In the context of the historic and momentous Supreme Court
decision legalizing gay marriage across the US, and its affirmation of the Fair
Housing Act, the third of the “trifecta” of progressive decisions announced
this week, the ruling against those who argued that the ACA forbid federal
financial support of federally-sponsored rather than state-sponsored insurance
exchanges, seems rather pedestrian. After all, it just decided that the intent
of the ACA was to achieve what its intent was – greater insurance coverage for
the American people – and this would not be invalidated by 4 poorly-chosen
words in a 1,000 page bill. What is more worthy of note is that there were
three Supreme Court Justices who voted against it, when it was clearly not a
real issue of law but an end-run to get it invalidated on a technicality. The low
point of the dissent was Justice Scalia’s juvenile characterization of the
majority decision as “jiggery-pokery”, an archaic expression most recently used
in the public domain in a Harry Potter movie. Of course, Scalia could make a
fair Harry Potter villain; not the potent evil of Lord Voldemort, but more of a
scowling, snarling Severus Snape.
But the decision has
real meaning. It means that millions of Americans in the 34 states that elected
to not establish state-based exchanges and thus depend upon federal ones will
not lose their health insurance. That is a good thing for those people, and it
is a good thing for America. It does nothing for those people who were excluded
by the SCOTUS decision 3 years ago (also written by Chief Justice Roberts) that,
while validating ACA, precluded requiring states to expand Medicaid. This left
millions more in the states that have not done so (like mine, Kansas) without
insurance. It certainly does nothing for
the millions of those without legal documentation who live here, or the many
others who fall between the cracks of the law. It still leaves us without the
moral, medical, social, and economic advantages that come from a truly
universal health system such as any of those adopted by every other wealthy
nation, which achieve better health for less cost (see graphic). But it does make
us seem slightly less cruel and benighted.
Not that this will end the discussion. A small article in
the New York Times of June 27, 2015 notes
that “Legal
challenges remain for health law”. These include a lawsuit by House Republicans
led by Speaker John Boehner maintaining ACA is invalid because it spends money
not appropriated by Congress, and a series of suits by religious organizations
about the law’s requirement that they cover contraception. Indeed, the whole
opposition to the law has becoming akin to a religion itself; according to its
opponents (obviously also including all the Republican candidates for
President) it is bad as a matter of faith, even though it does so much good.
Yes, it does good in costly ways, ensuring that insurance companies make their
profit; it does it in arcane ways; it does it in ways which in fact cost some
people more than they might have otherwise paid. But it provides several
million people the opportunity to not be the Donna Atkins or Tommy Davis of the
future (see Dead
Man Walking: People still die from lack of health insurance, November 17,
2013).
In response to a blog in which I posted a map that shows
that the vast majority of those remaining uninsured are in the states of the
former Confederacy and suggested that while Southern people might not be meaner
than others, the impact of their policies was (Medicaid
expansion and uncovered lives: are people meaner in the South?, February 8,
2015), Bobby Cohen wrote in a comment “If meanness doesn't explain the
rejection of Medicaid expansion by Southern states, what does?” Well, for many
people, I suppose, it is ignorance, of the sort demonstrated by “Keep the
government’s hands off my Medicare!” or what I have called the “Craig T. Nelson
fallacy” (“I've been on food stamps and
welfare. Anybody help me out? No. No.”!!). Or the beliefs of some of the
people in southeast Kansas interviewed for Kai Wright’s excellent article “Life
and Death in Brownback’s Kansas”, published in the June 22/29 issue of The Nation where it seems that “Everyone
is convinced that someone else is getting a better deal, that somewhere a horde
of Kansans are gaming the system and preventing the truly needy from getting help.”
In a true “What’s the Matter with Kansas”[1]
illustration, even the doctor at the community health clinic who is fighting
hard to get care for her impoverished patients who would have otherwise had
Medicaid is conflicted; Brownback, after all, is a strong anti-abortion
advocate, as is she.
All of these may explain some of the position of the leaders
of this movement, but a better explanation can be found in the answer to one of
the questions in “Steven
Pinker’s Mind Games”, a psychology quiz on the NY Times website: “the best liar is the one who believes his own
lies”. But it is hard to look at, not to mention listen to or read, the hard-core
right-wing justices on the Supreme Court (who, unlike the GOP’s many
presidential candidates are not even running for office) without thinking that
they are, essentially, mean. They are not only against helping people when it
will cost them, not altruists (another Pinker question), but even when it will
save them money (again, see graphic).
I do not claim to be a legal scholar of the status of any of
the Supreme Court Justices, or indeed the President. I gained some
understanding from “The elusive right to
health care under US law”, by Prah Ruger, Ruger, and Annas in the June 25,
2015 issue of the New England Journal of
Medicine, published before any of these SCOTUS decisions were announced.[2]
It’s a good and readable article which helps medical people like me understand
some of the logic of court decisions. One line I found of particular interest
was “American constitutionalism has
championed negative liberties more than positive rights.” The idea is that
the Constitution says government should not be allowed to take away our
individual liberties (e.g., our guns) but not so much that we have a right to
things (e.g., health care).
And yet, as pointed out by Gail Collins in “Supremes
hit a high note”, this Court has “…destroyed the nation’s campaign finance
laws, limited workers’ rights to challenge wage discrimination and women’s
rights to control their bodies. And basically disemboweled a 50-year-old Voting
Rights Act that Congress had renewed by increasingly large margins on
four different occasions.” These
decisions, almost all of which came out differently from those of the last 2
days only by the “swing vote” of Justice Kennedy (Chief Justice Roberts did
join the majority in the decision on ACA), do not always follow this logic. It
is quite an extension of the idea of liberty to say that corporations are
people (the founders certainly didn’t think so) or money is speech. It is quite
opposite protecting individual liberty to have laws limiting the ability
of women to obtain contraception or abortion (although they can sure have
guns!). Whether put forward by ignorant bigots, self-serving politicians, or
sanctimonious Supreme Court Justices, the concept is most consistently “people
should be allowed to do whatever they want, as long as they want the same
things I do, but not what I disapprove of”. Sometimes, particularly when
describing the actions of the powerful, this is described as political. But I
think Dr. Cohen is right; it is essentially mean.
A phrase we
commonly hear is that “mean people suck”. They do, but more important, when
they have positions of power, they can do a lot of damage to others.
[1]
Thomas Frank. “What’s the matter with Kansas?”. Henry Holt. 2004
[interestingly, published in the UK and Australia under the title “What’s the
matter with America?”!] ISBN 0-8050-7339-6.
[2] Jennifer
Prah Ruger, Ph.D., M.S.L., Theodore W. Ruger, J.D., and George J. Annas, J.D.,
M.P.H., The Elusive Right to Health Care under U.S. Law, N Engl J Med 2015;
372:2558-2563June 25, 2015DOI: 10.1056/NEJMhle1412262
