Last month the Supreme Court heard arguments surrounding the Patient Protection and Affordable Care Act with a ruling expected sometime in June. But regardless of the verdict, the healthcare debate will remain that annoying piece of toilet paper stuck to the sole of your shoe that you can’t shake off.

The constitutional component of the debate concerns the individual mandate and whether or not the federal government has the authority to force every American to buy health insurance…and to continue buying it year after year. Supporters point to the commerce clause as their ally and to the chilling effect that those without health insurance have on the entire society. But opponents argue that there is no other product that all Americans are federally required to purchase and warn us of the slippery slope on which we are if the individual mandate is upheld.

In deciding this, the Supreme Court will once again tackle the same issue of states’ rights vs. federal rights vs. individual rights that have been argued as far back as Madison’s Federalist Papers. And we are once again reminded that liberty and democracy are conflicting ideologies around which our nation has quarreled since our founding.

The good news in all of this is the recognition by nearly everyone that our healthcare system needs fixing. But with 45 million uninsured, costs continuing to escalate and society continuing to age, fixing healthcare will require every citizen to exercise moral courage in answering four fundamental questions.

1. Is healthcare a right to which every citizen is entitled? If so, is every citizen entitled to the same healthcare?
2. Whose responsibility is it to pay for care? When uninsured individuals present themselves at a hospital’s emergency department, care is provided. Some of the cost of providing that care is shifted to those who are able to pay, some may be paid by a government program, and some is simply absorbed by the hospital as bad debt. But hospitals need to pay their bills too, so shouldn’t there be a better way?
3. How do we hold individuals accountable for their own health so that they have a personal, financial stake in the game? This notion that everyone has an unlimited right to healthcare without also having some accountability for their own lifestyle and health habits is simply unsustainable. But how can we effectuate change without furthering the current debate regarding individual rights and unnecessary government intervention?
4. What incentives and drivers need to be put in place to assure that patients in need get the quality they deserve? One of the most applauded aspects of healthcare reform is “pay for performance,” which financially rewards both payers and providers who achieve quality metrics in defined categories. How do we make sure that this occurs and how do we assure transparency so that patients can use this information to make intelligent decisions about where to get their care?

In the final analysis, how we answer these questions will tell us a lot about our country, our society and ourselves.