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The Supreme Court and the Affordable Care Act: Milestone or Detour on the Road to Universal Coverage?

Robert B. Doherty, BA
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 10 July 2012.

From the American College of Physicians, Philadelphia, Pennsylvania.

Acknowledgment: The author thanks Anna Stoto for her help in editing and checking references.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1687.

Requests for Single Reprints: Robert B. Doherty, BA, American College of Physicians, 25 Massachusetts Avenue NW, Washington, DC 20001-7401.

Author Contributions: Conception and design: R.B. Doherty.

Analysis and interpretation of the data: R.B. Doherty.

Drafting of the article: R.B. Doherty.

Critical revision of the article for important intellectual content: R.B. Doherty.

Final approval of the article: R.B. Doherty.

Administrative, technical, or logistic support: R.B. Doherty.

Collection and assembly of data: R.B. Doherty.

Ann Intern Med. 2012;157(8):577-579. doi:10.7326/0003-4819-157-7-201210020-00509
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This commentary discusses the Supreme Court's decision to uphold the Patient Protection and Affordable Care Act and how the decision to allow states to opt out of expanding Medicaid could result in coverage gaps for the most vulnerable patients, rather than the seamless expansion of coverage originally expected.

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Affordability of the Affordable care Act
Posted on October 18, 2012
Stephen Vaccarezza
private practice
Conflict of Interest: None Declared
This article in the current Annals clearly only looks at potential benefits of universal health care. Unfortunately, the devil is in the details on several levels. It is the details that can make the utopian ideal unworkable. The detail in in the very nature of humans, people are people. People as a group will look out for themselves. This applies to the people who compose the masses in need of health insurance as well as the people who will be ostensibly in charge of providing health care. And this latter statement does not refer to the doctors but instead, to the policy makers in charge of running the programs. First, there will always be people that either do not or cannot pay for their health insurance. And the number of people who cannot pay for their own health insurance is probably lower than government estimates, since people spend more money on nonessential pleasures than on their health. Hence they are poorer than they may appear because of poor spending habits. Second, and probably most important, policy makers and their minions who will actually dole out the care (not the doctors) will also act in their own self interest and can walk us down a slippery slope of authoritarian rule. You cannot guarantee that a system set up to provide care based on a central government making decisions will remain free and pure over time. The only protection from this is to allow people to retain their own control. The price for this is a somewhat chaotic delivery of care but, as the polls show, this is preferable to a Department of Motor Vehicles model of care. Hence, the current system in place for so many years and has worked so well for 85+ percent of the population should not be changed to accommodate a small and frequently unwilling minority who struggle with it.
Author's Response
Posted on December 3, 2012
Bob Doherty, BA
Conflict of Interest: None Declared

I respectfully disagree with Dr. Vaccarezza’s characterization that the uninsured consist of people who could afford coverage but choose to spend money on “non-essential pleasures.” The Kaiser Family Foundation and the Urban Institute report that “the vast majority of uninsured people are in low- or moderate-income families, Individuals below poverty are at the highest risk of being uninsured, and this group comprises 38% of the uninsured population (the poverty level for a family of four was $22,350 in 2011). In total, nine out of ten uninsured people are in low- or moderate-income families, meaning they are below 400% of poverty” (1). These people lack health insurance because their employers don’t offer it and they can’t afford to buy it themselves, not because they choose to spend money on something else.He says that the Affordable Care Act will lead to “central government making decisions.” The law expands the federal government’s role in subsidizing and regulating coverage, but it mostly closes gaps in the current system of private insurance rather than putting people in a government-run plan. The Congressional Budget Office estimates that by 2022, 11 million more people will be enrolled in Medicaid, and 25 million will get coverage from private insurers offered through state- or federally-administered marketplaces (exchanges) but 157 million of us will continue to get health insurance from our employers. The number of uninsured will be reduced by 30 million (2). Lack of health insurance is a matter of life and death, not just an inconvenience. Analysis by the Urban Institute and Institute of Medicine finds that 165,000 Americans died unnecessarily from 2000 through 2006 simply because they were uninsured (3).And how can it be “authoritarian”, as Dr. Vaccarezza argues, to carry out a law that was duly enacted by a Congress which in turn was elected by the voters, and that is administered by agencies that report to appointees appointed by a democratically-elected President, and confirmed by the elected U.S. Senate? A law that will be subject to vigorous congressional oversight and to a Supreme Court that ensures its constitutionality? And to a free press that will scrutinize aspect of its implementation? I would call this democracy in action, not authoritarianism.


1. Kaiser Commission on Medicaid and the Uninsured. Key Facts about Americans without Health Insurance. The Uninsured. Kaiser Family Foundation. October 2012. Accessed at http://www.kff.org/uninsured/upload/7451-08.pdf on November 29, 2012

2. Congressional Budget Office. Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision. July 2012. Accessed at http://www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-CoverageEstimates.pdf on November 29, 2012

3. Dorn S. Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality. Urban Institute. January 2008. Accessed at http://www.urban.org/UploadedPDF/411588_uninsured_dying.pdf on November 29, 2012

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