Health Care: A Beginner's Guide to the (Non)-Sense of the US System

For us Brits who are used to debates and votes in both Houses of Parliament, followed by a Bill signed into law by a Royal Assent, the passage of the American Healthcare Reform Act was tortuous and confusing. We expect all the politicking to come before the event.

So could we assume that Obama signing the Bill into law on 22 March was the conclusion? Evidently not --- the Bill was required to go back to the Senate to reconcile it with the provisions passed by the House of Representatives, and even then it had to return to the House for a second vote to cover the minor technical differences. I think the process is now concluded, but the reporting in Britain of the Congressional procedures has been so poor that it is difficult to follow exactly what has happened.


Let us assume that the Bill has finally passed. Cutting through the confusion of what has been retained from the original proposals and what has been removed, the immediate changes for the American public are: 1) insurers can no longer deny coverage to insured persons because of pre-existing medical conditions; 2) the elderly will receive a $250 rebate to help them buy prescription drugs; 3) small businesses will receive a tax credit to insure employees; and 4) young people will be permitted to stay on their parents’ policies.

In 2014, the big changes arrive. A majority of Americans currently without insurance will be required to buy cover or pay a fine. Insurers will not be permitted to refuse policies because of pre-existing conditions which, in theory, should ensure that those Americans will be able to acquire cover. Most of the arrangements, under the bill's provisions, will occur in an "exchange" where insurers bid to provide the policies for groups of the newly-insured.

In 2018, a new tax will be imposed on high-cost insurance plans, as part of the effort to limit expenses, and the government expects that by 2019, 94% of Americans will have health insurance cover. The struggle between the executive and legislative branches on the legislation now ends, at least for the time being.

That, in theory, should be the process, but there could be a further complication if the Supreme Court enters the arena. There could be strong grounds to defeat the legislation, based on the 10th and 14th Amendments of the US Constitution. The former entitles the individual US states to object to federal legislation on issues that properly belong to the states.

The Federal Government can point to Medicare and Medicaid, both federally-based programs, to support its right to pass the legislation. However, the States can point to the requirement on individuals to buy insurance, a provision thought to be a matter for the States alone as there is nothing implicit in Article I of the Constitution to the contrary.

The 14th Amendment argument arises because Americans are entitled to equal protection under the law but, even after the legislation takes effect in 2014, there will be 15 million American who will not be entitled to the benefits of the legislation, as they will not be covered by the dealings of the insurance "exchange". Legally, the new law could fail as a result.

The Supreme Court is a political as well as a legal body, and eventually, possibly as early as 2011, cases will come before the Court. No doubt, the messages passed to Republican-appointed Justices by the party's rank and file, not to mention leading politicians, will be clear: “Hear the several appeals that will come before you. Strike the healthcare laws down.”

Does all of this still make little sense, given the fundamental that at least 35 million Americans are uninsured and many more "under-insured", vulnerable to a combination of illness, disease, or accidents and the economic circumstances that leave them unable to protect their health?

Well, if that is the case, it is because the debate in America over healthcare seems to have lost all sense of reality at the same time it has been mired in politics. Under George W. Bush, more than half the expenditure in his last three budgets was covering the cost of federal healthcare and Social Security, yet vast numbers of still Americans were unable to afford to pay medical bills. If “freedom” and “liberty” are basics of the American system, isn’t the right to proper medical treatment at an affordable price just as important?