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Roberts Saves Obamacare: Now the Real Work of Reform Begins

The narrow survival of the Affordable Care Act last week was certainly cause for celebration. But as the jubilation subsides, it's important to realize that having avoided what would have been a giant step backward doesn't mean we've taken a giant step forward.
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The narrow survival of the Affordable Care Act last week was certainly cause for celebration. But as the jubilation subsides, it's important to realize that having avoided what would have been a giant step backward doesn't mean we've taken a giant step forward. Because the law as it now stands is only the first step toward health care reform.

On Sunday's This Week, Vicki Kennedy (Ted Kennedy's widow) spoke movingly of how "health care reform was the cause" of her husband's life. "He believed that it was a moral issue," she said, "that it defined the character of who we were as a society, who we were as a country, and that decent, quality, affordable health care should be a fundamental right and not a privilege." She went on to say, "Families can go to sleep relaxed and happy knowing that their children who have asthma or diabetes or allergies are covered by insurance and aren't barred because they have a pre-existing condition."

But in fact we are a long way from that rosy description. Beyond the problems of implementation and whether this state or that governor will set up the required exchanges by 2014 or accept money for Medicaid expansion, the Act mostly extends a flawed system to more people. And while this is certainly a very good first step -- leaving 50 million people without insurance is unconscionable -- we quickly need to get to work improving it.

"All but lost in the commentary" about the decision, writes Eugene Robinson, "is that the Affordable Care Act was intended as just a beginning." Or, as Cornell's Robert H. Frank put it, "The point worth celebrating is that last week's ruling will at last enable our distinctly dysfunctional health care system to evolve into something better."

Primary among the next steps to continue that evolution is the need to focus on cost containment and prevention -- neither of which the Act adequately addresses.

"With or without Obamacare, the American health system will continue to unravel -- quickly if Romney is elected, slowly if Obama is re-elected," writes Dr. Marcia Angell of Harvard Medical School. And this is because the law doesn't actually reverse the unsustainable trend line of skyrocketing health care costs. "[Obama] also did nothing to rein in the profit-oriented delivery system that rewards providers on a piecework basis for doing tests and procedures," writes Angell. "So with all the new dollars flowing into the system and no restraints on the way medicine is practiced, the law is inherently inflationary."

As one health care lobbyist told Angell, if the Act cuts into the industry's profits, they'll just raise premiums -- something the new law doesn't prevent. When this happens, more and more people will opt out of the system, choosing to pay the meager penalty -- sorry, Chief Justice Roberts, I mean tax. This will lead to even higher premiums, and the vicious cycle will continue, albeit a tad more slowly than before.

This is because, writes Angell, "Obama gutted the law before it even passed." Aside from keeping most of the current system in place and simply extending it, there were the deals to not allow drug reimportation and the deals that prevent the government from negotiating for lower drug prices. In 2008, then-candidate Obama took on the latter provision being left out of the Medicare Part D bill: "That's an example of the same old game playing in Washington," he said. "You know, I don't want to learn how to play the game better. I want to put an end to the game playing." He clearly didn't.

Beyond the continuing problems of how to cover treatment once people are sick is the escalating problem that comes one step before that: dealing with efforts to prevent people from getting sick in the first place. Given current obesity and diabetes trends -- and the myriad medical problems associated with them -- it's not enough to focus on coverage. Any plan that doesn't aggressively tackle preventive care can't contain enough costs to be sustainable.

And though the Act has modest preventive care provisions, they're mostly about screenings for various conditions -- which is great, but not nearly enough to reverse the alarming trend lines. And even among those provisions, there are, as many patients -- and insurers -- have already found out, numerous loopholes.

"Perhaps the most pressing public health challenge for the United States today is the epidemic of... obesity," writes Ross A. Hammond of the Center on Social Dynamics and Policy, "which is linked to an array of costly and debilitating health consequences." Since 1960, obesity has risen nearly 35 percent. Looking just at children, nearly one-third of whom are obese or overweight, obesity is associated with over $14 billion in direct medical spending; overall, more than 20 percent of U.S. medical costs are now attributable in some way to obesity.

This obesity epidemic is also helping to fuel the diabetes epidemic (in addition to heart disease, cancer, asthma and a host of other conditions). As Hammond notes, a shocking one-third of all children born in America will develop type 2 diabetes at some point. "Even if the epidemic does not worsen," he writes, "these costs are likely to prove an unsustainable burden on the health system given the long-term growth of the federal debt." On the other hand, just a five percent decrease in diabetes could save an estimated $25 billion every year.

In response to the Supreme Court ruling, President Obama said that "with today's announcement, it's time for us to move forward -- to implement and, where necessary, improve on this law." The "where necessary" implies that it's just a matter of tweaking a few things here and there. But it's not about tweaks. We need to continue to think big. Among the many important aspects of passing the Act was simply putting to rest the notion that nothing can be done. Well, something was done -- but much more, especially on preventive care, still needs to be done.

In the weeks leading up to the ruling, we read a lot about the sense of urgency and alarm and resolve that health care advocates would have if the Affordable Care Act were struck down. Now that it's been largely upheld, we need to keep -- and build upon -- that sense of urgency.

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