Like most, I’ve done my tea-leaf reading. If we were sitting around over coffee or beer, I’d speculate with you on what the Supreme Court will announce tomorrow as its decision on the Affordable Care Act, health care reform. I won’t here. It’s pointless and there are thousands who’ve already covered that ground.
I will go a bit further and say that in my non-lawyer opinion, I believe the entire Act is Constitutional and that if the Court rules otherwise, it’s because the majority decided on the conclusion they wanted and then backed into it. If they do overturn the Act, or even just the part reputably most likely to be overturned, the mandate to purchase coverage, they will be undoing precedents that reach well beyond healthcare and the purchase of health insurance. Moreover, it would be part of a larger trend that started with Bush v. Gore, and moved on to Citizens United and, when combined with other factors has led, in the trenchant words of James Fallows, to a “slow motion coup.” Fallows later, unfortunately in my judgement, softened those words, but we certainly agree that the right-wing and the bulk of today’s Republican Party is “radical.”
And assuming the Court overturns all or part, what then? Here are a couple of examples that are nowhere need exhaustive:
- If the Court overturns the mandate, but only the mandate, then the health insurance industry is in trouble. Given how much money they’ve thrown into the public relations campaign against the act (the largest share of over $230 million), there would be considerable justice in this result because they would still have to adhere to a host of other requirements that will cost them money, but they won’t gain as many new, lower cost clients to balances things out. Because it’s central to the overall framework, I hope the mandate is upheld, but if it isn’t, I’ll feel no sympathy for the insurers.
If this is the result, Republicans in Congress without question and some Democrats will try to save the insurers. Despite it being far less than an ideal result, the Democrats should use this result for bargaining leverage and resist.
- Overturning the entire Act will produce a negative public reaction much greater than most of the pundits have actually anticipated. And the first reactions will center on the newly re-opened “doughnut hole” in Medicare pharmaceutical coverage, coverage of those with pre-existing conditions (count on a lot of local news coverage of individuals who will be hurt by this) and coverage for young adults (up to 26) on their parents coverage. It won’t only be the young adults, but their parents fretting about them who will react.
Of course if the Court upholds the entire Act, I’ll look for some friends with which to share a celebratory beer. If not, we can begin planning the counter-attack.
As many have pointed out and pessimists assume, historic failures to enact healthcare reform have been once-a-generation events. Therefore, it will be at least a decade to two before there’s another opportunity. I strongly disagree.
All the previous attempts at universal coverage failed. This one did not. In itself, that’s a game-changer, even more to the degree that the Court’s decision will be perceived as politically driven rather than legally principled. And the same dynamic, system pressures that strongly contributed to enactment of the ACA will compound and accelerate further increase the probability of success. The Republicans have no plan. And absent an individual mandate, they have no path to a plan that does not require even more governmental involvement than the ACA. Yet the dysfunction of the healthcare system, healthcare coverage, and the public’s distress over both will increase the pressure to solve those problems – a lot. And no Randian notion of doing nothing or even a Paul Ryan voucher plan for Medicare, much less everyone else will solve the problem either in terms of policy or politics. Rather than opposing anything the President touched while attempting to de-legitimize him, the Republicans should have declared victory, taken credit, and gone home. Not incidentally more people or at least a higher proportion from red states (Republican) will or would have benefited from the ACA than from blue states (Democratic).
If the ACA is overturned, success next time will come faster and will look different. I have argued for universal coverage for decades. I first wrote about it during the 1980s. Here’s something I wrote in 2005.
At the same time, I have also argued against “single-payer.” Despite those arguments, the need for universal coverage trumps the specifics of how. Absent a complete governmental takeover by radical conservatives who wish to return to the social and economic stratifications described by Dickens, the next version of reform will come faster than many expect and will be more centralized and more governmentally based. Regrettably, my working assumption is that the Congressional Republicans actively prefer Dickens. They do not want any solution or rather they want no solution. I’ve only come to believe this since the ACA was enacted since up until that time, most conservatives and Congressional Republicans in the policy-analytical and political realms supported such a mandate. Or at least they said they did. There’s no need to consider Mitt Romney anywhere in this debate because even if he took a position (leaving it to the states is not a position, much less a policy worth debating), we could not count on it for more than a week or two anyway.
The next version of reform, will either be “Medicare for All,” an extension of today’s Medicare program, which is primarily directly operated by the Federal government, but which has some private plan options or it will be something akin to what the ACA would have given us with or without the mandate, but with a “public option.” Essentially they’re the same. Public coverage as a default or backstop with a private plan option paid for by the Federal government. They just have different defaults and different emphases.
Most importantly, what matters most is not the politics and it’s not the policy debates, it’s universal coverage. When one burrows into the polls on the public’s attitudes on “Obamacare,” one finds that the public supports most of the components. One also finds there is a significant group that opposes it not because it went too far, but because it did not go far enough. And thus there are some who want universal coverage who also want the ACA overturned.
I’m not a policy purist. Delaying coverage for years for some theoretical ideal hurts individual people in the meantime. In the midst of all that as far as healthcare is concerned , there will be one essential to remember. Overturning any part of the Act will mean that fewer people are covered, more will be unhealthy, and more will suffer. And some will die.
One of the two or three most important things we’ve learned about healthcare in the past three decades is that no single factor has as much effect on whether and when people get necessary medical care than does whether or not they have health insurance.
Coverage matters.
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