• Next-day two cents

    It’s a day later and I have a number of running thoughts:

    1) I can’t believe how many times I’ve been asked, “what changed with the bill” with respect to the mandate. Um… nothing? With the exception of the medicaid expansion becoming optional, do people not understand that what the Supreme court did was decide NOT to make a change? They don’t write laws. The ACA does today what it did last week. Everything else is the same.

    2) On that note, I’m disappointed, but not surprised, to see that opposition to the bill wasn’t in the end about “freedom”. I challenged many of you in the long, long ago to voice your support for an ACA with a “tax” instead of a “mandate” if the tyranny offended you so. And now that it’s happened, I’m getting a lot of email and such angry about the “tax”. Nothing changed. The law reads just as it did yesterday. This “tax” isn’t new. I understand the political spin of calling the law a “tax increase” now, but we’re not going to engage that here.

    3) While I’m concerned about the potential new Medicaid problems, I lump them in with the many issues I still think need resolving. There are exchanges to set up. There are ACOs to regulate. Lots of work to be done. Unfortunately, I bet we’ll still just keep talking about repeal/not repeal instead.

    I’ll add more as they come to me.


    • The claims that this is a massive tax increase are absurd.

      It only applies to those who don’t have insurance but could easily afford it. That’s a very small number of people, maybe 1% of the population.

      The government needs to explain the law. Its parts (other than the mandate) are very popular, even to those who oppose it. Yet more evidence that ignorance (fed by lies) is what drives our political discourse.

    • I’m surprised about the mandate/tax thing, too. SCOTUS reigned in possible misuse under the Commerce Clause. Your ‘inaction’ is safe now. Unfortunately, tribal politics continues on.

    • On tax vs mandate: it’s not spin, The mandate’s status as being a tax was arrived at by the Court, – not the administration or its surrogates – on the basis of established legal thought and traditional legislative procedure. See Sejinder Singh’s explanation on SCOTUSBlog at bit.ly/L6d4ji

      • I didn’t say it was spin. I said it was semantics. It is, in the sense that the law hasn’t changed. How we think about it has.

        Oops. I did say spin. And, I guess the difference there is semantics, too. I still maintain that the law is the same.

        • Agreed. Roberts got it right. Semantics is for Grammar Girl and politicians. Roberts lifted the shirt of the ACA, saw it was a tax and made the call. And we can only guess he had to hold his nose doing it. I’m happy, not so sure Roberts is thrilled about it.

          • If it is gutted by reconciliation, since it is now a tax, you will be ok with that? They already have supporters trying to argue it’s not a tax and thus not subject to reconciliation. Words do matter, laws based on fussy intent and flexible interpretation in the moment are the tools of despots.

            Not the outcome hoped for by the majority of the country, on the bright side it will only take 51 votes to fix it. Unless it’s not a tax when that time comes.

            • It is irrelevant that SCOTUS called it a tax. Anything with budget impact is fair game for reconciliation. Hence, it was fair game before. All the rest of this debate is political positioning and nothing more.

    • On your second point, I disagree. You’re right, that people complaining that this is a tax may care more about the political aspect than the philosophical liberty aspect, but I, and many like me, believe that yesterday’s ruling was a small victory for libertarians. At least Roberts successfully erected limits on government power by saying the mandate fails the commerce clause test.

      I think that’s a critical aspect of the ruling, and I’m on net happy about the ruling even though the ACA was upheld, and even though, effectively, the government can still impose any type of mandate by applying tax disincentives. But that’s a power they’ve been using for decades, so it’s nothing new.

      The Democrats who are energetically celebrating the ruling, though, I think care more about the political aspects, and don’t really understand the underlying philosophical conflicts.

      That being said, I’m still perplexed as to what the difference between a tax and a fine is, because the mandate seems an awful lot like a fine to me.

      • Many are pleased to see coverage expansion and, to some of them, that’s all there is to it.

        • What coverage expansion? The total number uninsured has increased since it was passed. Partly due to cost, partly do to elimination of individual child market. Partly do to Student health plan changes. Some due to requiring churches to cover birth control.

          More people would be insured today if it had never passed.

          All anyone has is a promise that more people will be covered. The one thing 47 years of health care reform has tought us for sure is it won’t deliver half of what it promises and will cost 10 times as much. Where is the solice in that?

          The Internet is wonderous in its ability to mock past promises;


          The Health Insurance Portability and Accountability Act of 1996[6] is the single most significant piece of Federal legislation affecting the health care industry since the passage of the Social Security Act of 1965 that created both Medicare and Medicaid.[7] HIPAA, which was signed into law by President Clinton in August of 1996, includes provisions for health insurance portability, fraud and abuse control, tax associated provisions, group health plan requirements, revenue offset provisions, and administrative simplification requirements.[8]

          The importance of HIPAA is apparent in the fact that compliance is not an option – compliance is mandatory for each and every entity involved with electronic health care information.[9] Entities involved with electronic health care information include: all health care providers, health plans, employers, public health authorities, life insurers, clearinghouses, billing agencies, information systems vendors, service organizations, universities, and even single-physician offices.[10]

          The HIPAA legislation was passed in part to limit the problem of “job lock” within the American workforce.[15] “Job lock” is a condition associated with the reluctance to move from one company to another due to a fear of losing health insurance or health coverage.[16]

          How much of HIPAA promised was actually delivered? Most of what ACA is trying to accomplish is the same things HIPAA promised.

          Medicare was passed to protect grandma in the event of a serious or prolonged illness….and then specifically excluded those situtions.

    • It’s not clear to me if there is any arena of commerce in which non-participation can’t be deemed a statutory violation subject to penalties under the terms of the ruling, so long as it’s labeled a tax.

      Just to take everyone’s favorite vegetable – is there anything that emerged from this ruling which established a clear line between a “tax” that applies only to those who do not satisfy a statutory obligation to purchase broccoli?

      I wouldn’t have any liberty-related problem with the government using taxing authority to send checks to people who can’t pay for their own insurance or who can’t obtain insurance. I do have a massive problem with using the commerce clause to compel participation in commercial activity. I’m baffled by people who can’t tell the difference between the two – but then again I’m baffled by people who *really* think that a commerce clause grants the government the right to prevent people from growing food on their own land for their own purposes.

      As for medicine – “Après cela, le déluge.” If you’re an ACA fan, it’s time to stop worrying about the Supreme Court and start worrying about the bond market.

    • Edit.

      “Just to take everyone’s favorite vegetable – is there anything that emerged from this ruling which established a clear line between a “tax” that applies only to those who do not satisfy a statutory obligation to purchase broccoli and a penalty imposed exclusively upon those who fail to do so? “