost the government about $938 billion over 10 years, according to the nonpartisan Congressional Budget Office, which has also estimated that it will reduce the federal deficit by $138 billion over a decade.
This law guarantees access to medical insurance for tens of millions of Americans (about 30 million people). It also provides federal subsidies to help lower- and middle-income Americans buy private coverage. The court’s decision did significantly restrict (slow the pace of) one major portion of the law: the expansion of Medicaid, the government health-insurance program for low-income and sick people.
The ruling gives states some flexibility not to expand their Medicaid programs, without paying the same financial penalties that the law called for. When Mr. Obama said it was not true that the Democrats were proposing to provide health coverage to illegal immigrants, Representative Joe Wilson of South Carolina yelled back, “You lie!” Mr. Wilson later apologized, but his outburst led to a six-day national debate on civility and decorum, and the House formally rebuked him on Sept. 15.
Even with the court’s decision, the debate over health care remains far from over, with Republicans vowing to carry on their fight against the law. The presumptive Republican presidential nominee, Mitt Romney, has promised to undo it if elected.
Not a single Republican voted for the final version of the bill, and Republicans across the country campaigned on a promise to repeal it. Republicans never offered a unified health care bill, but the party’s Congressional leaders sketched out a fairly well-developed set of ideas intended to make health insurance more widely available and affordable, by emphasizing tax incentives and state innovations, with no new federal mandates and only a modest expansion of the federal safety net.
While the Congressional Budget Office has not analyzed all the Republican proposals, it is clear that they would not provide coverage to anything like the number of people who would gain insurance under the Democrats’ proposals. But Republicans say they can make incremental progress without the economic costs they contend the Democratic plans pose to the nation.
As one way to encourage competition and drive down costs, Republican members of Congress want to make it easier for insurance companies to sell their policies across state lines, an idea included in a limited form in the Democratic bills.
Republicans said their package would probably include proposals to allow sales of health insurance across state lines; to help small businesses band together and buy insurance; to limit damages in medical malpractice suits; and to promote the use of health savings accounts, in combination with high-deductible insurance policies.
Federal officials awarded nearly $516 million to states to help build new insurance exchanges, although some states whose officials are opposed to the law, like Florida and Alaska, have either refused the money or postponed any plans in hopes of getting the legislation overturned.
Republicans say they will try to withhold money that federal officials need to administer and enforce the law. The Obama administration said that it would not define a single unifornm set of “essential health benefits” that must be provided by insurers for tens of millions of Americans. Instead, it will allow each state to specify the benefits within broad categories.
Republicans denounced the law as an intrusion by the government that would prompt employers to eliminate jobs, create an unsustainable entitlement program, saddle states and the federal government with unmanageable costs, and interfere with the doctor-patient relationship. Republicans also said the law would exacerbate the steep rise in the cost of medical services.
For their part, the Obama administration and Democrats, who largely lost the health care message war in the raucous legislative process, see the renewed debate as a chance to show that the law will be a boon to millions of Americans and hope to turn “Obamacare” from a pejorative into a tag for one of the president’s proudest achievements. Democrats argue that repeal would increase the number of uninsured; put insurers back in control of health insurance, allowing them to increase premiums at will; and lead to explosive growth in the federal budget deficit.
Even though critics say the law does little to reduce the costs of care, its passage touched off myriad efforts to pare widespread waste.
An area of great concern is in birth control. In February 2012, facing vocal opposition from religious leaders and an escalating political fight, the White House sought to ease mounting objections to a new administration rule that would require health insurance plans — including those offered by Catholic universities and charities — to offer birth control to women free of charge.
As the Republican presidential candidates and conservative leaders sought to frame the rule as showing President Obams’s insensitivity to religious beliefs, Mr. Obama’s aides promised to explore ways to make it more palatable to religious-affiliated institutions, perhaps by allowing some employers to make side insurance plans available that are not directly paid for by the institutions.
Speaker John A. Boehner stepped into the battle, saying that House Republicans would push legislation to challenge the policy.
In the Senate, Roy Blunt, Republican of Missouri, introduced a sweeping amendment to the Obama legislation that would permit employers and insurers to refuse to provide or pay for coverage of “specific items or services” if the coverage would be “contrary to the religious beliefs or moral convictions of the sponsor, issuer or other entity offering the plan.”
Democrats’ desire for universal access to health insurance runs deep. President Franklin D. Roosevelt hoped to include some kind of national health insurance program in Social Security in 1935. President Harry S. Truman proposed a national health care program with an insurance fund into which everyone would pay. Since then, every Democratic president and several Republican presidents have wanted to provide affordable coverage to more Americans.
President Bill Clinton offered the most ambitious proposal and suffered the most spectacular failure. Working for 10 months behind closed doors, Clinton aides wrote a 240,000-word bill. Scores of lobbyists picked it apart. Congressional Democrats took potshots at it. And Republicans used the specter of government-run health care to help them take control of Congress in the midterm elections of 1994.
For President Obama, this is an act of long-needed sweeping health care overhaul that has eluded Washington for generations.
(Thank you to the New York Times, Friday, June 29, 2012, issue. The entirety of the article can be viewed at http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/health_insurance_and_managed_care/health_care_reform/index.html)