Look: either the individual mandate is constitutional, or it’s not. And I, like many ObamaCare supporters, was admittedly too sanguine about this issue when it first came up. There are, I’ve come to realize, certainly some very legitimate arguments that it’s unconstitutional. (The Volokh Conspiracy is all over this.) It’s unknowable how the Supreme Court will eventually resolve the issue, but it’s certainly possible the mandate will be struck down.
That said, the policy implications of that constitutional outcome could be GREAT NEWS!! FOR LIBERALS!! No, seriously. Ezra Klein makes the case:
The individual mandate began life as a Republican idea. Its earliest appearances in legislation were in the Republican alternatives to the Clinton health-care bill, where it was co-sponsored by such GOP stalwarts as Bob Dole, Orrin G. Hatch and Charles E. Grassley. Later on, it was the centerpiece of then-Gov. Mitt Romney’s health-reform plan in Massachusetts, and then it was included in the Wyden-Bennett bill, which many Republicans signed on to. It was only when the individual mandate appeared in President Obama’s legislation that it became so polarizing on the right. …
The individual mandate was created by conservatives who realized that it was the only way to get universal coverage into the private market. Otherwise, insurers turn away the sick, public anger rises, and, eventually, you get some kind of government-run, single-payer system, much as they did in Europe, and much as we have with Medicare.
If Republicans succeed in taking it off the table, they may sign the death warrant for private insurers in America: Eventually, rising cost pressures will force more aggressive reforms than even Obama has proposed, and if conservative judges have made the private market unfixable by removing the most effective way to deal with adverse selection problems, the only alternative will be the very constitutional, but decidedly non-conservative, single-payer path.
File this under “be careful what you wish for.”
Pingback: Tweets that mention No individual mandate = single-payer? -- Topsy.com
I expected an argument to be made along these lines at some point, and I’m happy to unleash my ready-made counter.
The short of it is this: If individual mandate is struck down as unconstitutional, that has no bearing whatsoever on the political viability of universal coverage. Should the individual mandate be found unconstitutional, there are simply no facts and data that would suggest universal coverage would suddenly come back in vogue and win popular support. Liberals, for some reason, have a really hard time grasping the fact that the vast majority of people — who, by the way, already have health insurance, and are more or less happy with it — are not willing to jeopardize that in the name of covering X millions of uninsured (the numbers of uninsured, and the circumstances around why they are uninsured, change to fit the agenda of whoever is making the argument). Universal coverage sounds great in moral theory, but for most voters, it’s about as popular as spending cuts and tax hikes once you get down to specifics.
That being said, what is still completely relevant, constitutional, and potentially popular and politically viable, are healthcare tax credits. Figure the broad, simplified outlines of the system this way:
The government figures that the average premium cost across the entire population for basic and catastrophic healthcare coverage is $10,000 a year. If you’re enrolled in a company plan, the company gets an $10,000 tax credit. If you enroll in your own plan privately, insurance companies are required by law to allow you to enroll despite any pre-existing conditions, and you get that $10,000 credit to apply to those premiums (if you find a plan for less than $10,000 a year, you get to keep the difference — hooray for tax incentives and consumer choice driving competition and efficiency in the marketplace!). If you choose not to enroll, you lose that $10,000 credit, and the government instead uses it to fund a national insurance plan for folks who decline coverage and then apply for coverage upon picking up an illness or some other healthcare condition. This plan guarantees that insurance companies don’t go bankrupt, or alternatively premiums aren’t jacked up for its other customers, because they are forced to foot the bill for people declining to pay into the system until they have a condition that necessitates some level of care.
This kind of system simultaneously preserves one’s individual right to decline to purchase healthcare, while also improving the solvency of the overall system, and has the side benefit of improving consumer choice and thriftiness in healthcare — something sorely lacking in third-party payer systems (whether HMO-style care or government-run healthcare).
