Here come the “health care” editorials, the blizzard of Supreme Court decision “I told you so’s” and hand-wringing over the future of “health care.” Too bad the Supreme Court’s decision on the Affordable Care Act has precious little to do with health care.

All of Washington’s permutations of health “reform” – ObamaCare, RyanCare, Simpson-Bowles – all of them, regardless of where their creators sit on the ideological spectrum are about how we pay for treatments, rather than the bigger issue of how we improve health.

Our health debate should be much more about medical science: curing disease, identifying who’s at risk to get a disease and helping them avoid it, and creating regenerative technology to end crippling disabilities.

But in Washington, how you pay for something is the thing itself. How we pay for health care is health care.

Thus, a Supreme Court decision over how our insurance system is structured is, to Washingtonians, a decision about health itself. Perhaps this is the old “power of the purse strings” concept run amok, but it is a precept that earns unquestioning allegiance across the ideological spectrum, from free marketeers (patient choice solves all, as if a person having a heart attack or just diagnosed with metastatic cancer is going to take a few days to shop around) to single-payer advocates (where all-seeing bureaucracies always know what’s best).

The Supreme Court’s decision on ObamaCare is one of those “teachable” moments when we can change the framework of the health debate. Both parties have tried, repeatedly and frustratingly, to change our nation's health by manipulating payment schemes. Clinton failed, Bush accelerated fiscal ruin, Obama whiffed.

Let’s start over.


The health debate should be first and foremost how we cure serious disease, end crippling disability, and help people at risk of getting an illness to reduce the chance that they get sick in the first place. This is, after all, how most people think when they get sick. There first question is, “Doc, how do I fix this?” not how will I pay for this. Cure first, payment second.

Take Alzheimer’s Disease, one of the greatest medical and fiscal risks facing America, indeed the world. Ask Americans which matters more to them: figuring out a cure for Alzheimer’s or tweaking how Medicaid covers assisted living costs? Most, I’m sure, would say curing Alzheimer’s. Solve the disease, or figure out how to delay its onset, and Medicaid formulas will take care of themselves.

Less disease equals less cost. But doing it the other way, trying to force down costs ahead of a medical solution does little on both counts. We end up with no cure and rising costs.

So, with the bankruptcy of Washington-style health care reforms, here are two principles to guide a real health reform:

First, people matter more than money. Who is doing medical research and how patients or those at risk of a disease are involved in the search for cures matters far more than how much we spend. Complex diseases have complex contributing factors. We need a massive mobilization of Americans – sick and well – to understand who is likely to get a serious disease, and which combinations of treatments are most likely to work.

To match greater public involvement, we need a radical rethinking of how research is done, greater efforts to retain top researchers in the US, incentives to manufacture medical technologies stateside, and lower barriers for workers to “do” science through on-the-job training instead of having to incur tens of thousands of student debt and years of study.

Money is not irrelevant. In areas like Alzheimer’s and complex conditions, we may need to spend orders of magnitude more. But in a time of economic constraint, the creative possibilities of mobilizing researchers and patients in more open, collaborative enterprises will help us direct resources more efficiently, and pay dividends faster, than relying on federal largesse and philanthropy.

Second, technology matters more than insurance. Technology is about the future. Insurance is about the past. Technology is creative. Insurance is protective. Sometimes technology advances are incremental, sometimes they are transformative. But discovery has a virtue of its own, and practical discovery a virtue and a value that fosters never-before imagined industries, jobs, wealth, and better health. And, whether or not we improve technology, our greatest health adversaries – bacteria, viruses, and malignancies – are unreservedly committed to technological change. For them, improving technology to infect, grow, and replicate is a matter of life and death. As ultimately, it is for us humans as well.

This is not to say insurance is irrelevant. Protecting individuals from the cost of catastrophic health costs is critical. People should not be forced into destitution by illness, and it is important for citizens to contribute to each others’ welfare to prevent this. However, insurance by its nature, can only protect against that which is known. It does little to incentivize that which should exist.

Interestingly, the Supreme Court’s decision on ObamaCare is the second health-related decision this term. Its other decision in the Prometheus case had a lot more to do about curing disease, reshaping the rules on patenting human genes and diagnostic tests to target specific treatments to individual patients.

If we follow the map to real health reform – people over money, technology over insurance – fifty years from now, scholars may remember this Supreme Court term for the Prometheus decision, and its impact on opening medical innovation, far more than its ruling on the Affordable Care Act.

The ACA, indeed the whole Washington-driven fixation on health insurance over health, may then be seen properly as being of a piece with today’s political stalemate, when policymakers worry more about tinkering with transfer payments than spurring a real neo-Hamiltonian drive for medical breakthroughs.

Jeremy Shane is a past  president of the online consumer health publisher, HealthCentral, and has led businesses in energy and enterprise software. He worked in the administration of President George H.W. Bush.