Healthcare ruling a start, not an end

What Chief Justice John Roberts might have explained as an exercise in judicial modesty got him called "crabbed" by Justice Ruth Bader Ginsburg on one side and "overreaching" by four dissenting justices on the other.

Ultimately, his majority opinion for the Supreme Court on Thursday was a historic upholding of a historic expansion of health insurance in the United States.

Probably to underscore the importance of the ruling as a legal, not political, instrument in the grand scheme, Roberts quoted from Chief Justice John Marshall, founders Alexander Hamilton and James Madison and even Benjamin Franklin's familiar "nothing can be said to be certain, except death and taxes."

"We possess neither the expertise nor the prerogative to make policy judgments," Roberts wrote. "Those decisions are entrusted to our Nation's elected leaders, who can be thrown out of office if the people disagree with them."

Republicans immediately pounced, even setting a U.S. House vote on repealing the Affordable Care Act for July 11.

Opponents also spun to their advantage the court's rationale for upholding the law: A 5-4 majority said it's a valid exercise of Congress' constitutional taxing power -- not unlike cigarette taxes that raise revenue from a regulated product but also seek to change individual behavior.

U.S. Rep. Michael Burgess hyperbolically and inaccurately said in a statement that the law imposes "a tax increase and a very large tax on middle-class America."

In fact, the law's requirement that individuals purchase health insurance or pay a tax would affect mainly those who don't have employer-provided coverage or don't buy it through private companies or new state exchanges. The tax starts low and gradually increases but wouldn't go higher than the cost of a policy.

In reality, those who carry insurance now are "taxed" in the sense of helping pay for uninsured free riders whose healthcare costs are spread around in the form of higher bills for premiums and medical services.

The inevitable cheering from the law's supporters and ranting from detractors aside, the ruling should be seen for what it really is: first, a boost to the Supreme Court's legitimacy as a neutral arbiter of wrenching debates rather than just another raw political player; and second, only a starting point for improving this nation's healthcare system.

Some aspects of the law are widely popular: no exclusions for pre-existing conditions; coverage for adult children on their parents' policies up to age 26; "doughnut hole" prescription assistance for seniors; broader coverage without co-pays for some preventive services; a tax credit for small-business owners who provide insurance for their workers. Some major insurers already said they'd keep key elements regardless of the court's ruling.

But the law itself can't moderate the costs of medical procedures or reduce the overuse of expensive tests. It won't bring down drug prices. The law still leaves millions of Americans uninsured. Instead of wasting time, effort and energy on repeal, why not refine and reform where it's still needed?

Key questions remain about how states like Texas will deal with the law's expansion of Medicaid, the federal-state partnership to cover medical costs for pregnant women, children, needy families and the elderly and disabled.

Under the act, states must raise their income eligibility limits and cover childless adults to receive increased federal Medicaid funds.

A 7-2 majority of the justices said threatening to cut off all federal funds is like "a gun to the head" rather than constitutionally acceptable pressure to get states to act as Congress wants. That means states can decline to expand but not lose existing funding; most will probably participate, though, given that the federal government will initially cover 100 percent of the cost for new enrollees.

Texas was among the states that sued over Medicaid expansion. And Attorney General Greg Abbott on Thursday was tweeting unhelpful provocations like, "On #ObamaCare, we have only begun to fight. Who's with me?"

Instead of continuing to pour money into legal bills, Texas should work harder to reduce its number of uninsured residents. Nothing in the law or the Supreme Court's ruling prevents that.

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