Does the company split the $10K with you if you have to pay part of your premium? What if the company does not have $10K per employee in tax liability? Or if you are purchasing it yourself what if you don’t have $10K in federal tax liability? What if you are married and/or have a family…Is the $10K a per person number or a per couple or per family number or does the tax credit go up for each family member?
Oh and lets see $10,000 x 250,000,000 people would be annual cost of 2,500,000,000,000 or 2.5 trillion dollars per year cost to the government???? Is my math off somewhere?
Kenneth, I used $10k as an easy round number without bothering to do the math, I was really just focusing on illustrating the generic mechanics. You are right, though: the actual tax credit amount would have to be much lower — perhaps $3,000 or so — and would not cover the full cost of the insurance, but primarily just the premiums. For a high deductible HSA plan like what I have, $3,000 would go a long way, but if I was enrolled in my employer’s traditional medical plan, my guess is the total cost of the insurance would be 3 or 4 times that amount.
As for how it is applied to family members etc., those are the kinds of details that would need to be worked through carefully. I’d assume the amount would go up if you claim one or more dependents, but probably not $4,000 per dependent. All of these calculations would need to be based on actuarial formulas and such.
Finally, regarding tax liability, a credit is yours whether you owe taxes or not. If you choose not to file because you have very little tax liability (and you are not listed as a dependent on someone else’s returns), then the government obviously pockets that credit and the money goes towards the national insurance pool.
As far as I can tell, lawsuits against Obamacare seem to have moved from 2 ruling For and 2 rulings Against, to 2 rulings For and 3 rulings Against, prompting this quote from current Administration source(s) – “The Justice Department, which has been defending the law in court, noted that the law has now been upheld more times than not.
“We welcome this ruling, which marks the third time a court has reviewed the Affordable Care Act on the merits and upheld it as constitutional,” said spokeswoman Tracy Schmaler. “This court found — as two others have previously — that the minimum coverage provision of the statute was a reasonable measure for Congress to take in reforming our health care system.”
”
(From here – the only source online I have found discussing it, so far)
My question becomes this …
Of the judges ruling in the 5 cases, what are their track records for being reversed by a higher Court ? Based upon that track record, what does that suggest for a final SCOTUS ruling ?
I think your math is wrong. The latest suit which you link to resulted in a dismissal of the case. Thus it was a ruling FOR the Health Care Act. and thus the statement by the administration spokesman is correct…..of course the math has no bearing on what the Supremes will eventually decided anyway.
(blush) Kenneth – my phrasing was not obvious, and, for that, I apologise …
As I typed it, I was thinking of rulings relative to the lawsuits rat5her than relative to Obamacare – and I did not make that unambiguous …
So – my question basically is – how much have the three judges who favoured the side of Obamacare been reversed in their decisions over the years ? And how much have the two judges who ruled on the side of those challenging Obamacare been reversed over the years …
So far, the only one I know about is Kessler, who has been reversed, and not subtly …
Okay, can we start with first principals.
Do you believe that health care in the US is fundamentally broken or not?
I mean this BOTH on the provider side (which the Republicans tend to like to point out, spiraling costs, malpractice run a muck etc.) and on the payor side, Health insurance picking and choosing, soaring premiums, lack of portability, issues with preexisting conditions etc. which the Democrats like to talk about.
So if health care is broken, the question is, what do we do to fix it?
I think we need to address both sides. We need to fundamentally re-work BOTH how we provide health care and how we pay for it.
The simplest answer in two steps:
One, comparing cost to outcomes the Mayo Clinic is exceptional in this country for how cheep it is and how effective it is. Figure out what it is about the Mayo Clinic model is that works so well and implement it everywhere.
Two, medicare works and people like it. And it’s per patient cost is comparable to, or better than private insurance while it’s overhead is minuscule compared to both for and not for profit health insurance. More importantly, Medicare is something people understand, so, let everyone sign up for medicare regardless of age. If you sign up for medicare early your FICA withholding automatically increases to cover the additional cost inherent in doing this. As with anything FICA, when you are employed your employer pays half the increase you pay the other, and now you’ve just built in health benefits at a much lower cost to the employer, unless the employer is like wallmart and doesn’t pay a dime now. I like to call those employers Asshole, so fuck them.
