After the nation's long, nail-biting wait for a judgment, the U.S. Supreme Court swept all the questions about the constitutionality of Patient Protection and Affordable Care Act off the table.

Now what?

For starters it's time to stop the dishonest broadsides about socialism. And presidential candidate Mitt Romney and congressional Republicans need to move beyond their bombastic pledges to repeal Obamacare. That's not likely to happen in this election cycle -- not unless the GOP pulls off an unlikely sweep of the White House and practically every Senate race.

Nor are the Democrats poised to sweep to big majorities in the House and Senate and move forward on their goal of enacting a single-payer system.

So the Affordable Care Act is the law now and is likely to remain so for some time. It's moving toward full implementation in 2014. That's when at least two major mandates take effect. They require everyone to have insurance, and for states to expand Medicaid eligibility and to provide exchanges where insurers will compete to cover small businesses and individuals. The clock is ticking.

No one really expects Republican candidates to drop their calls for repeal as Democrats try to seize the renewed opportunity the court gave them to sell voters on the law. But the partisan skirmishing shouldn't become the sum total of the debate.

The nation would be better served by a more productive election-year discussion about how best to build on the law's provisions to constrain health care spending before it breaks us.

The Affordable Care Act does make a stab at cost containment. It includes reforms such as a pilot program to try bundling payments to groups of service providers for a course of treatment rather than paying fees for individual tests and procedures. That fee-for-service model is the norm now, but it gives doctors and hospitals no incentive to limit procedures that don't improve patient outcomes. It actually encourages costly excess since the more doctors and others do, the more money they make.


Efficiency research to determine the most useful and cost-effective procedures should help. So should the law's focus on preventive care and shifting to electronic medical records.

But the cost-cutting impact of those reforms is uncertain, will take time to materialize and is unlikely to be enough to control runaway spending. We need to find consensus on additional approaches. There are plenty of ideas.

Washington should consider allowing insurers to sell policies across state lines, which is currently limited due to varying coverage mandates in individual states. That would increase competition for customers and push insurers to offer lower-priced plans.

Tort reform should be on the table. Capping noneconomic damages for people who successfully sue doctors and other medical providers for negligence is popular. But that would put the entire burden of reform on people who are grievously and negligently injured. There are better ways to limit providers' financial exposure on lawsuits. For example, for families with babies injured during delivery, a no-fault system similar to workers' compensation would prompt many defendants to forego the time and uncertainty of litigation in exchange for less money but certain compensation. Or malpractice suits could be moved to special courts, with liability and damages decided by dispassionate judges rather than emotional juries.

Medicare premiums may have to be increased or the age of eligibility raised from 65. And the law should be changed so the government can negotiate directly with pharmaceutical manufacturers for lower drug prices for people in the program.

Policy-makers need to find ways to expand Medicaid coverage now that the Supreme Court has gutted the law's power to coerce states into participating by withholding existing funding. For instance, individual states or Washington could cut back on the medical services Medicaid covers to free up money to enroll more people.

The nation must also find a way to limit costly but futile care for the terminally ill in the last months of their lives. The result is often needless suffering and expense. Less aggressive palliative care to ease pain and discomfort while keeping patients lucid, so they can share precious time with loved ones, is often better and less costly. We should make sure the terminally ill and their families have the information they need to weigh different approaches and understand how they affect quality of life.


While this is far from an exhaustive list, the point is there are ways to control spending that need informed debate about the choices to be made. That won't happen in this critical election campaign if it's just another round in the tedious fight over Obamacare. There is a more vital discussion about health care to be had.

In its landmark ruling last week, the court said its job is to interpret the law, not to make policy judgments. "Those decisions are entrusted to our Nation's elected leaders, who can be thrown out of office if the people disagree with them," the ruling said. The people vying to be those leaders need to tell voters what they believe needs to be done.


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