JAMA Forum: Listening to History in the Making

Andrew Bindman, MD (Image: Ted Grudzinski/AMA)

Andrew Bindman, MD

The revolution will not be televised,” poet-musician Gil Scott Heron famously said, and apparently neither will the US Supreme Court case reviewing whether the Affordable Care Act (ACA) is constitutional.

About a week before the historic proceedings got under way at the Court, Chief Justice John Roberts reported that the Court had rejected requests from members of Congress and news organizations for live, televised coverage of the arguments on the ACA. However, the Court did agree to release audio recordings of the proceedings on the same day. Somewhat unimpressed by this offer, Democratic Senator Richard Durbin of Illinois said that “For that gesture, I guess we can congratulate the United States Supreme Court for entering the radio age.”

When I heard Senator Durbin’s remark describing the Court’s release of audiotapes as akin to a radio program, it immediately conjured up a memory of the first major event I can recall hearing on the radio: the 1964 heavyweight title fight between Sonny Liston and Cassius Clay. At the time, Liston was the champ and Clay was the upstart who wasn’t given much of a chance by anyone. I was 6 years old, listening to the hi-fi radio in my father’s home office. I was there because I sensed that he sensed that this was something significant, and in 1964, the radio was the only way other than attending the fight in person that one could get a glimpse of what was happening.

As magical as it was to listen to that event with my dad, the significance of that fight has only grown over time, as we all realized that it marked the beginning of a new era in sports. Mohammed Ali, as Cassius Clay came to be known, went on to become not only one of the greatest athletes of the 20th century but also someone who, through his achievements and personality, elevated the perception of African Americans in America. Ali became a transformative figure, in large part because of his willingness to put his celebrity and career at risk by taking a public position against a highly controversial social issue, the Vietnam War.

Those who listen to the audio recordings of the Supreme Court debate taking place this week in Washington will not have the benefit of Howard Cosell’s blow-by-blow commentary to help them know who is winning, but they will be witness to a heavyweight debate that, like the Liston-Clay fight, has the potential to change the course of history. The arguments at the Court are being heard over 3 days. The first day focused on whether the fight should be stopped early. The Court considered arguments that the case is not yet ready for the Court’s consideration because as yet and not until 2015 will anyone be subject to financial penalties associated with not meeting the requirements of the individual mandate. Fueled by arguments from both the president’s and the plaintiff’s legal team that the case is in fact ready for the Court’s consideration, the fight will continue into days 2 and 3.

The second day, today, addresses whether it is constitutional for the federal government to require individuals to have health insurance coverage. The third day of arguments, tomorrow, will address whether the size of the federal financial penalty for states not expanding their Medicaid programs under the ACA results is coercive, as well as whether overturning the individual mandate would nullify the remaining portions of the law.

How the Court will rule is anyone’s guess. There is some speculation that it will be something of a split decision, leaving the Medicaid expansion that is expected to cover 16 million uninsured intact but overturning the individual mandate that would expand private coverage to a similar number. President Obama will score a technical knockout and a significant boost in his political capital if his legal team can convince 5 of the 9 judges that the individual mandate and the state Medicaid expansions do not represent an unconstitutional use of federal power. The president’s Republican adversaries will declare victory if they can persuade 5 of the judges that the opposite is true.

While there are many parallels between the Supreme Court case on the ACA and a heavyweight title fight, there is a major difference: now we aren’t just watching, or I should say listening, for pure entertainment. In this case, there are literally millions of lives that will be directly affected by the outcome.

First and foremost are the 32 million who are expected to gain coverage when the ACA is fully implemented. Research has consistently demonstrated that lack of health insurance coverage is associated with increased morbidity and mortality. Health care professionals also have a great deal at stake in the outcome of this debate. If it remains intact, the ACA will provide a substantial increase in the funds available to provide care to those who are currently uninsured.

Listening to the 1964 Liston-Clay fight was entertainment on the grand stage. No doubt the media will attempt to promote the US Supreme Court case on the ACA in a similar manner. What we did not know in 1964, but we can sense now, is that the arc of history is about to bend. The opportunity is there because once again a public figure, in this case the president of the United States, was willing to take a very public position on a highly controversial social issue. While we won’t be able to watch the action in HD using remote control and instant replay, we can be a witness to history by downloading and listening to the audio recordings. That is what I plan to do with my dad this evening.

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About the author: Andrew Bindman, MD, is Professor of Medicine, Health Policy, Epidemiology and Biostatistics at University of California San Francisco (UCSF). He is the founder and Director of the University of California Medicaid Research Institute, a multicampus research program that supports the translation of research into policy.

About The JAMA Forum: To provide ongoing coverage throughout this election year, JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide insight about the political aspects of health care. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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