June 26--The Supreme Court is expected to rule Thursday on the constitutionality of the Patient Protection and Affordable Care Act, known to most of us as Obamacare. Though no one knows what the court will do, most legal experts seem to think the central issue is whether the Constitution's commerce clause empowers the federal government to require just about everyone to buy health insurance or pay a tax.

I assume that when people accuse President Barack Obama of being a socialist it is that requirement of the act they are talking about, even though that approach to health care financing:

--Was proposed in 1994 by Republicans in Congress (including Sen. Bob Dole) as a free-market alternative to President Bill Clinton's health plan.

--Was introduced in Congress in 2007 with 11 Republican co-sponsors and, according to Ezra Klein of The Washington Post, was endorsed during a "Meet the Press" appearance in 2009 by Mitt Romney, now the presumptive Republican presidential nominee.

--Was designed to protect the private health insurance industry from the risks that came with other provisions of the act requiring insurers to issue policies to everyone, regardless of current health status.

--Applies to only 15 percent of the population, because 85 percent of Americans already have coverage.

For a provision that generates so much talk radio fulminating, tea party outrage and campaign rally sputtering, you don't hear the health care providers and administrators talking about it much. When they do talk about it, their concern is how they are going to find enough people to care for 40 million more people with health insurance when there are not enough providers on the job as it is.

Of far greater concern to the people I talk to are some of the more obscure provisions of the ACA that might actually improve health care in the United States.

To be clear, the health of a population improves when people have a way to pay for health care. People without insurance defer care, stop taking medications and don't get the same treatment as people who can pay for it. Families USA recently estimated that 26,000 people died prematurely in a year because they don't have health insurance.

If it is a national goal to have a healthy population, then a national commitment has to be made to pay for health care for everybody, one way or another. It really is that simple.

However, just because health care is funded properly doesn't mean it's good. ACA has some provisions that suggest the federal government, which administers Medicare, pays most of the nation's Medicaid bills and runs health care systems for veterans, understands taxpayers aren't paying for high-quality care. They are paying for a lot of care.

Health care providers deliver a lot of high-quality care, of course. But the payment systems operating in much of the health care industry are not designed to purchase quality. Complicating matters is that for many disease states there is not even much agreement about what constitutes high-quality care.

Employers spend an average of $8,000 per employee a year for health care benefits. Employees spend about $5,000 a year for their share of insurance premiums, copayments and deductibles. In return, everybody would like a healthy, productive employee. Most payment systems are not designed to do that.

Let's say your employee, Ed, is obese. He played high school football until he broke his foot. Now he's diabetic, which causes foot problems anyway. The extra weight he is carrying puts a lot of strain on his feet, and that old football injury hurts like the dickens.

Ed goes to his primary care doctor, complaining of foot pain. She refers him to a podiatrist, who takes a bunch of X-rays and MRIs and determines Ed needs surgery. Ed's insurance plan pays for the primary care visit, the X-rays, the MRIs, the podiatrist visit, blood work, surgery, hospitalization and a certain amount of rehabilitation.

However, Ed is no healthier, but not because the primary care doctor and the podiatrist don't recognize that Ed is obese and diabetic, which is why his feet hurt.

It's because the payment mechanisms available to most of us pay for tests and surgery, so that's what Ed gets. No one is paid for making Ed healthy.

It's not as simple as it sounds. How does a primary care physician bill an insurance company or Medicare for helping Ed feel better? How does she bill for helping Ed lose 50 pounds? How does she share the payment she gets with the dietitian and exercise therapist and gym manager who also helped Ed lose weight?

A physician can check a box on a form that says she examined Ed's blood work. She needs a box to check that says Ed is healthy. Otherwise, we'll pay for a lot of blood work, whether it makes Ed healthy or not.

The most important ACA provisions are trying to find a way to reward health care providers for improving the nation's health.

Fortunately, insurance companies, state governments and employers are looking for the same thing. If they are successful, the nation's health will improve no matter what the court says Thursday.

UpFront is a daily front-page news and opinion column. Comment directly to Winthrop Quigley at 823-3896 or wquigley@abqjournal.com. Go to www.abqjournal.com/letters/ new to submit a letter to the editor.

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