THE TRUE impact of the Supreme Court’s decision on President Obama’s health care law won’t be felt on the high court or the presidential campaign trail: In each arena, the status quo more or less prevails. But the court’s approval of the legislation, the first attempt at comprehensive reform of the sprawling health care bureaucracy, is a landmark event nonetheless. It preserves a crucial framework for wrestling with issues of cost, access, coverage, and quality that would have been completely lost had the court’s activist conservative wing — which sought to derail the entire enterprise — carried the day.

The law, in itself, is not a panacea. The court’s ruling may hamper the expansion of Medicaid, a key way in which the law offers medical coverage. Other provisions, like the medical-device tax, will also need to be rethought. Still others, such as the penalty for working adults who decline to carry coverage, may have to be adjusted over time. The best-practices data that are useful in controlling costs must be properly applied. Cost savings, such as those from the computerization of records, must be tabulated.


The law is a collection of component parts. Some are popular, like the requirement that insurers let children stay on their parents’ policies until they are 26; some are unpopular, like the “individual mandate,” which demands that adults who can afford health insurance should buy it. But each of the provisions works in concert with the others: The unpopular mandate, which the court upheld Thursday, begets the popular requirement that insurers write policies for even people with costly illnesses; without the mandate, adults could put off buying insurance until they get sick, thereby gaming the system.

The law may never be embraced as a solution in itself. This is no generous entitlement, like Medicare, and no quick fix. But it provides, for the first time, a template for addressing the glaring deficiencies in the American health care system. Changes to the cost structure, payment rules, or required benefits will be far simpler to make in a comprehensive framework whose motivating principle is that all Americans deserve coverage, one way or another.


In a dissent, four justices of the court’s conservative wing made it clear they were ready, even itching, to torpedo the entire law. The justification cited by Chief Justice John G. Roberts Jr., the court’s deciding vote — essentially, that a Congress with the power to tax people should be able to penalize them for not buying something — is a triumph of common sense over hard-edged ideology.

The Affordable Care Act is neither a savior nor a threat. It’s a call to action. And Congress, and Americans of all political persuasions, now have the power and the responsibility to wrestle with the vexing issues of access to health care and its costs, in the months and years to come.