The Patient Protection and Affordable Care Act has been found to be constitutional in its entirety by the United States Supreme Court, including the provision requiring most Americans to maintain “minimum essential” health insurance coverage.  Here is the good, the bad, and the ugly of that decision.
I. THE GOOD
What the Supreme Court has upheld is the only healthcare reform that the politicians will allow us. Had the court struck down the law, there would have been no replacement. For years prior to the law’s enactment, suggested reforms designed to give us anything resembling universal health coverage encountered utter intransigence on the part of our political leadership, and there is no reason to believe that Congress wouldn’t behave exactly the same way in the future.
What’s more, the act has many features that will be of benefit to citizens who have previously been marginalized by the U.S. healthcare system. Coverage can no longer be denied based on pre-existing conditions.  Lifetime limits on coverage have been abolished. All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay, or coinsurance.
The list goes on. There can be no doubt that the healthcare system has become better and more accessible for most Americans.
The federal budget deficit has justifiably been a concern as of late. Contrary to the expectations of some, the act will actually reduce the deficit.  The law includes cuts, including $500 billion in cuts to Medicare spending, which will result in a net deficit reduction.
II. THE BAD
This is not universal health coverage. In 2016, two years after the law’s health insurance exchanges begin operating, 27 million people will remain uninsured. Among those are people for whom health insurance premiums would cost more than 8% of household income.  Such people would not be subject to a penalty for not purchasing health insurance, but the fact remains that there will still be certain low-income people who will remain marginalized by the healthcare system.
Additionally, unlike a single-payer system, which would be supported by tax dollars, a substantial amount of the cost of the program will be born by private business. This will only be partially offset by tax credits for small businesses. American businesses will thus remain at a competitive disadvantage vis-à-vis companies that operate out of countries that provide universal government funded healthcare, and employment figures might well be adversely affected.
Universal single-payer health coverage would be less burdensome to business, would involve cost reductions in the practice of medicine in that health providers would have only one insurer to contend with, would reduce the healthcare market to one purchaser, thereby bringing down costs, and would cover everyone. But as the new system becomes institutionalized over time, politicians, who will assure themselves they have addressed the issue of healthcare, will likely become even less willing to consider the clear merits of a single-payer system.
III. THE UGLY
A requirement that individuals purchase health insurance, or anything else, is clearly beyond the constitutional powers of Congress. The Supreme Court acknowledged this fact in its ruling.
But if the court specifically said that Congress cannot compel individuals to purchase health insurance, how did it uphold the entirety of the healthcare reform law, including the provision requiring individuals to make that very purchase? By construing the penalty to be paid for not buying health insurance as a tax.
A tax and a penalty are not the same thing, and are readily distinguishable. As the joint dissent points out, a tax is an enforced contribution to provide for the support of government, while a penalty is an exaction imposed by statute as punishment for an unlawful act. But the penalty to be paid under the healthcare reform law is exactly a punishment for failing to obey the law by buying health insurance. What’s more, the Act calls it a penalty.
A decision based on bad reasoning like this is bound to make for bad precedent in the future. To wink at straining the obvious meaning of statutory language beyond credulity in order to obtain a desired result is penny wise and pound foolish. In future cases, the court will have to uphold the tortured reasoning confounding taxes and penalties, or risk another constitutional attack on the healthcare reform law, and the consequences of that eventuality cannot be foreseen.