Benefits overhead is expensive for a company, adjusting FICA withholdings is cheep. So lets do it this is good for most businesses, good for most workers and good for those that are self employed. If private insurance is afraid they will get their lunch eaten by this move, well a) sounds like private insurance isn’t really all that competitive in the first place and b) tough toenails.
Two, medicare works and people like it.
Huh? Medicare is a mess and completely unsustainable without significant reform. It’s going broke (the trust fund will be bankrupt within the decade, depending on who you listen to) while paying less than 60% of seniors’ medical expenses, so I don’t know in what sense it “works.” Proponents often cite Medicare’s lower administrative costs, but conveniently overlook the fact that Medicare pays hospitals 30% less than private insurers for the same services, and physicians 20% less, so if you took half of privately-insured patients and shifted them to a plan paying Medicare rates, hospitals would lose tens or hundreds of millions per year and many would go broke. Moreover, not only does Medicare’s fee-for-service payment system significantly underpay doctors and hospitals (resulting in more doctors taking fewer Medicare patients), but it also drives up costs by encouraging overuse. Medicare needs to be fixed in a big way before it’s anything for reform advocates to emulate.
Medicare is going broke because you the Republican party took all the money people paid for Medicare in a specific tax for Medicare and went and pissed it away on random wars and sundry military hardware we don’t need along with tax cuts for trust fund million / billionaires. Cry me a river, but I’m not buying that it is some going broke all by it self.
Now, where did I put Al Gore’s lockbox…
Also, cost per outcome. You are totally focused on the $$ side of this. We also need to fix the patient care side of the equation. Mayo has proven that better patient care is not more expensive and in many cases is cheeper than the alternative. Which is basically crappy patient care which is really expensive.
Given that seniors nearly shat a brick when they thought that the goal of Obama’s health care reforms was to take away their Medicare, I would say the people like it part of the statement is completely accurate. So if it is true that Medicare only covers 60% of seniors real costs then it seems they wouldn’t like it so much. Not to say that part D isn’t a total cluster fuck, but that mostly has to do with the fact that Bush was is one of the most incompetent businessmen in history.
As for paying 30% less than private insurance, so your argument is that private insurance has driven a shitty bargain, check.
Now, there is certainly another way to deal with the hospitals going broke issue, but I figured you would have more of an issue with HHS style systems. So I figured I would go for the less dramatic fix. If you really think that hospitals would go broke if everyone was on medicare, then I suppose we could just go HHS style.
dcl #9 – what are you ? A teacher of something other than English ? Or what ? (grin)
dcl #9 + Joe Mama #10 – those folk I know who have Medicare as their health insurance who will say they are content with it also have another private insurance over and above Medicare – so their health care needs get covered …
I don’t have names and dates immediately to hand, but, over the past 2 decades, in the Los Angeles area, a bunch of hospitals have stopped having Emergency Rooms and have stopped taking Medicare patients, because it was driving them out of business – too many undocumented uninsured patients were showing up and the hospitals were hemorrhaging money …
Outside of the teaching hospitals, it is getting harder and harder to find doctors who are willing to take MediCal or Medicare … between Meduicare reimbursements rates keeping falling, and the time it takes to actually get reimbursed, doctors (who still have to pay in a timely manner for their office rent, their staff salaries, their malpractice insurance premium, and their other costs of doing business) can’t afford to see Medicare patients … rather than go out of business, they stop seeing Medicare/MediCal patients in their own office, and they volunteer at various free clinics around the LA area …
The system is clunky, and works, for the great majority of people … yes, some do fall between the cracks – but the average Joe in the street in the LA area is way better off medically, with a better prognosis for a longer healthier life than his counterpart in a Cuban city outside Havana …
Oh, and thank you for bringing up the example of the Mayo Clinic …
Let us see …
Is it Government-run ? Nope …
Does it give better outcomes for its patients than the VA (FedGov run healthcare) ? My money’s on “Are you kidding?” …
Do the Mayo Clinic doctors have to report to government bureaucracy superiors ? Nope …
So – while you – dcl – didn’t intend to prove our point, you just nicely established that non-governmentally-run health care works better than governmentally-mandated …
My point with Mayo is that good healthcare need not be expensive. In terms of cost benefit and dollars to outcome Mayo is extremely cheep and efficient along with having a reputation for some of the best care in the world not just the US. Mayo accepts Medicare patients, generally bills Medicare less than some crappy hospitals that have far worse outcomes, has consistently better long term outcomes for their medicare patients and isn’t going broke.
