Below is an article from the Woodrow Wilson School of Public and International Affairs at Princeton
, which discusses key questions of the Affordable Care Act with Princeton faculty, including Future of Children
Senior Editor Janet Currie.
Wailoo, Townsend Martin Professor of History and Public Affairs Woodrow Wilson
School of Public and International Affairs
ACA: Lessons from
the Road Taken
Court's ruling on the Affordable Care Act (ACA) is surely a health care
milestone, but it is also a remarkable civics lesson about the political and
legal complexities involved in making policy on such a grand scale.
path of the health care law illustrates why major initiatives like this happen
so infrequently. First, there was the brief window created by Barack Obama's
election and the unexpected Democratic take-over of both houses of Congress
with a filibuster-proof majority in the Senate. The possibilities for reform
were nearly snatched away many times, most notably after the death of Senator
Kennedy. Even after the President and Congressional Democrats took the daring
risk of resuscitating the law - knowing that it would cost them politically in
the 2010 elections - the political and legal fate of the law seemed unclear.
For years to come, the episode will illustrate risk-taking leadership, as well
as the ugly horse-trading and imperfections of the legislative process.
tortuous phase of the ACA - the legal debate - offers another lesson... about the
thin line separating politics and ideology, on one hand, and constitutional
reasoning on the other. Yes, the Supreme Court's decision revolved around
matters of legal interpretation: the Commerce Clause (the limits of the federal
government's power to regulate interstate commerce) and the federal
government's power to tax. But the ruling also highlighted the tensions between
the so-called liberal wing of the court and conservative bloc.
"In the interplay
of politics and law, the most important civics lesson to emerge from the court
phase of the ACA was the tension between two conservative justices - Antonin
Scalia and John Roberts.
favors expanding federal power, but this time he seemed to be swayed by the
political milieu. He echoed the libertarian objections to the ACA
mandate, noting that 'everybody has to buy food sooner or later, so you define
the market as food, therefore, everybody is in the market; therefore, you can
make people buy broccoli.' By contrast, Chief Justice Roberts tried hard to
mark the line between politics and law. In his opinion, 'Members of this Court
are vested with the authority to interpret the law: we possess neither the
expertise nor the prerogative to make policy judgments. Those decisions are
entrusted to our Nation's elected leaders, who can be thrown out of office if
the people disagree with them.' With these words, Roberts walked the high court
back from the political precipice. Had he sided with the dissenters, commentators
would have questioned the High Court's partisan politicization - seeing them as
nothing more than politicians in black robes - for decades to come.
Robert's ruling saved the court from this fate.
what can we expect as the legal dust settles?
"Calls for repeal
will continue, but they will fade. The legal imperative to implement the
law pushes elected officials beyond repeal. Governors, even those from the 26
states who argued against the law, must make tough policy decisions, getting
into the weeds of coverage and setting up insurance exchanges. Some will
continue to resist, at least until the November elections. All along the
tortuous path, there has been an irony - the states whose citizens will benefit
most from the law's provisions are often those where the elected leaders are
most whipped into frenzy over the laws unconstitutionality. How long that frenzy will last is
difficult to say - surely it will dissipate, but perhaps not until after
Election Day 2012.
"Of course, the
most important effect of the Supreme Court decision - punctuating the nearly
four-year fight - will be on the people's health. Now that the political and
the constitutional law phases have played out, we have an opportunity to
refocus, finally, on health and health care. Perhaps Americans will shift to
the underlying story of health care reform that started us down this path in
the first place - the people with pre-existing conditions, the young adults
without insurance, the small businesses looking for affordable ways into the
health insurance market, and the many others for whom a new world of
possibilities has just opened. When the dust of this sandstorm has settled,
this will be the lasting story of the ACA. But after so many years
of political and legal saturation, it may be a while before we can focus again
on the people whose lives will be improved."
Keith Wailoo is
author of "The Troubled Dream of Genetic Medicine," "Dying in the City of the
Blues: Sickle Cell Anemia," the "Politics of Race and Health; How Cancer
Crossed the Color Line," and other studies on the history and politics of
health care in America. He is co-editor of "Three Shots at Prevention:
The HPV Vaccine and the Politics of Medicine's Simple Solutions." At
Princeton, he teaches courses on history and health policy; on race, drugs, and
drug policy; and (in the fall 2012 with Princeton University President Shirley
M. Tilghman) Modern Genetics and Public Policy.
Reinhardt, James Madison Professor of Political Economy and professor of
economics and public affairs, who is recognized as one of nation's leading
authorities on health care economics:
"It may seem that
the Supreme Court's decision to uphold the Affordable Care Act of 2010 hinged
on semantics: whether the letter sequence 'p e n a l t y' is in the nature of
punishment for a misdemeanor or a tax. In fact, from an actuarial perspective,
one might construe the penalty as a crude approximation to the actuarial
average cost uninsured, individuals as a group might visit on hospitals in the
form of unpaid bills. Therefore the revenue from penalties should be paid hospitals
through disproportionate share moneys.
