Correction: An earlier version of Dan Schnur’s commentary incorrectly said there is no penalty for refusing to pay the new health-care tax. There is no criminal penalty, although the Internal Revenue Service has the authority to take people to court to compel payment. The following article has been corrected.
Political commentator and host of MSNBC’s “The Rachel Maddow Show”
The policy upheld in Thursday’s Supreme Court ruling is a rough approximation of the Republican Party’s 1993 federal proposal for insurance reform and of then-Gov. Mitt Romney’s bipartisan insurance reforms in Massachusetts five years ago. It’s fun to denounce it as socialism or the “end of America” or whatever, but in reality the Affordable Care Act is a small-c conservative reform that preserves the private insurance system. Without reform, that system has produced outcomes that no one should have been satisfied with — compared with other well-off industrialized countries, we’ve been getting lousy outcomes, for twice the price, with tens of millions of Americans left out of the system altogether. Scuttling Medicare isn’t going to fix that system, nor is doing nothing. But these reforms might. Beyond the bloodthirsty partisanship that is so desperate to deny this president anything that looks like a victory, I think history will view this ruling, and this policy, as simple affirmations that the country can and ought to use policy to try to come up with practical solutions to even our big, complicated problems.
Former chairman of the Democratic National Committee; former governor of Vermont
The Supreme Court’s decision will have three long-term consequences. First, barring a Romney win in November and repeal of the Affordable Care Act, the debate about the private sector’s role in health care has been settled. With the exception of the roughly 100 million Americans who get their care through Medicare, Medicaid and the Veterans Administration, universal health care in this country will be based on a regulated private-sector model.
Washington is abuzz, tallying the political winners and losers of the ruling. More important is what this means for people. The president, Congress and now the courts have expanded access to health care, mostly using the framework already in place. That means our American system of health care will continue to evolve along the federal-state partnership model that exists in the Medicaid system and in the private sector.
Second, the Affordable Care Act’s heavy emphasis on electronic medical records and accountable care organizations will lead to a restructuring in the private sector on how we pay for health care. This will mean insurance companies and hospitals are likely to merge in preparation for the change in the reimbursement system from per procedure to per patient. This is happening in Massachusetts, where this kind of health-care reform was essentially piloted by Mitt Romney six years ago.
Third, more Americans will now buy their health insurance in the individual market, much like the approach John McCain suggested in his 2008 campaign. Small businesses, followed gradually by larger ones, will stop providing a health insurance benefit beginning in 2014, thus breaking the link of health insurance to employment. This will help the competitive position of American businesses while creating new jobs among smaller businesses. In their criticism, Republicans continuously neglect to point out that businesses, particularly small businesses, will pay a lot less for health care and that what they pay will be far more predictable.
Former governor of Mississippi and Republican presidential candidate
Americans feel hoodwinked by the Obamacare decision. President Obama and his Democrat allies, in passing the legislation with no Republican votes and no votes to spare in the Senate, vociferously denied that the bill’s penalty for failing or refusing to buy health insurance was a tax. If Republicans made that accusation, they were lying.
Now the administration has succeeded, by the barest margin, in winning approval of the law from the U.S. Supreme Court — because the court has ruled that the individual mandate is a tax.
How can the American people feel anything but hoodwinked?
And now the president says we mustn’t refight this battle! He’ll be surprised to learn the American people disagree because they don’t like to be deceived.
Manager of Al Gore’s 2000 presidential campaign; author and political commentator
The Supreme Court’s decision upholding the Affordable Care Act was a moral victory for those who believe every American should have a head start and a healthy start in life. For Americans with preexisting conditions, for women and small-business owners (myself included), this law helps to reduce our deficit; once all of the provisions are implemented, the ACA will help provide a lifeline to 30 million Americans who are living without health care.
Many predicted the decision would be decided on partisan grounds. Chief Justice John G. Roberts Jr. must be given credit for rising above partisanship; his opinion reflected deep thought and a concern for precedent and legal reasoning. Ironically, he is being castigated by some on the far right for his commitment to judicial restraint.
President Obama and his congressional allies risked much politically (and personally) to fight for “what is right for America.” The political battle is far from over, but as Americans learn the truth about Obamacare, support for the act itself, because of what it does, will grow. Social Security, Medicare and now the ACA — steps in “providing for the general welfare” — are steps toward “a more perfect union.”
EDWIN MEESE III
Attorney general in the Reagan administration; chairman of the Heritage Foundation’s Center for Legal and Judicial Studies
With its decision on the Affordable Care Act, the Supreme Court has left it to Congress to uphold the Constitution and its limitations on the power of the federal government. It is now imperative that Congress repeal the entire Obamacare statute.
The president and his partisan allies in Congress rammed through the legislative process a law that gives federal agencies virtually unlimited power to govern health care in the United States. The people of our country oppose this legislation and increasingly fear its consequences: massive tax increases, higher insurance premiums, expanded government spending and debt, undermining of the doctor-patient relationship, violation of religious liberty, and detrimental interference by government in people’s daily lives.
