• No, overturning ACA would not smooth the way to single-payer care

    This morning’s post by Matt Yglesias notes a fairly obvious but important issue that bears attention.

    The comportment of conservative Supreme Court justices in oral argument leads many people to seriously consider what would happen if ACA is crippled or struck down. (Like Jonathan Cohn, Henry Aaron, David Cutler, Charles Fried, and Jonathan Chait, I was appalled by the oral argument. You can read my column at healthinsurance.org for more on that subject.)

    Several commentators assert, or at least have mused, that overturning ACA might improve the prospects for a single-payer system. It’s easy to see why one might think so. Single-payer is less vulnerable to the commerce-clause challenge that bedevils the mandate. Outright failure of ACA would discredit bipartisan, market-based strategies within many core Democratic groups. The political and organizational simplicity of single-payer is appealing, too. Killing ACA heightens the contradictions of our fragmented and costly health care financing system, while taking off the political table some of the most workable strategies for incremental reform. Absent a serious and workable alternative, Medicare for all might look surprisingly attractive some years from now.

    Still… I just don’t see it.

    In the first place, I am confident that a smart and determined conservative judiciary would entertain new constitutional challenges to a single-payer system. Such a system would end or would damage much of the private insurance industry. It would reorder relations between the states and the federal government. It would upend self-insurance arrangements under ERISA, and more. If you believe ACA’s 2,700 pages was long and complicated, wait until you see the junk DNA that would accompany a politically and administratively viable single-payer bill. That’s fertile legal ground for opponents, even absent the current political polarization of the federal judiciary.

    Single-payer also runs straight into precisely the political and institutional obstacles Democrats precariously navigated with ACA. I was reasonably closely involved in the public option debate. Many people believe the public option failed because Senator Lieberman hated liberals, or because insurers opposed it. These things mattered. Something else mattered, too. Pretty much everyone on the supply-side of the medical economy—including many constituencies who were otherwise strong health reform supporters—was very nervous  about the federal government acquiring so much bargaining power to dictate prices and other terms of medical care.

    When wheelchair manufacturers, your community hospital, insurers, and many medical specialties line up against a single-payer bill, the path to sixty Senate votes seems narrow indeed. Whatever the American voters might tell pollsters right now, a concerted ad campaign supported by these same constituencies would be quite damaging.

    Finally, there is the legislative Vietnam syndrome sure to ensue if the Affordable Care Act comes to naught. Health reform supporters acted with skill and determination, spent hundreds of millions of dollars, and took huge risks by devoting much of President Obama’s first term to enacting path-breaking legislation that was only made possible through the largest, most cohesive Democratic majority since 1964.

    A core of furious activists might be energized if conservative justices snatch away the football. It might even help President Obama counterpunch to victory this November.  More fundamentally, though, people are energized by the possibility and the experience of actually winning.  Health reform supporters will be quite dispirited by the opposite experience. Across the ideological spectrum, political pros will be quite leery of undertaking such a massive effort again. Maybe in 2030, America would make another concerted effort to cover the uninsured. For thirty million people, that’s a long way away.


    • I don’t see how the failure of a progressive approach improves the odds of passing an even more progressive approach. This is just wishful thinking on the part of progressives. Progressives have not won a major nationwide issue since passage of good environmental laws during Nixon’s term. It’s time they recognize that they have not been able to sway public opinion effectively and that the country’s drift to the right is real. It is very, very hard to make progress with the south and middle states solidly conservative and anti-government in their outlook.

      The logical approach for progressives now is to implement universal health care in a state by state process. We need to push for Romeycare for everyone that lives in a blue state, and let the red states have their own approach.

    • It’s not as sexy as a health insurance man-date, but nothing will change America better and faster than Instant Runoff Voting.
      If we could vote for anyone that we pleased and didn’t have to worry about wasting our vote because it automatically transfers to a second choice candidate, then politicians would have to compete for our vote in a way that they don’t have to now.
      There are some who would like to hide this information from us, but when the 99% finally demand an upgrade to the voting system, the petty games of two party politics will be over. This would dramatically boost the confidence of voters and generate participation, such as we have never seen before. The influence of big money donors would be greatly reduced, accountability would be improved, and alternative parties would finally have a place at the table. In short, the quality of life and culture in the United States would blossom in ways that we can only dream of now.
      Whatever your pet issues, whether it’s animal rights, human rights, agriculture, education, funding for the arts, unions, or the evils of the McNews diet, we need to champion the cause of Instant Runoff Voting, first and foremost or our aspirations for a more just and noble society may remain forever out of reach.
      We all need to write a letter to our president, urging him to include IRV as a central message in his campaign. He needs this to draw some alternative party votes in this strange, super-pac election year. The Democrats will lose some power in the future but the county will be much better off.
      IRV is change we can believe in. Let’s get this conversation started!

