PROVIDENCE, R.I.

If the U.S. Supreme Court declares the essential "individual mandate" in the federal Affordable Care Act unconstitutional--or Republicans throw out the reforms--then it's back to the past, back to the economy-dragging health care mess we've been calling a "system."

Republicans say that Americans don't want top-down government control of their health care. But what we have now is top-down corporate control of health care. Insurers, drug makers, sellers of expensive equipment, hospital executives, labs, home health care services, and others unnamed prosper by exploiting the chaos in our health care system.

They get other payers (be they private or government) to purchase $50 drugs when $10 drugs are just as effective. They make more money if patients have to be re-admitted into the hospital. They profit from pushing surgery, when careful watching or less-invasive therapy might do the trick at far lower cost and risk. They casually order CT scans without much thought to the expense or the patients' exposure to radiation.

The motives are undoubtedly mixed. Some providers see opportunity in siphoning the poorly regulated Niagara of health care dollars into their pockets. Many doctors prescribe far more tests and surgery than do their colleagues, either out of habit or fear of being sued. (Republicans are right about the need for tort reform to curb litigation against responsible doctors.)

Here's the point of an individual mandate requiring the uninsured to obtain coverage. The reforms call for state-run health-insurance exchanges, where the uncovered can find affordable health plans. The plans can't remain solvent if young and healthy people can choose not to join them, leaving an insurance pool heavy with expensive sick people. Only a handful of states have moved forward on the exchanges, as others wait for the Supreme Court to rule on the individual mandate.