Healthcare undone by lack of public option?

Tracking the the health care debate over the past couple of days, and  especially yesterday with many SCOTUS-watchers predicting doom for the health care mandate, I can’t help wondering if the mandate would have survived had there been a public option in the background?

A mandate directing individuals to either buy, or opt-in to a broadened Medicaid program (which would surely benefit with an influx of healthy members as well as the positive cash-flow from a buy-in population).

Certainly the political feasibility of a program like that is questionable. It’s not part of the plan for a reason — although I’m not sure it’s really been put to the political test since the Obama Administration abandoned that aspect of the health care overhaul so early and so completely in the the process.

Now I’m wondering what happens if the Supreme Court overturns the mandate. Could that put the public option back on the table, and open the door to a mandate that would pass the court’s test?




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22 Comments . Leave a comment below.
  1. More than just a public option

    Without a mandate, only government-sponsored single-payer health care can work. The question is how much time, pain, and money it will take for Americans to accept this reality.

    • The mandate...

      … was an attempt to use regulation to make risk pools for private insurers efficient enough to handle a world without the consideration of pre-existing conditions.

      If it is shown that the government lacks the power to regulate in that way, it may well be argued that expansion of the public risk pool is the best way to gain efficiency.

      People will need to come up with other ideas – the GOP in particular. They can sit there and say the current system isn’t broken and be laughed at or they can propose their own solutions. When they’ve proposed solutions in the recent past, however, those solutions didn’t pass the laugh test either. So in the end we may rot with what we already have because of the GOP’s firm desire that the federal government not be efficient at social services at all (which is sort of how we go to the ACA in the first place).

    • The answer to the question

      depends heavily on the limits to what constitutes “health care.” As long as it is unlimited, it’s going to be controversial. But if it is limited to basic health care and prevention, stuff that 95% of people agree they want to cover, then it won’t be very hard. Leave the controversial stuff out, and let private plans and charities cover that stuff.

      • Controversy is not the same as unnecessary

        The medical and statistical evidence supporting the inclusion of contraception as “basic health care” is compelling and overwhelming. The objection to that inclusion (a) comes from a minority of the people and (b) is based in religious belief, not science. Whether “controversial” or not, Reiki Healing is never going to meet a standard of scientifically documented (through clinical trials and statistical analysis) effectiveness.

        I think that the primary standard for establishing coverage should be scientifically-documented effectiveness. I think the many questions of what limits should be imposed and by whom are thorny and will require a great deal of debate. I am loathe to hand-wave away those questions by bromides like “95% of people agree”.

        We can’t get 95% of people to agree that evolution is real, never mind climate change.

        • Your last sentence...

          … depends if the pool of people you’re measuring are scientists. ;)

        • Then forget about passing single-payer

          Is pissing off people and forcing them to submit to the scientists really more important to you than getting non-controversial health care covered for everyone? I think the 95% test would include just about everything, but things like Reiki and acupuncture would probably fail that test, and people would have to pay for it themselves, or buy a private insurance plan that covered stuff like that.

          • "Forcing them to submit to the scientists"?

            So are advocating for “faith based” health care? Do propose to determine efficacy by popular vote? Apparently you are one of those who associate reliance on science with “liberal”.

            Yes, I suppose I am suggesting that those who are “pissed off” by a reliance on science should be ignored. I sincerely hope they are a minority.

            • Outside the boudaries of civilization

              Once you find yourself arguing whether we should make decisions based on evidence, you should realize that you are arguing with a barbarian — or a barbarian point of view. At that point, logic ceases to be tool for persuasion; you have entered the realm of superstition and totemism.

              Might I suggest trying emotional appeals?

            • I'm advocating for achievable health care

              You are way more interested in spanking people who don’t submit to the authority of scientists and technocrats and making them say “uncle” (or is it “aunt?”) than you are in actually achieving a workable real-world solution to the problem of people not getting the non-controversial medicine they need.

              • Ugh! Ugh!

                Eek! Eek!

              • Whatever it is you advocate for, it isn't "health care"

                I invite you to share where I wrote anything about “spanking people” (is that a fantasy of yours?).

                I really don’t comprehend what you mean by “submit to the authority of scientists”. You seem to be proposing that we instead rely on religion (in the case of the contraception debate) or popular vote (I don’t know how else you discern what medicine is “non-controversial”). Is there some other way to interpret your apparent contempt for “scientists”?

                • It sure is health care

                  I think basic non-controversial hospital services and emergency care should be free and not billed to the patient, just paid out of the daily operating budget, which is paid from general funds. Everyone should be able to go to their doctor or a hospital or clinic and be seen by experts and given the most effective treatment that restore them to health. But people recognize that this would be super expensive if we let people do everything with no limits, we see things like the OctoMom and her comrade in arms Sandra Fluke and Dick Cheney’s billion dollar heart, etc, and we hear people making the general demand for No Limits! So we balk at Single Payer out of fear it will be abused and we’ll have to subsidize horrible things. But if we just set some limits, gave a sista-souljah brush-off to sex-entitled law students, organ transplant entitled, IVF entitled, futile cancer treatment entitled, sex change surgery, etc, then we could easily achieve Single Payer for everything else. But because you loudly insist on No Limits, you take an “inordinately zealous approach to matters of form and propriety”, and that shows you’re more interested in “calling the balls and strikes” and calling out people who aren’t the Party ideal, than in simply ignoring objectors and accepting limits.