      Thank You.

      Steve Spears
      Truck driver/philosopher

    • “Pretty much everyone on the supply-side of the medical economy was very nervous about the federal government acquiring so much bargaining power to dictate prices and other terms of medical care.”

      Exactly. In Japan, the government has that power, and it works really really well. Dental care and drugs are covered, mothers and babies do much better than in the US, no one goes bankrupt due to medical bills, and overall per-patient costs are about 1/3. The patient pays 30% up to some limit per disease per month, but since charges are so strictly limited, anyone and everyone gets the medical attention they think they need. I had a head MRI done for the fun of it the other day, and my 30% of the cost was under US$100; my out-of-pocket costs for an office visit are usually US$7.00 to US$15.00 or so.

      But the insurance industry is out in the cold and doctors’ incomes are much lower than in the US.

    • While I found the arguments in front of the court very informative, I kept wondering if this was really addressing the task at hand. Does the law impede upon the commerce clause (beats me)? Whether my neighbor should be covered by his parent’s insurance plan until he’s 26 or what is the fate of our uninsured friends is not material, in my opinion, to the task at hand. So when Harold Pollack says the supreme court has no business debating the policy merits of the health reform bill, I basically agree. While I won’t hide my opinion that I’d like to see the whole law blown up, I want it blown up because a majority of the justices feel the healthcare plan doesn’t meet constitutional muster pure and simple. While I have some doubts a conservative majority can keep the politics out of their decision, I’d be just as doubtful (perhaps even more so) that a liberal majority could do any better.

    • It’s amazing how good Hilary Clinton’s universal tax supported catastrophic health care coverage looks now. Private insurers could then offer much lower rates for preventative and care and for typical health problems and citizens could buy the coverage they choose but would always have the catastrophic in case of serious and expensive health problems.. Oh but that’s socialism. Oh horrors.

    • I think Jim had it right. Let each state move to implement the solution their citizens will support. The Federal government can help by giving the states the money to setup exchanges. Our costs are too high.
      It is the singular thought that the Federal Gov’t can force people to buy a service and control it in Washington that mobilizes peoples to be against this law. ACA was crafted to keep the power in Washington; wrong approach.

    • What’s the basis your the “junk DNA” fear? Medicare already exists, Congress (with a Democratic majority) COULD simply pass a bill lowering Medicare eligibility age to 0.

    • I agree with Jim’s comment, that is the ACA falls, the blue states should go ahead and try to implement a version of universal health coverage. A recent video documentary featured interviews with random people in a small Mississippi town about their views on health reform. Those interviewed appeared to be poor and in bad health (obese, few had teeth), yet they were all against “government health care” because it would somehow infringe on their liberty. If such individuals are so unconscious about their own self interest, they, and other red state citizens are probably a lost cause.

    • If the supreme court strikes down the individual mandate, how will the republicans ever privatize social security? If citizens are forced to save don’t they have to open up an account? Isn’t that a commercial transaction? Don’t banks and brokerages collect fees? Don’t mutual funds collect fees? How can I be forced into a commercial transaction against my will?

      • @invhand

        I’m sure privatized Social Security would be voluntary. If you still chose not to participate even after they kill the public one, the GOP are sure to applaud your rugged individualism and wash their hands of you.

    • Just because the government and the US are locked into a political battle of epic proportions, creating separate health care systems in each state in not the solution. In every area of social policy we have a serious political divide. Other countries offer health care much as we once provided utilities with enforced regulation. In California when we deregulated utilities, we were blackmailed with blackouts. That is the same process used by the health care industry. They select the healthy to increase profits and frankly, they let the not-healthy poor die. We lose 50,000 people a year to lack of health care. A quick trip to the emergency room (that is not free) is not health care. Until we can deal with this issue, we can not move forward into a better country. Hopefully we can come together in discussions like this before the chaos leads to worse outcomes.