The choice is clear for the Supreme Court, author says: Uphold health care reform. Killing mandate won't fix health care

With hearings starting Monday, the U.S. Supreme Court is poised to deliver a pivotal decision that will profoundly affect the future of our country. At stake is whether millions of Americans can have greater access to affordable health care coverage — or whether the nation’s health care system will be plagued by uncertainty, imbalance and spiraling costs.

The justices are to rule on a critical element of the Patient Protection and Affordable Care Act, the now two-year old, groundbreaking health care reform law. They will determine whether Congress has the authority, under the Commerce Clause of the Constitution, to mandate that every U.S. citizen must buy health insurance.


The court will also consider whether the entire law would be unconstitutional if the personal coverage requirement was struck down, or whether it can be separated from insurance market reforms, like guaranteed issue, which ensure that everyone has access to affordable health insurance. Referred to as “severability,” there is no provision in this law — as is often the case involving complex policy matters — that would normally clarify this question.

From both a legal and practical perspective, the choice is clear. Congress was well within its authority in passing the individual mandate to regulate the interstate effects of an industry that is almost 20 percent of our nation’s economy— more than $2.5 trillion each year.

The only real question, in fact, is whether we have an individual mandate — one that requires individual responsibility, which I always thought was claimed as a conservative value — or we have a community mandate.

The community mandate is what we have now. It requires us to pay more than $64 billion in uncompensated care through higher taxes, low payments for health providers and higher premiums for those who already pay for insurance. This mandate costs the typical family more than an estimated $1,000 a year in higher health insurance costs. It drives people to seek care in the most expensive ways — rather than focusing on primary care and prevention.

However the court decides, there is no doubt that the mandate and reforms are fundamentally intertwined. Everyone deserves access to affordable, high-value coverage. But it’s virtually impossible to have anything close to universal coverage without a mandate. Insurance works when the cost of health care is spread among everyone — young, old, healthy and infirm.

The basic issue, though, is that not everyone wants to pay for health insurance. Those of us that have spent decades trying to improve the private insurance market have struggled to find a solution to this central dilemma.

Other alternatives — including automatic enrollment and subsidies — have been studied and attempted, without success. In fact, a mandate is virtually the only way to avoid adverse selection in the insurance market and to requireguaranteed issue and the accompanying community rating mechanisms on which universal coverage is built.

Consider what happened in the nine states that attempted to implement health insurance reform in the 1990s without a personal coverage requirement. Two-thirds of these states, including my home state, South Dakota, have since repealed these laws because they led to skyrocketing premiums and reduced choice for consumers.

Congress was well aware of the experience of these states and knew that the insurance market reforms at the heart of improving coverage under this new act are inextricably linked to a mandate that requires all of us to take responsibility for our health. For those who need help with the expense, Congress took great steps to provide financial assistance and ensure that obtaining health insurance does not become an unfair burden.

If the court rules that the mandate is unconstitutional but leaves intact the insurance market reforms, the consequences will be dire. Premiums will skyrocket, while consumers will face dwindling choice and insufficient coverage.

This is not the market any of us — Democrat or Republican — desires. It will also add to our enormous deficit problem. The federal deficit will rise by at least $145 billion over the next decade, according to the Congressional Budget Office, if the law is struck down.

Most important, we must consider the fate of the more than 50 million uninsured Americans. The number of people without health insurance is expected to jump significantly if the law is struck down. Some estimate that it will rise by 12.5 million, while other estimates range as high as 16 million to 20 million.

Let’s not forget that, at its core, this is not an issue of financial impact but, rather, an issue of human rights. Too many American families know the unparalleled pain of watching a loved one suffer through illness that is preventable and treatable with access to basic medical services. As much as we Americans like to pride ourselves on our resilience and ingenuity, these qualities are meaningless unless the benefits can be shared among all members of our communities, regardless of age, income or geography.

Whether or not the court concludes that the Affordable Care Act is valid, the only path forward is for Congress and the Obama administration to continue the mission to ensure that every American has access to affordable and comprehensive, quality health care. In the two years since this health law passed, stakeholders have come together to create new approaches and make tremendous investments to move forward with its goals. We cannot let these efforts go to waste.

It is increasingly urgent that our leaders put partisan politics aside and instead come with up solutions that align incentives and policies with the behaviors that drive innovation and foster efficiency in all our communities.

There is reason for encouragement. Most Republicans have long endorsed insurance models with competitive bidding in open exchanges — an idea that originated with The Heritage Foundation in the early 1990s. Members of both parties have supported quality-based pricing, increased transparency, the elimination of unnecessary care, effective chronic care management and the acquisition of more health information technology.

That is only way to achieve our shared goal of a high-performance and high-value health care marketplace — one based on greater access, better quality and lower costs for all Americans.

Former Sen. Tom Daschle (D-S.D.) served as Senate majority leader.