A 5 to 4 majority of the court has unfortunately sided with those who believe there are no limits on how much the government can control our lives. In short, those justices chose tyranny over freedom. Health insurance may be a good thing, but can government compel you to buy it?
The court was correct in finding that Congress does not have the authority to compel purchases under the Constitution’s commerce clause. But it erred in contorting the statute to declare the penalty a tax. And the court’s decision to allow this abuse under the government’s taxing authority, not the commerce clause, doesn’t change the fact that individual freedom has been dealt a serious blow.
The Constitution created a government of enumerated and thus limited powers. The intention was to protect liberty by denying the federal government a roving charter to promote public welfare. Our Founders knew that, left unchecked, governments tend to grow by degrees into nanny-state leviathans.
President and chief executive of the Kaiser Family Foundation
With the Supreme Court’s decision, the Affordable Care Act’s coverage expansions, consumer protections and cost-containment provisions will continue to move forward. A great deal of attention was focused on the individual mandate — so the big surprise was the court’s weakening of the law’s Medicaid expansion, which was to provide coverage for more than 16 million low-income people. The federal government will no longer be able to withhold all Medicaid funding for states that do not expand Medicaid to cover more of their poorest residents. The federal government will initially provide 100 percent of the funding for the state Medicaid expansion and then scale back to 90 percent — still a substantial carrot that is likely to induce most states to go forward, although some conservative governors could balk.
The (often toxic) partisan wrangling by both sides over the ACA will continue at least through the election. The decision of the conservative-leaning court is obviously a big plus for President Obama, adding legitimacy to the health-care reform law, even if it also energizes the right. But it is not a game-changer. Opinions of the ACA are dug in along partisan lines, and the ruling will reinforce views more than change them. This remains an election about the direction of the economy, not health-care reform.
After the election, Washington will change the channel, focusing on the budget deficit and health care’s big entitlement programs, Medicare and Medicaid. We will shift from a debate about expanding the role of the federal government, a topic that energizes the right, to a debate about cutting government back, which could energize the left. Medicare may trump the ACA as health care’s big issue in 2013.
President and chief executive of America’s Health Insurance Plans
The Supreme Court provided legal clarity, but no one should underestimate the policy challenges ahead. Thursday’s ruling preserves the link between the market reforms and universal coverage. The disastrous experience in states that tried to implement similar market reforms in the absence of universal coverage will not be repeated nationally.
With that uncertainty removed, now is the time to turn to affordability.
Job No. 1 should be to address provisions in the health-care-reform law that increase costs for consumers and small employers. For example, the forthcoming premium tax will increase the cost of coverage purchased by small businesses and individuals, as well as Medicaid and Medicare beneficiaries with private coverage. The essential benefits and actuarial value requirements will mean that millions of Americans have to buy more coverage. In addition, rating provisions in the law will result in young people subsidizing coverage for others, creating further unintended incentives for them not to buy insurance. Unless they are addressed, the cumulative effect of these and other provisions will result in higher costs and coverage disruptions.
We must also address the unsustainable rise in medical costs that are burdening families and employers, taking up a greater share of federal and state budgets, and threatening the long-term solvency of our nation’s safety-net programs. Until we confront the nation’s spending issues, the promise of health security for all will remain out of reach.
While the focus has been on insurance market reform, health plans have been leading collaborative efforts to reform the payment and delivery system to promote prevention and wellness, help patients and physicians manage chronic disease, and reward quality care.
DOUGLAS E. SCHOEN
Democratic pollster and author of “The Political Fix.”
Thursday’s Supreme Court ruling upholding the centerpiece of President Obama’s health-care law is an undeniable victory for Obama. But the court’s decision that the individual mandate is a tax will not make the law more popular in the long term; on the contrary, it is likely to make it even less popular.
Going forward in the 2012 campaign, Obama needs to do something that he has been reluctant to do — take on the issue of entitlement policy in the context of overall fiscal and budgetary reform. He must position Obamacare as the centerpiece of an overarching plan to address the issue of costs in a serious and sustained way, while simultaneously facilitating economic growth and private-sector job creation. Moreover, he must put forth a comprehensive set of policy prescriptions to address the issues that the American people regard as fundamental, and a long-term economic agenda that emphasizes tax reform, fiscal prudence and economic growth — as well as the need to rein in entitlements, balance the budget, and reduce the debt and deficit.
To that end, he can talk about Obamacare in a manner that emphasizes cost-containment and innovation, within the context of fiscal discipline and budgetary restraint — specifically referring to the work of the Simpson-Bowles commission.
For his part, Mitt Romney will almost certainly say that his first act as president will be to repeal Obamacare — and in the short term, attacking the law and its effects makes sense. But with Romney’s own favorability ratings low and a new round of polling showing Obama with a consistent advantage in key swing states, it is a strategy with limited upsides. Romney too will need to articulate a vision for comprehensive health-care reform.
