The conventional wisdom following the oral arguments before the Supreme Court last week is that, at the least, the health insurance mandate portion of the Affordable Care Act is going down. Many observers thought it likely that the Republican-controlled court would strike down the entire bill. Either way, it will be necessary to do some serious rethinking of health care policy.
The simpler case, where the mandate is struck down but most of the rest of the bill is left intact, could likely be repaired without great difficulty. The mandate that everyone buy insurance was a quid pro quo with the insurance industry. Insurers are prohibited from discriminating against sick people in issuing insurance policies; in exchange the government is going to force healthy people to buy insurance.
There is a real problem of adverse selection in this case. If everyone knows that they can wait until they get a serious illness to buy insurance, then only people who are in bad health will have insurance and the cost will be very high.
There are mechanisms that can be used to get around this problem. They generally involve imposing a higher price or excluding coverage of pre-existing conditions for those who delay buying insurance. This would substantially reduce the number of people who might try to game the system.
Even assuming that the Republicans keep control of Congress this fix may be possible. The group that faces an immediate problem in a world with Obamacare, but without mandates, is the insurance industry. It can always count on a sympathetic ear from Republican politicians.
However, we will be in a qualitatively different world if the Court rules that the bill in its entirety is unconstitutional. That puts health care reform back at square one.
A number of people have commented that this would be an opportunity to pursue Medicare for All; a program that extended Medicare coverage to the entire population. This would be a far more efficient system, since it would eliminate the administrative waste created by private insurers. It would also be far more effective in restraining payments to providers than the current system.
While a universal Medicare program is desirable from the standpoint of both public health and economic efficiency, it is hard to see how losing in the Supreme Court gets us there. We didn't get Medicare for All before because its supporters did not have anywhere near the firepower necessary to overcome the power of the insurance industry, the pharmaceutical industry, the medical supply industry and other provider lobbies.
Perhaps a defeat in the Supreme Court will lead to a newly energized public that will demand that their representatives in Congress clean up the health care system and give us universal Medicare. That would be great, but it is difficult to see it happening. It certainly did not happen the last time a moderate health care reform measure went down in flames in 1994.
If we aren't going to win by going through the front door, we will have to go around the back door. That means undermining the base of power of the health care industry by taking away their money. This is exactly what the Right did to progressives. They were not content to just win elections; they wanted to destroy all the bases of support for progressive politics.
This meant undermining unions, first in the private sector and now in the public sector. It meant neutering institutions like the Corporation for Public Broadcasting and Legal Aid and even putting universities and colleges on the defensive, making them fearful that they could lose funding if their faculty and student bodies appeared too progressive.
While the right has far more money, and therefore levers of power, than progressives, we can use the inefficiency of our health care system against the industry. There are enormous potential cost-savings from taking advantage of the more efficient health care systems in other countries.
For example, surgeries that may cost $200,000 in the United States can be performed in top quality facilities by well-trained physicians in India or Thailand for one-tenth this amount. If states passed measures that allowed insurers to share the savings with patients from having major medical procedures performed in other countries, and also took steps to ensure quality control, it is likely that many people would take advantage of this option.
Increased use of foreign facilities would both reduce the demand for highly paid surgeons -- putting downward pressure on their bloated salaries -- and also educate the public about the incredible inefficiency of the U.S. health care system. Every person who had successful heart surgery in India and walked away with $50,000 in their pocket would be a billboard proclaiming the wastefulness of the U.S. health care system.
Going halfway around the world for health care is crazy. But the reality is that we have no better way of fixing the current system. We can keep losing by doing the same old things or we could try something new and hope for a different outcome.
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Taxes are one thing. We are used to those. But forcing healthy people to go out and make intelligent decisions about healthcare is simply asking too much. After the mandate went into effect, ACA would be repealed exactly 1 day after the landslide anti-ACA vote in the next election and the new Congress sworn in.
SCOTUS tossing the mandate is the best thing for Democrats since the solar panel.
Realistically, there is no way Congress could successfully pass Medicare for all, because all most certainly don't want Medicare. The US has become far too politically and culturally divided to allow a one-size-fits-all health program.
The only thing which makes sense is to allow all insurance products to be sold across state lines and then divide the states up into culturally homogeneous regions for the purposes of providing health care programs. The federal government would simply block grant funds to each regional health coordinating body and step out of the picture.
Health care in Dixie won't look like health care on the Left coast, and New England's won't resemble that in the Mountain West. However, every region would get what their various states' citizens could ideologically tolerate and creating health care regions made up of several states each addresses the economies of scale.
Republicans believe that the government should do nothing to ameliorate the brutality of unrestrained capitalism. Democrats believe that government is the extension of We the People and morally obligated to address the great good of the nation, not only the great wealth of the few.
These two philosophical differences are not reconcilable.
Your title was pure obfuscation. The first paragraph was a long winded tease. The rest of your article was worse. Do you need some help? I'm for the Affordable Care Act. You can send me rough drafts and I will help you edit them. I'm a retired engineer who's willing to help - if you really have something to say.
Vincent in Colorado
Even with two of his OWN judges, one of which WORK ON OBAMAS campaign, he cant get this through.
Even with a dead senators vote being counted to make 60 votes....even with buying off Sen nelson from nebraska.
Pathetic that lefties dont see how this has been sqingled through to get this far.
And FYI....your 4 liberal judges are the minority and the constitution is the majority.
Not congress or Geirge Bush or whatever your straw man of the week is.
Go oOn Paul!
Paul's words are clear: ""Well, it's the fact the government's big and they can pass out so much is the problem, not to the fact that you can have an organization, you can spend your money any way you want. That is what I think is the problem rather than saying the right of corporations. Even corporations... See, I have trouble with that court ruling because I don't know whom you work for but if you work for a corporation... So if the corporation on the radio and the TV, or a newspaper can do something up to the last minute, and slant the news, why shouldn't other people spend their money in support or counteracting that?"
Freedom is maintained even if it freedom to do something you don't like.
Like the prostitution issue, liberty is a two-edged sword of responsibility. Don't participate in it if you object to it. If you want to change it, educate people about it and fight the practice.
Simply dispersing the information about campaign contributions is enough to educate people. with the internet and social media it has never been easier to disseminate information.
Hardly. The facts are that the vast majority are happy with their private insurance and oppose government run health insurance by heavier majorities than they do Obamacare.