          • every single thing ...

            … about this comment, even including the use of the words ‘and’ and ‘the’ , demonstrates your complete and utter inability to comprehend the debate.

            You would need a pound of marijuana, three more years of the 8th grade and major surgery, before you get it.

            • I'm way ahead of most people

              My track record on this debate has been very good. Everyone is surprised by the questions from the justices except me. Those things about limiting principles and broccoli were the same points I’ve been making here for months!

              Look at this. Here is me, almost a year ago, and here is the Globe, yesterday.

              • so instead of boken clock...

                … that’s right twice daily, you’re a broken calendar that’s right twice yearly.

                Simpleminded arguments used to justify… ahem… pre-existing conditions remain simpleminded no matter how many other simple minds parrot them.

                • you're full of insults

                  None other than Justice Kennedy came to my rescue in my argument with David. And the Globe writing that article shows that I have a pretty good comprehension of the debate, as well as the legal issues. You guys can pretend it’s all about the limits of Congress, but that’s a fiction, it really does come down to the rights of citizens.

              • The fact that the right-wing justices...

                …are getting their talking points from right-wing idiots like you leave me fearful for this nation’s future. Any thinking person should feel the same way I do.

  2. Why some progressives think that

    striking down the mandate will hasten the advent of a single-payer system is really beyond me. It is the height of naivete to claim that “everybody will just realize how screwed things are” and will thus turn to a public option or single-payer system as an alternative. We’ve been trying to get a full single-payer system since the 1940s and have still failed to do it, despite the health care problem being far worse now than it has been in the past. Thinking it will happen as a result of a Supreme Court decision that would limit federal government power is lunacy.

    (Not to mention that if the entire ACA is struck down rather than just the individual mandate, years worth of progressive efforts will go down the tubes along with it. Even if one is a progressive who is no fan of the individual mandate, hoping that it gets struck down by the Court, thereby risking other valuable achievements of the bill and further limiting federal power makes absolutely no sense from a progressive perspective).

    • I have no illusions

      If the mandate is struck down, I think things will get much worse for a long time before they get any better — if they get any better.

      If the ACA is struck down, health care costs will continue to spiral. The already anemic “recovery” of the American economy will be slowed even further as we will spend a greater and greater share of the GDP on health care, while our outcomes will continue to worsen.

      I am truly baffled by the delusional irrationality of the GOP. They attack the ACA primarily because they care only about destroying the presidency of Barack Obama; they offer no remotely plausible alternative to the ACA.

      The ACA cannot work without the mandate. If the mandate is struck down, what do you think will happen next?

      • If the mandate is struck down

        than health care costs will spiral even higher than if the entire ACA is struck down (because of the pre-existing conditions piece and other elements of the ACA). So I think we agree as to the outcome here.

        Either way, however, it has become so difficult to pass anything through the Senate that spiraling health care costs or not, Congress will sit on its hands and do nothing. Unless the Democrats get 60 votes — something that they never did even when the ACA passed — I don’t see any significant progressive health care policy passing the Senate, regardless of how bad health care costs get or how many people are uninsured.

        Remember that during the periods of great progressive lawmaking in the 1930s and 1960s, the Democrats had massive majorities. I’m not sure when that will happen again.

  3. Still thinking that lack of public option is the undoing

    Still thinking that lack of public option is the undoing of this version of health care reform.

    If all un-enrolled persons were presumed to be covered at least by Medicare, and that in order to receive care at the point of service, an uninsured person had to claim an enrollment, in either a private or public (Medicare) plan, with a schedule of benefits (and penalties) for not having the coverage ahead of time, then I think a mandate would stand.

    Why? Because at the point of service they would have to elect an enrollment, this if they had procrastinated earlier against choosing, were incapable for one reason or another, were too cheap to buy, too poor, or too inclined to mumble `Fuck the man’ all the time. Try saying that when you can’t understand what that pain is in your gut, or when you break a leg on a sheet of ice in your driveway.

    This is not a lot different than the basic presumption that a person who shows up at a hospital must be cared for. It just structures it in terms of personal responsibility — the decision at the hospital to claim either a Medicare membership, private insurance membership — or I suppose the cash liability, would be a personal election.

    I don’t see how this would be a government intrusion at this point and I think a mandate would stand because it would rely, ultimately, on a choice by an individual.

    Merely caring for the uninsured and then floating those costs across an inefficient bureaucracy without structuring the delivery of that care, ie not allowing the uninsured the presumption to join Medicare as a last resort, is irresponsible. And it really is a status quo that is being preserved by the enormous business interests in health care that want to contain the bargaining power of the the biggest player at the table.

    I don’t agree with the reflexive business paranoia that opening up Medicare to elective enrollment would be a threat to private providers. Better care, better service and the cache of a premium plan as one’s employment climbs the economic ladder, or is negotiated, would keep plenty of insurers in business.

    That insurers were able to dismiss or reject claimants for `pre-existing conditions’ for so long should be a national embarrassment.

    I remain extremely disappointed that Obama abandoned the public option, really without a fight; and I think it might be the undoing of what he did get accomplished by being too-cute-by-half with the adoption of a pro-business, Republican model, which must have seemed like the perfect way to pass the bill.

  4. Live chat today over at the Herald

    Live chat on this topic today over at the Herald…

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Wed 29 Mar 1:00 PM