At its best, U.S. health care is exceptional — but the battle isn’t over yet

David T Jones

Canadians believe that they won the War of 1812 and that their health care is the best in North America. Americans would debate both contentions, but while 1812 is 200 years in the past, health care is all too contemporary. And with Affordable Health Care ("Obamacare") even more politicized following the June 28 Supreme Court decision, the future of U.S. medical care will be one of the drivers for the upcoming presidential election — and likely well into the next administration regardless of whom is the victor in November.

Indeed, historians may conclude that the Iraq War caused Obamacare. The war — whatever its logical rationales at inception — proved so maladroit in execution that its domestic unpopularity was a significant factor in the 2008 election. The result was a disproportionate Democrat victory, winning the presidency and Congress, and permitting passage of Obamacare with virtually no Republican support.

As passed by Congress, Obamacare is a Rube-Goldbergian labyrinth with ramifications and costs still substantially unknown. The Supreme Court judges have both clarified and obscured it. They have confirmed that the Affordable Health Care law is entirely constitutional. However, the individual mandate — requiring every individual to carry health insurance — is now defined as a "tax" and not a "penalty" (if the individual doesn't purchase health insurance). This difference is critical. If the individual mandate were constitutional under the interstate commerce clause of the Constitution, health care could be regarded as a constitutional right with those refusing to buy health insurance in violation of the law and fined/penalized. This was the argument advanced by the Obama administration. As a tax, however, it is a function of the Congress, and the cost can be raised, lowered, or eliminated by majority vote. Thus if Governor Romney wins the presidency and the Republicans hold their current House of Representatives majority and win the Senate, they can repeal Obamacare — as Romney has pledged to do.

Thus the stakes, so far as the roughly quarter of the GNP devoted to health care is concerned, could not be higher.

[ David Kilgour - Despite its warts, Canada's health system is strong ]

Even if the Republicans fall short — and politically it is an uphill fight — individual states under the Supreme Court's ruling cannot be penalized by having federal Medicare funds withheld if they do not implement the Obamacare requirements.

Health care in the United States is now an existential issue — it seems even more important than individual life and death. It has become an argument over the degree to which government can direct private action and individual choice. At the core, liberals argue that the government has an obligation to care for its citizens' welfare, and their health is paramount among these obligations. Conversely, conservatives argue that individuals' personal liberties are paramount and that choice, particularly for a matter such as health care, should be an individual decision unconstrained by threat of punitive taxation or penalty.

Underlying these contrasting arguments is the fact that most Americans already have health insurance with which they are satisfied. They anticipate Obamacare will bring substantial increases in their insurance/medical costs; they are hostile to such a development. Nor do they welcome tax increases to cover government health care financing; they regard President Obama's statements that increases will fall only on high incomes as disingenuous at best; duplicitous at worst.

The reality is that various horror stories about U.S. health care are canards. Those without insurance are not dying while scratching at emergency room doors (they are cared for in ERs with uncompensated costs absorbed in hospital overhead). At its best, U.S. health care is exceptional. Throughout the world, those with the worst afflictions seek first-rank U.S. hospitals for salvation (or at least prolonged life). If one has good health insurance coverage, effective care is quickly available, and waiting times are minimal.

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But at worst, there are terrible societal problems: insurance denied for "pre-existing conditions"; premiums boosted to out-of-sight levels for individuals with expensive problems; insurance "capped" with lifetime limits. If Obamacare is repealed, these issues must still be addressed.

The essential problem, however, is that we are outliving our design specifications. We are living past the Biblical three-score-and-ten life expectancy and costing society ever greater sums to sustain our lives in these out years.

It may be that the United States cannot afford both the world's strongest armed forces and comprehensive health care for its citizens. We have seen the choice made by Europe and Canada with minimalistic defense/security forces and expenditures devoted to the social safety net. Americans still have that choice ahead of us.