Along with eco­nom­ic secu­ri­ty, the future of Medicare has emerged as a sig­nif­i­cant issue in the pres­i­den­tial cam­paign. The Patient Pro­tec­tion Act, passed more than two years ago and recent­ly upheld by the U.S. Supreme Court,  pro­vides insur­ance reform, not health­care reform. But both are needed.

The Patient Pro­tec­tion Act imposed new require­ments on health insur­ers: young peo­ple can stay on their par­ents’ plans until age twen­ty-six, cov­er­age can­not be denied to peo­ple with pr-exist­ing con­di­tions, there are larg­er caps on life­time expen­di­tures on behalf of the insured per­son, and eighty-five per­cent of pre­mi­um income must be spent on patient care. The Act also man­dates that every­one pur­chase health insurance.

The indi­vid­ual man­date was one of the focal points of the law­suit brought by just over two dozen states’ attor­neys gen­er­al against the Act.

The states argued that the indi­vid­ual man­date is uncon­sti­tu­tion­al because it exceeds the pow­ers that the Con­sti­tu­tion grants to Con­gress. But the Supreme Court rea­soned that the penal­ty due from indi­vid­u­als who don’t buy health insur­ance con­sti­tutes a tax — and Con­gress has the pow­er to impose taxes.

Do the jus­tices see the ram­i­fi­ca­tions of what they’ve done?

If buy­ing insur­ance is a pay­ment in lieu of a tax, why not call the pay­ment a tax? If it’s a tax, why have the insur­ance com­pa­nies col­lect it? We have an Inter­nal Rev­enue Ser­vice that already col­lect taxes.

The insur­ance com­pa­nies are not a friend of effi­cien­cy in health­care: their prof­it is derived from a por­tion of the mon­ey that pass­es through their hands on the way to your doc­tor or hos­pi­tal. While an insur­ance com­pa­ny may balk at pay­ing for the care you need, on the whole, they want to see more pay­ments made to health­care providers. With more pay­ments to doc­tors, the insur­ers get to keep more: cost con­tain­ment is not one of their goals.

Insur­ance com­pa­nies con­tribute to inef­fi­cien­cy: each has its own forms, its own meth­ods, its own hur­dles for your physi­cian to jump over. Physi­cians spend too much time bat­tling insur­ance com­pa­nies on behalf of their patients. Win­ning those bat­tles is a form of patient care, but that isn’t what your physi­cian trained to do. When your physi­cian has a back-office staff to join the bat­tle, that staff con­tributes to the bill, not direct­ly to your care.

The Patient Pro­tec­tion Act was craft­ed to reduce fed­er­al spend­ing on health­care. Paul Ryan’s bud­get plan, devi­ous­ly named “Path to Pros­per­i­ty”, counts on these sav­ings, even though Repub­li­cans have vowed to repeal the leg­is­la­tion. Mitt Rom­ney, just nom­i­nat­ed by the Repub­li­can Par­ty as its can­di­date for pres­i­dent, repu­di­ates the Patient Pro­tec­tion Act, even though it was mod­eled in part on the insur­ance reform he signed into law as gov­er­nor of Massachusetts.

We have health insur­ance reform – if we can keep it. We need health­care reform – if we can achieve it.

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