Healthcare reform needs everyone in the pool

Doctor's Orders
Doctor's Orders: Everyone in the Pool (Photo by Lauren Nelson on Flickr)

Republicans are crowing over the recent district court ruling declaring the individual mandate part of the Patient Protection and Affordable Care Act is unconstitutional.  This ruling will be appealed and also stands against four previous district court rulings that threw out similar cases as having no merit.  The likely outcome being an eventual hearing of this issue by the Supreme Court.

The core issue is whether or not the Commerce Clause may be stretched to require individuals to make a purchase.   That’s arguably pushing the envelope, but the Commerce Clause has certainly been stretched and distorted before in many creative ways.  For example, it was the basis for implementing No Child Left Behind as a federal program.  Regardless of the eventual court decision, it’s worth considering the impact if the individual mandate should be ruled unconstitutional.

Polls show the requirement of everyone to buy health insurance is far and away the unpopular element of the bill.  Meanwhile, prohibiting companies from discriminating based on pre-existing conditions, closing the donut hole, and eliminating lifetime coverage caps are very popular.  This amounts to people liking all the benefits, but not liking the method of payment.  At issue then is how would the popular reforms be paid for without the individual mandate.

Under the current plan, it is only by forcing everyone into the insurance pool that private companies would be able to abolish things like pre-existing condition clauses and lifetime caps.  Removing those restrictions without everyone in the pool would cause rates to skyrocket, and make coverage unaffordable for many more people.  If that were to happen, count on the GOP to tout how Obamacare made the healthcare problem worse.

Another alternative would be to make up the difference by providing large government subsidies to private insurance companies.  This money would have to be raised through new taxes or add to the already unmanageable national debt.  Again, a political victory for Republicans as they would roast the Democrats for being fiscally irresponsible.

Democrats might also recognize the impossibility of Obamacare moving forward without an individual mandate and move themselves to repeal the rest of the programs.  Again, the GOP would claim victory for forcing repeal, and possibly also strafe the Dems for taking away popular benefits.

Note that none of the above scenarios have a positive effect on you as the consumer of healthcare, but they all have a political upside for the Republican Party.  The individual mandate was initially a Republican invention.  It was explored by Presidents Nixon and Bush Sr. and was a key element of the GOP counter-proposal to Clinton’s plan.  It was the way to keep healthcare insurance a private industry and eliminate the need for an unarguably constitutional public option such as Medicare for all.

Any substantive reform of healthcare insurance requires everyone in the risk pool one way or another.  A public option brings everyone in via taxes while the private option requires the mandate.  Notably, employer provided healthcare already recognizes this as all employees are in the plan.  Businesses could not afford to provide a healthcare benefit if healthy people could opt out of the coverage and take the cash instead.

There simply are no other reasonably affordable options to having us all in the pool.  Healthcare is too expensive for the cost to be borne directly by any but the very rich.  Yet Republicans stand opposed to any incarnation of this key reform element—not because it’s what’s good for you, but because it benefits them short term at the polls.

The only potential upside for citizens in declaring it unconstitutional for the federal government to mandate the purchase of a private sector good is that it would also make the privatization of Social Security unconstitutional.  After all, if they can’t make you buy health insurance, they can’t make you buy retirement investments.

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