William Sage on the ACA: Hearts, Minds and Health Care Reform

Professor William Sage penned a thoughtful—and deeply personal—essay about his reaction to the Supreme Court’s verdict in King v. Burwell, for the Health Affairs Blog. It was one of the blog’s most popular posts of the month. We reprint it here with their permission.

Hearts, Minds, And Health Care Reform

by William Sage

William SageThinking about the Affordable Care Act (ACA), King v. Burwell was not a difficult case. The congressional majority that passed this long and complicated statute sought to expand health insurance coverage for all Americans and found constitutionally permissible ways to do so. In a 6-3 ruling released on June 25, the Supreme Court interpreted a technical provision that had been poorly drafted in a way that furthers rather than frustrates the law’s larger purpose.

Oral arguments last March offered little intellectual novelty; the straightforward majority opinion contains even less. As President Obama said to conclude his public statement applauding the decision, “Let’s get back to work.”

But sometimes one also should feel a law and a Supreme Court opinion. So let us pause to do so.

Feeling The Affordable Care Act

I have never personally suffered racism, violence, poverty, or discrimination based on gender or sexual orientation. Laws that shape our society in those areas—for better or for worse—are felt by those who face such challenges or affronts. And when the nation’s highest court speaks on those issues, its words are deeply felt.

I do feel the Affordable Care Act, and therefore I feel the Court’s words in support of it. I have personally experienced the fear and actuality of illness, the successes and failures of medical treatment, the deaths of people I love, and the emotional and financial burdens that resulted. As a physician, I have cared for others, and often succeeded but sometimes failed. As a legal and policy scholar, I have worked for many years to build a health care system that is more accessible, more respectful, more reliable, and less costly.

Late in the evening of March 21, 2010, my wife and I gathered our two young children in front of the television in our bedroom to hear the last arguments about the Affordable Care Act in the House of Representatives and watch the votes be registered. As the affirmative votes inched toward a majority, the suspense was palpable. My family knew that I had spent my entire professional life working toward that moment; when the votes in favor passed 200, our 9 year-old son was particularly (and viscerally) affected. The final tally of 219-212 did not feel like triumph but affirmation, not closure but a path forward.

Opponents of federal health care reform feel the ACA in very different ways. Some of those feelings seem deserving of respect, others markedly less so. I do not pretend to understand them all, but I hope that they will soften over time. We are, after all, in this together.

In Praise Of The Chief Justice

Three years ago, I wrote in this space about the Supreme Court’s decision in National Federation of Independent Business (NFIB) v. Sebelius, which was a full-throated constitutional challenge to the ACA, not an administrative dispute over four relatively random words. In that essay, I praised Chief Justice John Roberts for “preserving the Republic” and repeat that sentiment now. Our democracy is continually challenged, which I suppose is the nature of democracy. Today, as in 2012, a majority of the Court voted for our noble if flawed democratic institutions. When it could have divided us further,King v. Burwell helps move us forward together.

The Chief Justice’s majority opinion is plain-spoken and commonsensical. Justice Scalia’s dissent is, forgive me, intemperate and sarcastic. The majority addresses the citizenry; the dissent seems directed at a more sophisticated, more jaded, and considerably smaller audience. On both sides, however, the Court deals with the case on its merits, without much apparent need to secure longer term advantages in the federal jurisprudential contests that often consume the nine strong-willed, life-tenured justices.

Unconstitutional coercion, raised as a possible bargaining chip during the litigation, is not mentioned in the resolution. Administrative law makes an undramatic appearance (perhaps presaging an imminent environmental ruling in another case), though the Internal Revenue Service is put in its place a bit too harshly. Overall, the focus is where it should be, on the goals and means of expanding health insurance throughout the nation.

Getting Back To Work

Let me end, therefore, with a tribute to the combatants that emphasizes their commonalities rather than their differences. First, to Chief Justice Roberts, whose views on the ACA seem to have changed from grudging acquiescence in the will of Congress to appreciation of the intricacies of health care reform:

Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter. Section 36B can fairly be read consistent with what we see as Congress’s plan, and that is the reading we adopt.

Second, to Justice Scalia, who recognizes a moment in history even if he will not embrace it:

Perhaps the Patient Protection and Affordable Care Act will attain the enduring status of the Social Security Act or the Taft-Hartley Act; perhaps not. But this Court’s two decisions on the Act will surely be remembered through the years.

Third, to President Obama, who in his remarks on the decision publicly articulated—to my knowledge, for the first time—the core challenge of building social solidarity around health care in a nation skeptical of domestic policy-making:

And unlike Social Security or Medicare, a lot of Americans still don’t know what Obamacare is beyond all the political noise in Washington. Across the country, there remain people who are directly benefitting from the law but don’t even know it. And that’s okay. There’s no card that says “Obamacare” when you enroll. But that’s by design, for this has never been a government takeover of health care, despite cries to the contrary. This reform remains what it’s always been: a set of fairer rules and tougher protections that have made health care in America more affordable, more attainable, and more about you — the consumer, the American people.

As for me, I am glad that my confidence in our system of government has been reaffirmed and my optimism for health reform restored, but I feel that there is still much to be done. My current project: helping the health care system become more competitive and more efficient. Like the President said, “Let’s get back to work.”

“Hearts, Minds and Health Care Reform” by William Sage was originally posted on June 26, 2015.
Copyright ©2010 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.