What now with Obamacare?

The decision by the U.S. Supreme Court narrowly upholding the Affordable Care Act resolves the constitutional question of the individual mandate. What remains unresolved are the more difficult policy and political implications of fully implementing the law.

From a policy standpoint, the act is imperfect, but represents first steps in the right direction. And, from a political standpoint, the battle lines for November have been more sharply drawn, and the rhetoric has ramped up on both sides of the widening political divide.

As an actively practicing physician, I applaud the goal of near universal health insurance coverage, despite the immense challenges of funding and achieving it. The hardest things are often the ones most worth doing. As the most advanced and powerful nation in the world, it is shameful that we perform so poorly against other smaller, developed nations on many measures of health outcomes, while spending, and wasting, far more money than do those top performers.

There is much to like in the Affordable Care Act, including the provision that protects individuals with pre-existing conditions, restrictions on life-time insurance limits, and providing access to family health coverage for young adults under 26 years of age. These "young invincibles" will also access lower-cost, high-deductible plans up to the age of 30.

I also appreciate the many demonstrations aimed at studying, then adopting, new models of health care delivery, including accountable care organizations and patient-centered medical homes for Medicare beneficiaries. The fact that many private health care organizations are already on a path to adopting these models is a testimony to the potential promise these hold for improving the delivery of quality health care.

Unfortunately, the ACA falls short in providing for more effective measures to tie improved outcomes to lower costs, such as through comparative effectiveness research, and to move from an emphasis on volume-based, fee-for-service medicine to a value-based reimbursement framework.

Much work still needs to be done to take the initial steps built into the act, and to refine and improve upon them through additional legislative modifications. But to say, as many have, including Sen. Orrin Hatch and GOP presidential candidate Mitt Romney, that we should "repeal and replace" the act, is a wasteful use of resources, taxpayer money and time.

Perhaps we will learn before November what "replace" really means, but it is clear that there are many provisions of the act that are popular now and work now. Will people really want to see those repealed and trust that they will be reinstated? Let's vow to retain what works now and replace what does not or will not.

The misplaced anger and rhetoric over "rationing," and the so-called "death panels," have distracted many from the fact that rationing is a reality. It is found in medically appropriate utilization management programs which identify better use of limited care resources, while also improving patient outcomes. There is, too, the unfortunate fact that "those who cannot afford to pay" for access to health care, suffer a particularly cruel form of economic rationing every day.

What we, the American public, need are a Congress and a president that work together and keep their pledge to "support and defend" and "to preserve, protect and defend" the Constitution of the United States. That is the only pledge of office that I am interested in seeing upheld, not the misguided "I will not raise taxes" pledge that so many members of Congress have also taken.

That pledge does not protect our Republic, defend our Constitution or preserve the public health of this nation.

Ronald Weiss is a physician practicing in Salt Lake City.