Debating Approaches to Providing Health Care
The president’s Affordable Care Act, to be taken up by the Supreme Court on Monday, was designed to address several critically important problems.  Now that the legislation is before the Supreme Court we can see that there are additional conflicts playing out in and through this fight over health care.

Ruth Marcus, from the Washington Post, reminds us that one of those problems to address was the tax burden created for the majority of American who have health care but must subsidize the health costs of those who do not…at a much higher price tag then it could cost us to provide them with health insurance in the first place.

“The most compelling sentences in the Obama administration’s brief defending the constitutionality of the health-care law come early on. “As a class,” the brief advises on page 7, “the uninsured consumed $116 billion of health care services in 2008.” On the next page, the brief drives the point home: “In 2008, people without insurance did not pay for 63 percent of their health care costs….

Yet this is a provision that the overwhelming majority — those with insurance — should support, for the simple reason that they currently end up footing the bill for much of that $116 billion. As the government’s brief notes, “Congress found that this cost-shifting increases the average premium for insured families by more than $1,000 per year.”

In other words, those worried about having to pay ever-higher premiums should be clamoring for the individual mandate, not agitating for repeal.

Indeed, for all the bristling over the mandate, it will be irrelevant to the 80 percent of non-elderly Americans who already have insurance, either through their employers, government programs or purchased on their own. The biggest real-world risk to these people would be if the court were to overturn the mandate yet allow the rest of the health-care law to remain in place, driving premiums ever upward.

Amazingly, Republicans have managed to transform the mandate from an exemplar of personal responsibility into the biggest public policy bogeyman of all time.”

At least two points worth noting here.  First, we are reminded that we (taxpayers) already pay the health care costs of the uninsured in higher premiums to support hospital subsidies.  We also pay in diminished public health (think disease spreading in schools, for instance) and in an estimated loss of $65 to $130 billion of economic activity.  Why not pay less in taxes to provide all Americans with health insurance?

Physicians for a National Health Program report on dozens of studies done by the General Accounting Office, the Congressional Budget Office, and think tanks at the state and federal level repeatedly demonstrating that the administrative savings provided by a single-payer plan would at least offset the additional costs of covering every American…in many state studies the analysis showed enormous savings to taxpayers, such as $344 billion in California over ten

The second point of note in Marcus’ column is the partisan flip flop on individual mandates.  An idea that came from the conservative Heritage Foundation and was once the Republican alternative to a single-payer plan because it was based on individual responsibility…is now, without irony or shame, routinely described by these same Republicans as socialism.  It may not be a good idea.  In fact, I agree that it is not the best idea in this case, but it is a conservative idea, and nothing at all related to socialism.  But Marcus digs deeper to point out why many refuse to see this as hypocrisy. 

“In part, hostility to the mandate reflects a broader uneasiness with perceived big government encroachment…

But opposition to the mandate also stems from the public’s failure to understand — or, alternatively, the administration’s failure to communicate — basic facts. For example, Kaiser found that when people were told that most Americans “would automatically satisfy the requirement because they already have coverage through their employers,” favorability toward the mandate nearly doubled, to 61 percent.

Favorable attitudes rose to nearly half when people were told that without the mandate, insurance companies would still be allowed to deny coverage to those who are sick; that without the mandate people would wait until they were sick to purchase insurance, driving up premium costs; or that those unable to afford coverage are exempt.”

While recent debates about contraceptives and forced vaginal examinations make it very difficult to claim only one party is pushing big government…this concern should not be taken lightly by elites on either side.  This is a perennial question, however, since voters routinely say (demand) they want smaller government at the same time that they say they want more government services like police and fire protection, trash pick up and prisons, better schools, fewer potholes, and a stronger national defense. 

Nor should the calculated effort to misinform Americans about health care, revealed in the Kaiser data, be overlooked by either side.  Even if it works on this one issue, and that is never certain, what deeper damage is being done to the preconditions needed for democratic deliberation, since that is, ultimately, the foundational mechanism we need to function properly if we are to productively address any conflicts we face.

And finally, will those who frequently criticize the Supreme Court for legislating from the bench call on it now to defer to the more democratic branch (see this conflict as not ripe)?  Or has the orginalist the call for judicial restraint actually been just a misleading way of expressing dissatisfaction with particular court decisions, and not really opposition to court action in general, as we saw in the response to Bush v Gore? 

I have no doubt that there are many good reasons to oppose the particular court decisions usually attacked as judicial activism, but I would welcome the candor that would come with just saying we support or oppose a decision for these reasons, in place of pretending it is the nature of the institution or interpreting the Constitution that offends you, because the former debate is more likely to strengthen democracy and the latter is not.