however, the Supreme Court decision is the outcome of just one more skirmish in
a decade's long fight over the question: to what extent must healthier
and more fortunate Americans be their poorer and sicker brothers' and sisters'
keepers in health care?
of the ACA deserve a moment of joy over the Courts decision, but for them it is
just a short 'R and R,' as soldiers call it. The next big battle will be fought
in the upcoming presidential and congressional elections. It will be fierce and
tenacious, supported by huge sums of money on both sides.
Romney win the White House and bring with that victory a Republican Congress,
attempts will be made to repeal the entire Act, although that probably would
not survive a filibuster by Democrats. But portions of the bill - especially
the subsidies and Medicaid expansion - might be gutted through a budget
"In the end,
though, the bluster that 'I (or we) will repeal the entire ACA' always evokes
in me the image of a dog chasing a car. What will the dog do when the car
"In this case,
what alternatives to coping with the large number of uninsured and poor
Americans who cannot pay out of pocket for health care do the opponents of the
ACA have in mind?
"An answer to
that question will be even more interesting that the Supreme Courts historic
"So, stay tuned."
professor of economics and public policy; director, Center
for Health and Wellbeing (CHW). The Center runs a program in U.S. Health Policy:
ruling removes the uncertainty about the constitutionality of the Affordable
Care Act. The next test will come in November. In the meantime
states have much to do setting up health care exchanges and preparing to expand
their Medicaid programs. The ruling did allow states to opt out of the
Medicaid expansion, but to do so would leave billions of federal dollars 'on the
table' and would leave poor adults few options for health insurance coverage.
There is likely to be great pressure on states to implement the Medicaid
expansion from their own hospitals and medical providers.
"All we have learned from previous expansions of public health insurance
programs to the previously uninsured suggest that it will make people happier
and healthier -- the recent expansion of Oregon's Medicaid program also
reduced the probability that people faced medical debt. But higher
numbers of people with health insurance coverage generally means more medical
spending rather than less.
'Bending the cost
curve' is the next policy frontier, and this requires understanding the drivers
of medical spending and variations in medical spending that are unrelated to
Mahmoud, Senior Policy Analyst Lecturer with the rank of Professor, Woodrow
Wilson School and Molecular Biology
Court decision may open the way for the United States to join the rest of the
world in offering ALL of its citizens a system that guarantees some form of
healthcare coverage. I hope it adds
strength to the Administration and those who care to focus on what matters for
the future of the country without the diversionary tactics of politics as
usual. The road ahead is still treacherous and needs thoughtful involvement
of a lot of those planning or implementing one of the most complicated
healthcare systems in the world. It is one step forward!"
Howard, lecturer in public affairs at the Woodrow Wilson School and director of
the State Health Reform Assistance Network*
Supreme Court affirmed the constitutionality of the Affordable Care Act, which
would extend health insurance coverage to 32 million Americans. In a divided
opinion, a majority of the court found that the individual mandate would be
unconstitutional under the Commerce Clause, but surprisingly Chief Justice
Roberts joined the liberal members to uphold it under Congress' taxing
authority. The court also affirmed the constitutionality of the
Medicaid expansion, but in an interesting wrinkle held that Congress cannot
withhold a state's entire Medicaid funding if the state refuses to adopt the
"The focus will
now turn to state implementation, as states build health insurance exchanges,
institute new insurance reforms to strengthen private insurance markets and
ensure the availability of affordable insurance products, and prepare for the
Medicaid expansion. Some states may
still wait until after the election to start moving, while others are likely to
build on planning work to date, jumpstarting their implementation work in an
effort to meet the aggressive timelines in the ACA. While states appear now
to have flexibility to reject the Medicaid expansion, there will be tremendous
pressure from consumers, hospitals and other providers to take advantage of
full federal funding in the initial years and to avoid gaps in coverage for
*The State Health
Reform Assistance Network is focused on setting up insurance exchanges,
instituting insurance market reforms, expanding Medicaid to newly eligible
populations, and streamlining eligibility and enrollment systems. Funded
by The Robert Wood Johnson Foundation, it is providing states with essential
resources to implement key health insurance coverage provisions of the
Affordable Care Act.