President of the Center for American Progress; director of domestic policy in the Obama-Biden campaign and former adviser to Health and Human Services Secretary Kathleen Sebelius
Now that the Supreme Court has ruled that the Affordable Care Act is constitutional, all of us should put aside partisanship, roll up our sleeves and work to implement the law. Most important, states that have held off on implementation of the insurance exchanges should now move aggressively. States that don’t implement their own exchanges will have a federal exchange, so states with conservative governors who believe in states’ rights should start now on implementation. The ACA says that the exchanges must be operational in 2014, so states have limited time to get going. If they don’t, their exchanges will be run by the federal “bureaucrats” that many of them malign.
Getting going on implementation is critical because positive benefits of the ACA are already apparent. Millions of young people have coverage through the law, seniors have lower prescription drug costs and medical inflation is decreasing. For decades we’ve seen national health-care costs increase at a higher rate than all other costs, which leads to higher and higher premiums for insurance. But in the past year or so medical inflation has flattened, which has led to lower premiums. Many experts believe that is because the ACA creates incentives for hospitals, doctors and other health-care providers to innovate in ways that produce greater value — more efficient and effective care at lower costs. Lower health-care costs have a range of benefits — from reducing consumers’ premiums to lowering the costs for businesses to hire to shrinking our federal deficit.
Deputy assistant to President George W. Bush and deputy White House press secretary from September 2006 to January 2009
It’s hard not to see the Supreme Court’s decision on the Affordable Care Act as a net victory for the White House and a net defeat for the statute’s opponents. President Obama will take a victory lap in his campaign and hope that an unattractive law now ruled constitutional will earn its butterfly wings and become beautiful. The difficulty for the administration is that a majority of Americans simply don’t like the policy. So the decision is a “win” for Obama, yet it also provides a political and policy opening for Mitt Romney’s campaign.
The court’s protection of the individual mandate under Congress’s taxing authorities is also a complication for the administration and congressional Democrats, leaving them in the uncomfortable position of having imposed higher taxes — a label that the president and congressional Democrats objected to during the legislative debate.
The House has scheduled a repeal vote, but the likelihood of legislatively defeating the bill is minimal, given the balance of power in the Senate. So the nation is now stuck with an unpopular yet un-repealable bill. And that’s the lesson of politics: Elections do have consequences. Take them seriously.
Director of the University of Southern California’s Unruh Institute of Politics; communications director for John McCain’s 2000 presidential campaign
Although the next few days will be filled with fireworks from both sides, it’s difficult to see how health care will remain a significant issue for the rest of the presidential campaign. Neither candidate has much incentive to talk about the issue: President Obama knows that, even though the law is constitutional, it’s still extremely unpopular. And Mitt Romney doesn’t have much desire to spend the fall talking about why or how his health-care plan in Massachusetts differed from this one. For most voters, the conversation will be back to the economy in a matter of days.
Although health care is unlikely to matter to most swing voters, there’s more than enough fodder in the court’s decision to inspire the true believers in both parties all the way to Election Day. Democrats can celebrate that the law is still in place. And they can continue to use the portion of the law that allows adult children to remain on their parents’ insurance plans to reach out to young people and female voters. Republicans still have a “repeal Obamacare” message to motivate their base and don’t have to worry about defending the loss of the law’s more popular provisions. Even better, now they have a new tax to attack.
The bottom line: more rhetorical ammunition and turnout motivation for the parties’ bases. Not much difference for everyone else.
Senior policy adviser at DLA Piper. Former U.S. senator from South Dakota; Senate majority leader from 2001 to 2003. President Obama’s initial nominee to be secretary of health and human services.
The Supreme Court’s decision to uphold the health-care reform law is an enormously positive step for health care in America. Our country is just beginning to meaningfully address the cost, access and quality challenges in health care today. This ruling provides the green light to full implementation of insurance, payment and delivery reform to effectively create a high-performance, high-value health-care infrastructure with lower costs, higher quality and greater access.
The debate about the role of government in health care will go on in the chambers of Congress and in our political system through this election and, most likely, many more. But implementation can now go forward, unimpeded by questions of constitutionality, and in so doing create stability and a positive environment that will prove catalytic in bringing about meaningful change. The Department of Health and Human Services can now work with states to establish insurance exchanges. It can partner with the private sector in moving away from our volume-driven approaches to health-care finance, and it can drive meaningful improvements in the delivery of care in all health settings.
Achieving this goal demands America’s best thinking and innovating. One of the primary keys to success will be public-private collaborations that create new and innovative approaches to affordable, value-based and efficient care.
The convergence of crisis and leadership brings about transformational moments in history. This is one of those moments. Now everyone, including all members of Congress, needs to work together to build on what President Obama has started.