Mayo is proof that medicine can work, can be affordable, can be efficient, and have good outcomes. Mayo is also a non-profit group practice. And those two things are, arguably, why it works as well as it does and the way it does.
The non-profit group practice model is not antagonistic to the government run healthcare model.
Both public and private and VA run hospitals are highly variable in their quality of care and the cost for outcome. Walter Reed does quite well in the VA system. The variability is certainly a massive issue on the providing healthcare side of the equation. The other side of the equation is the paying for healthcare. And that is broken too. My primary point is we need to fix both or we are not going to be able to fix either.
dcl #13 – an d *my* point about Obamacare and its ugly stepmother Hillarycare are *both* excessively expensive and do not provide superior outcomes …
Yes, Walter Reed does well – at the expense of the rest of the VA system …
Mayo Clinic takes Medicare patients for the same reason that they take folk with no coverage … they’re basically decent rational capitalist folk who aren’t out to spend other folks’ money …
Mayo Clinic also has built up a very respectable Foundation, allowing them to practice excellent medicine in spite of governmental intrusions …
You *almost* got to the logical part with “The non-profit group practice model is not antagonistic to the government run healthcare model.” – mostly cuz the non-profit group practice model doesn’t give the proverbial rat’s fundament about the government as long as said government leaves it well and truly alone (or at least with minimal interference) to function well …
The problem is that Obamacare (” the government run healthcare model.”) *is* antagonistic to “The non-profit group practice model” … after all, how can a model which isn’t run by political elites be any good ?
One of Mayo Clinic’s biggest strengths is that the folk there don’t condescend to the help … in an OR, everyone from most exalted Surgeon through the least of the nursing staff has both the opportunity and the responsibility to see that everyone does their best … there is no “Gorelick Wall”, there is no politically-motivated decisions as to who to treat, there are no unionised staff going out on strike just because they don’t like their new boss …
One of the biggest problems I have with Democrats is how proud they are that the laws they make don’t apply to them … HR 1 in 1995 reversed a whole bunch of that … has Kerry paid the taxes on his luxury yacht yet ? Or is he still evading them by mooring it in another State ? Is Almost-President Gore cutting back on his *own* Carbon Footprint ? Or is he just trying to get the little people to do so ?
(/rant)
Al, I do see your point vis-a-vi politics, instead of rational medical care insidiously working it’s way into any government system. And I agree that that is a real and valid concern. Especially since it is obvious that politics, special interest or not, has worked its way into many things run by the government where it should not be.
Things like food safety, or discussing the relative nutritional values of carrots grown with different methods (and there is a big difference, I’m sorry if I get Brendan sued for saying so). That system is so overrun that the nutritional guidelines our own government puts out don’t make sense and are self contradictory and that is because of politics and lobbying cash. And it is nuts to have the same people promoting the food industry as regulating it. It’s stupid.
Back to the topic, so you are right, perhaps it is naive to think that the government could actually manage to keep politics out of a government run healthcare program. But then, perhaps the bigger question is how do we get the politics out of military spending, farm policy, and everything else that it should be out of but that we can’t seem to get rid of. NASA itself is an intractable mess, but it was set up so that at least some little finger of it is in almost every CD in the country. Which makes it’s mess of a budget fairly safe, or at least it did. But lets be honest, allowing corporations or any organization to give infinite sums to political campaigns is not going to fix that problem.