Mismanaged care: the challenges facing judicial interpretation of contemporary health policy.

At a time when the U.S. Supreme Court stands accused of undermining the legitimacy of American democracy, it might seem superfluous to question its wisdom in the interpretation of more mundane matters of public policy. But the Court is rarely given an opportunity to tinker with electoral outcomes. By contrast, it is constantly in the business of interpreting congressional legislation. Doing so involves more than simply establishing the constitutionality of a law. It also requires sensitivity to the substantive implications of a ruling, as reflected in the Court’s analysis of congressional intent. These judgments are made difficult when the substantive implications are hard to discern or confusingly complicated. These difficulties can compromise sensible judicial interpretation of laws that shape contemporary health policy. Few domains of public policy rival medical care in sheer complexity. Even experts in the field have, at best, a limited understanding of the constituents of effective treatment. To complicate things further, American medicine is characterized by dramatic and persistent change, in both the nature of medical services and in the institutional arrangements through which they are financed and delivered. Labels and conceptual frameworks often lag behind these changes, creating a confusing disjunction between the basic features of the health care system and the terms in which that system is typically described. These circumstances can greatly complicate the task of judicial review. It is difficult to discern a coherent sense of congressional intent from laws written by those who have at best a partial understanding of the health care system. Only about a quarter of the congressional staff with responsibilities for health care have had any training in the field. Elected officials face even bigger challenges, since they must have a working knowledge about a wide range of policy concerns. Evidence suggests that they are not always up to these