On the morning of June 28, 2012, I logged on to a website that I had never visited before: The SCOTUS Blog. I had heard that this website was the most reliable and fastest way to find out about the Supreme Court's decision regarding the fate of the Affordable Care Act. As a European, I had grown up with the idea that everyone should have health insurance, because access to healthcare is a basic human right. When I came to the U.S. and especially when I started practicing medicine in the U.S., I was devastated when I found out that millions of Americans do not have health insurance. Many uninsured Americans do not see their physicians for preventive care visits, they do take prescribed medications or follow up after diseases have been diagnosed because they cannot afford the medications or visits. Unfortunately, the lack of adequate prevention can lead to catastrophic illnesses such as a stroke or a heart attack.
In the past, patients who suffered from such a catastrophic illness were often not eligible to apply for health insurance because medical insurance companies would turn them down due to their "pre-existing conditions." Thus, the medical suffering of uninsured patients was compounded by the worries about the financial survival of their family, concerns about losing their homes and bankruptcy.
When the Affordable Care Act was passed, many experts agreed that that even though it was not ideal, it would help the millions of uninsured Americans to access affordable healthcare. Among the many Americans who would benefit from the Affordable Care Act, I was especially happy for patients with pre-existing medical conditions who could no longer be turned away by health insurance companies. I felt a great relief when the law was passed, but I also knew that it would face numerous legal challenges, in part driven by those who were deriving large profits from the current healthcare system or those who opposed all of President Obama's goals, regardless of whether they were beneficial for the American people.
These legal challenges against the Affordable Care Act ultimately ended up at the Supreme Court and its decision was going to be announced on June 28, 2012. Based on all that I had heard in the past weeks, I was dreading that the Supreme Court would declare the "individual mandate" unconstitutional and thus endanger the whole Affordable Care Act. The mandate required that every American would need to have health insurance, and was a key component of the Affordable Care Act. It was difficult to imagine that the law would survive, if it were stripped of the mandate.
As I read the live Scotus Blog, I saw the first mention of the decision:
10:07 Amy Howe: We have health care opinion.
My first reaction was worry. I was worried that millions of Americans would suddenly lose their newly gained access to affordable healthcare.
10:08 Amy Howe: Parsing it asap.
10:08 Amy Howe: The individual mandate survives as a tax.
I had not expected that the individual mandate would survive. I felt a tremendous amount of joy, because this would potentially mean that the whole Affordable Care Act could survive!
10:09 Amy Howe: It's very complicated, so we're still figuring it out.
10:10 Kali: We are still here. Don't worry.
10:10 Tom: So the mandate is constitutional. Chief Justice Roberts joins the left of the Court.
10:11 Amy Howe: The Medicaid provision is limited but not invalidated.
Now I felt utterly confused. I understood it was complicated, but why would the Bush appointee Chief Justice Roberts side with the judges that generally lean towards liberal decisions? Judge Kennedy was supposed to be the swing vote. What if the SCOTUS blog folks had just gotten it wrong? Perhaps the Affordable Care Act had been nullified by the Supreme Court?
10:15 Tom: Chief Justice Roberts' vote saved the ACA.
10:18 Amy Howe: The money quote from the section on the mandate: Our precedent demonstrates that Congress had the power to impose the exaction in Section 5000A under the taxing power, and that Section 5000A need not be read to do more than impose a tax. This is sufficient to sustain it.
It finally began to sink it. Chief Justice Roberts had decided to vote based on his legal expertise and conscience and had not been swayed by the political pressures of the conservative opponents of the Affordable Care Act.
10:21 Amy Howe: On the Medicaid issue, a majority of the Court holds that the Medicaid expansion is constitutional but that it w/b unconstitutional for the federal government to withhold Medicaid funds for non-compliance with the expansion provisions.
10:22 Lyle: The key comment on salvaging the Medicaid expansion is this (from Roberts): "Nothing in our opinion precludes Congress from offering funds under the ACA to expand the availability of health care, and requiring that states accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding." (p. 55)
After reading this, I was flooded with a sense of gratitude. Gratitude for all the people who had made the Affordable Care Act possible, from patient advocates to President Obama and the courageous legislators and for the Supreme Court that had upheld the law that will provide the much needed access to healthcare for struggling uninsured Americans. An excellent analysis of the Supreme Court decision was also posted later . As additional news emerged, I was able to understand that Chief Justice Roberts had voted in favor of upholding the law, because he felt the penalty associated with the individual mandate was basically a tax and that Congress had the right to tax people.
The German expression for what I experienced during those fifteen minutes is "Wechselbad der Gefühle", which literally translates to "changing bath of emotions". Wechselbad is often translated with the English idiomatic expression "roller-coaster," but I think that the metaphor of the sedentary bath that is changing its temperature is a more suitable metaphor for what we feel when we are glued to screen watching the unfolding of a real-time landmark decision. I won't forget this Wechselbad of emotions. These fifteen minutes reminded me how the health and fate of millions of humans can hinge on single decisions. But the most important lesson I learned was that we need to keep our simmering cynicism in check. People and institutions can surprise you in a good way. Chief Justice Roberts will likely be attacked by many conservatives and far right organizations, as evidenced by the appalling comments made by conservative commentators who are implying that his personal illness and potential medications he may be taking could have clouded his judgement. Such comments reveal a lot about the conservative attackers and their lack of respect for people with illnesses. Roberts probably knew that he would endure such attacks, and it is all the more laudable that he chose principles over politics. The Supreme Court's landmark decision ensures that millions of uninsured Americans will now have access to affordable healthcare. It also gives us hope by reaffirming the Court's integrity. In the long run, it will help restore faith in the democratic institutions of the United States.
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