The Obamacare Challenge We Need? Improved, Expanded Medicare for All

As a primary care pediatrician who sees children of low-income families in Washington, D.C., I am reminded every day of the vulnerability of our children's health to the ill-informed whims of our lawmakers and courts.

Those children will be on my mind as I gather with others outside the Supreme Court today.

Just yesterday, I saw my 16-year-old patient Mary, who suffers from Down's syndrome and congenital heart disease, both conditions with lifelong disabilities. I have known Mary for the last 13 years.

Her family has been through some very rough times. I still distinctly remember listening to Mary's mother tell me that her family was homeless, just a few years ago. Mary's mother was in tears. They had no place to live, two children to feed, and both parents were unemployed.

The ACA is fundamentally flawed because, by design, it perpetuates the central role of the private insurance industry and other corporate and for-profit interests.

To the best of my ability, I reassured Mary's mother that despite hard times for her and her family, she would still have me as her child's pediatrician, and Medicaid for her child's health insurance.

At that moment I reminded myself that it takes a societal commitment to public institutions like Medicaid and community health centers to provide care to millions of Americans like Mary who would otherwise go without.

Yet when Mary turns 21, she might not qualify for Medicaid. Depending on what state Mary and her family live in, she may or may not have access to the doctors she will need for the rest of her life.

Children and their families need stability in their lives, and yet health insurance in our country remains prone to great instability and harsh surprises. Mary's case is by no means unique.

How is it possible that in 2015 one of the richest countries in the world still does not guarantee every resident the right to health care? This question would not be necessary if we had a health care system worthy of the name - single-payer national health insurance, or an improved and expanded Medicare for All.

Today, at the Supreme Court, the latest assault on the highly convoluted, corporate-friendly Affordable Care Act is unfolding. The justices will be hearing oral arguments in the case of King v. Burwell. The case is a legal challenge to a small piece of the ACA that, if upheld, would have potentially big consequences.

At issue is whether the ACA's language allows the federal government to provide subsidies to people who buy health insurance in states that didn't set up their own "marketplaces," i.e. in states that rely on the federally run marketplace, HealthCare.gov, in whole or in part, to serve their populations.

Only 13 states (plus the District of Columbia) set up their own state-managed marketplaces. Thirty-four states declined to do so; three others turned to the federal marketplace when their own IT systems failed.

King and his fellow plaintiffs argue that a subsection of the ACA that says subsidies should flow to people "through an exchange established by the state" should be interpreted to mean that only people who live in those 13 states with state-managed marketplaces should be entitled to subsidies. They say people who buy through the federally run marketplaces should not get subsidies.

If the Supreme Court upholds the King challenge, the health and financial harms to our nation's patients will be substantial.

For example, the Urban Institute estimates 9.3 million people in 34 states would lose their subsidies within the year, making their premiums largely unaffordable. An estimated 8.2 million would consequently join the ranks of the uninsured.

We know that lack of insurance means a much higher risk of death. One landmark study suggests that if an additional 8 million people lose health insurance coverage, we'll witness an estimated 8,000 "excess deaths" annually.

So here is the picture: nine very well-insured Supreme Court justices are literally holding the lives of many thousands in their hands. Their ruling is expected in June.

But that's not the half of it. Keep in mind that, by the same calculus, under the Affordable Care Act, some 30,000 preventable deaths are occurring each year due to the law's lack of coverage of 30 million people. And about 24 million of those would still be uninsured even if all the states had accepted the Medicaid expansion.

Regardless of how the court rules, the sad reality is that the ACA won't be able to achieve universal coverage. It won't make care affordable or protect people from medical bankruptcy. Nor will it be able to control costs.

The ACA is fundamentally flawed in these respects because, by design, it perpetuates the central role of the private insurance industry and other corporate and for-profit interests (e.g. Big Pharma) in U.S. health care.

In contrast, a single-payer system - an improved Medicare for All - would achieve all three goals mentioned above: truly universal/comprehensive/lifelong care, affordability, and effective cost control.

It would be legally robust and simple to administer, saving approximately $400 billion annually by slashing the administrative bloat in our private-insurance-based system. That money would be redirected to clinical care, allowing us to eliminate all copays and deductibles.

But single-payer national health insurance is not just about financing health care. It goes much deeper than that. It is the first most important step we can take in this country to level the playing field between the rich and poor, the sick and healthy, the young and the aged, and among all colors of the human race.

Single payer would restore a sense of ownership in both those receiving and providing health care, by democratizing our health care system, rather than leaving it in the hands of politicians and vested interests who hold their purse strings.

It is time that we take back our health care system, and run it in a fair, rational way to provide quality comprehensive lifelong health care to every American. Our children and their families have no time to lose.