How The Supreme Court’s ACA Decision Will — And Should — Change Medical Dramas

In the pilot for Mindy Kaling’s excellent new sitcom debuting on Fox this fall, The Mindy Project, the titular character, an OB/GYN, tells the son of a patient, a single, observant Muslim mother, to promise her that the family will have health insurance by the time she was due to deliver her baby. It’s a familiar trope in medical procedural shows: a doctor makes the decision to take a patient on who doesn’t have health insurance, frustrating hospital or private practice suits, or a doctor who’s previously worked for wealthy patients has their life and worldview changed by working among uninsured patients and witnessing their normally abysmal level of care. The former reoccurs in almost every medical procedural. The latter was the premise for CBS’s now-cancelled A Gifted Man, where the ghost of a surgeon’s ex-wife encourages him to begin spending time at the free clinic she ran, and it’s at the heart of the USA Network’s Royal Pains, about a concierge doctor in the Hamptons who also runs a clinic for low-income clients.

Thanks to the Supreme Court’s decision to uphold the Affordable Care Act today, starting in 2014, there will be many fewer uninsured patients, thanks to a combination of a mandate to purchase health insurance or pay a compensatory tax. It’ll be harder for television shows to generate drama and opportunities for doctors to demonstrate their compassion out of patients who were denied coverage because they had preexisting conditions. In the absence of that kind of emotional stimuli, I’ll be curious to see where medical procedurals turn to generate drama and to generate opportunities to demonstrate human kindness. Will they challenge things like doctors’ lack of engagement with patients, a rebuke to the brusqueness fetishized on House that is not so cute when it happens in person? Shifts in the profession that have made nurses more important and made them key points of contact for patients? The Affordable Care Act will dramatically change who is insured in the United States, but it will hardly eliminate all the issues in our medical system.

But if shows do want to tell stories about uninsured patients in the future, it’ll be interesting to see if they acknowledge that those people are insured for political reasons. As Matt Yglesias explains, the Supreme Court’s decision means that the federal government will be offer states new money to subsidize the coverage of poor patients through Medicaid, but not to penalize states who decline to kick in 10 percent of the cost of coverage themselves. “Since your state’s citizens have to pay taxes to the federal government one way or the other, you’d have to be pretty crazy to refuse the carrot if you ask me,” he writes. “But ideological zeal may well lead some states to turn it down.” Previously, medical procedurals were able to treat uninsured patients like they were an accepted fact of the practice of medicine. Treating them in defiance of commercial pressure allowed television doctors to demonstrate apolitical concern for individuals. And taking as an assumption that a vast tide of uninsured patients would always exist means television doctors are essentially exempt from questioning the larger market in which they operate. But in the future, uninsured patients (who are not undocumented immigrants or prisoners) will not be an inevitable fact of American life — they will be created by the very specific decisions of individual states. Whether any television show will have the courage to identify that fact will be a fascinating question for the genre, which has yet to have a show that does for medicine what shows like The Wire and The Shield have done for law enforcement.

The production cycle in American television is long — but so is the time it takes to implement major societal legislation. I hope there’s a smart writer somewhere out there who is looking forward to the 2014 fall television season and seeing in today’s historic decision an opportunity to reinvent medical procedurals as our health care system undergoes its most dramatic changes since the invention of the form.