An artist's sketch shows Solicitor General Donald B. Verrilli Jr....

An artist's sketch shows Solicitor General Donald B. Verrilli Jr. speaking in front of the Supreme Court in Washington, D.C. (March 26, 2012) Credit: AP

Three days of warfare in the U.S. Supreme Court over the Patient Protection and Affordable Care Act have left that sweeping health care reform wounded -- and maybe on life support.

Justices whose votes are needed to keep the law intact aggressively grilled the attorneys defending it, appearing deeply skeptical that the law's mandate requiring everyone to buy health insurance is constitutional. So it's tempting to handicap the outcome of President Barack Obama's signature domestic achievement and pick political winners and losers this election year, when the federal role in health care has become a touchstone issue.

If the court rules that the mandate is unconstitutional and overturns the law, then the nation will be back at square one with a ruinously expensive and mind-numbingly complex system in which costs double every decade and millions are uninsured. The rest of us pay for those without coverage in the most costly, inefficient way imaginable.

If the court upholds the mandate and the broader law, millions of additional people will be insured. But we will still have to find pragmatic, politically acceptable ways to control surging costs.

Another option for the court is to declare the mandate unconstitutional, carve it out of the law and leave the rest intact. But Republican presidential candidates and some in Congress have promised to repeal the law, or whatever remnants the court may leave. So no matter what the court does, this battle won't end.

The nation is locked in this legal showdown because the health care overhaul was crafted to retain a role for private insurers while extending coverage to uninsured people. That's why the individual mandate at the heart of the constitutional dispute was imposed.

Under the law, scheduled to take full effect in 2014, insurers won't be allowed to refuse to cover anyone, including people with pre-existing conditions. They won't be able to cap the amount they pay for care annually or over a lifetime, or to refuse to renew a policy after a person gets sick. Those important insurance reforms will protect policyholders' medical and financial well-being. But they will dramatically drive up costs for insurance companies, which will pass those costs along to policyholders.

The mandate would offset the additional costs by increasing the number of young and healthy people who buy insurance but require little treatment. Eliminate the mandate and the popular benefits would have to go too. Otherwise the cost of insurance -- already out of reach for millions of people -- would soar even higher.

Washington has been struggling for decades to find a way for the nation's blended, public-private system to deliver quality care for all and pay for it without breaking the bank. Despite incremental changes over the years, the cost of health care is inflating federal budget deficits and undermining economic growth. If we have to start over, lawmakers should reconsider the benefits of a single-payer system for basic health care while keeping a role for private insurance.

No matter what the court decides by late June, the nation will still have health care problems to solve, and no political consensus about how to do it. Unless that changes, the public will be the real loser.


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