If the healthcare law is overturned, universal healthcare is dead forever

[anvi]

I'm with Beet on this one.  Not only in American political discourse, but the world over, there are only two routs to universal coverage, a national system funded through taxation, or a multipayer system backed up by mandates.  You can't finance pre-existing conditions, catastrophic care, long-term care for chronic illness or elder-care, ect., without everyone being in the insurance pool. 

On the other hand, you can't finance universal coverage without some strong mechanisms in place that control health care cost inflation.  If the mandate are overturned by SCOTUS, and we don't want cost controls and we don't want a national system either, then, in the short term, we won't have universal coverage  And we'd be saying, in effect, that we would rather ration tens of millions of people out of health care coverage entirely than ration procedure and medicine coverage for everyone in the pool, and this is one thing that, to my mind, is just disgraceful about our system.  But, on the other hand, if we don't want any of these three things listed above, then the steady increase of costs added to the demographic trends of the U.S. will bankrupt us anyway. 

There have been some proposals floated recently about insurers offering pre-existing conditions coverage in exchange for continued enrollment (incentivizing buy-in), and of course there is always the tax-subsidization for premium costs route.  But I'm not sure how to work the details of the former, and in the case of the latter, without dramatic measures taken in cost inflation management, that solution would be headed to the same abyss everything else is.

[anvi]

I admit I have a bias here. I hate long wait times to get medical services, so rationing that way just does not suit my demanding self-centered little personality.

You're not the only one, Torie.  One reason the U.S doesn't have universal coverage yet is that getting it would require people who already have insurance and providers to give up some privileges that they've become used to, and no one in the U.S really wants to give up anything.  But that time is marching toward us when we won't have much of choice.  On lots of fronts, not just this one.

The thing is, I don't believe that the only alternatives with health care are either longer wait times or what we've got now.  The Bismarck system counties that I lived in didn't have long wait times; indeed, for some specialist care, getting services was even faster than it is here.  But, I digress.

[anvi]

The thing with the SCOTUS decision regarding the Obamacare mandate, as Mr. Philps indicated at the top of the thread, is that, if they decide to strike it down, that closes the door to any model of universal coverage that would be implemented through a mandate.  That means, as far as I can tell, that the only route left to universal coverage would be a national insurance system, which, to my mind (others on the forum may disagree), doesn't work as well as the multipayer Bismarck system, which features mandates.  That's to say that, in thinking about this thread, defending Obamacare specifically wasn't my main concern; my concern was rather which doors we may be leaving open or closed in terms of future reforms way may have to make. 

[anvi]

So, let me get this argument straight, Torie.  On the one hand, the Obamacare mandate is so weak and toothless that allowing it to remain in the law or severing the rest of the law from it would make practically no difference.  That is supposedly the case, aside from penalty and tax credit issues, primarily because it has no enforcement mechanism, and so doesn't really function like a mandate anyway.  But, on the other hand, retaining the mandate would destroy the constitution because the mandate is far too strong; it would give the government carte blanche authority to mandate the purchase of any item in the name of regulating markets.  So, the very same mandate is too weak to make the legislation in question effective as regulation of the one market it was intended to regulate, but too strong for the commerce clause to bear the weight of because it threatens to give the government authority to force product-purchase in all markets.  Am I getting this right?  If so, how can a mandate be simultaneously so weak that it doesn't even require product purchase in the law in which it's found, but so strong that its authority could compel product purchase in every other market? 

Anyway, if SCOTUS agrees, then the implications are, I think, as I've stated above.  

[anvi]

I agree Alice is very much alive.  I speak to her daily on numerous occasions, in fact.  I'm just saying I don't think it can be both in this case.

[anvi]

I wrote many drafts of a response over the past few hours, and then just gave up.  Hopefully some wisdom will descend upon me in the future, which will permit me to give up far sooner.

[anvi]

Ok, I'll just write it.  We've been through this over and over, so I guess arguing about it now doesn't make much sense when the big nine will rule as they rule soon enough anyway.  But, whatever.

Of course irony doesn't make something untrue.  But saying that one and the same bear is too weak to rip open one plastic bag but powerful enough to rip open all plastic bags is not irony.  And saying that one and the same law that is too weak to compel product-purchase in one market is strong enough to compel product-purchase in all markets isn't irony either.

But, instead of saying that, we're now saying that PPACA's mandate should be struck down because it could have been, or could be worse?  The argument now is that SCOTUS is supposed to shoot down a current law, not because the current law breeches the constitution, but because a future law sort of similar to it but only stronger might?  So, now we have SCOTUS striking down fantasy laws by using the ones before them as proxies?

I was really unaware that I don't give a damn about the states.  I had not thought about that.  But it could be true.  I guess, at the end of the day, I believe that an individual's right to access health care coverage trumps a for-profit insurer's right to deny them coverage or rescind them just because they were already sick.  That is the point of striving for universal coverage.  Do I think mandates are the only way to get there?  Well, the only two routes to universal coverage that I'm aware of so far have been the two mentioned above.  Now, we're told again and again that the "socialized medicine" of a national system is "un-American" and on top of it won't work.  That means that, if the U.S. is to achieve universal coverage, it will have to do so within the framework of a multipayer system.  Well, so far, universal coverage in a multipayer system has required the implementation of mandates.  Now, I'm not some a priori dogmatist.  There's nothing precluding the possibility that someone may come up with a new route, so maybe individual mandates are not the only tool in the box.  If we were trying to get universal coverage with mandates, than I surely agree that the Obamacare mandate is woefully inadequate to the task.  No argument there.  But then again, I don't really believe that health insurance, even if we preserve its offering through private companies, should be a for-profit industry in the first place.  Not because of red-herring issues like the size of profit margins, since health insurance is a low to middling profit-maker to begin with, but because I think making investors happy shouldn't be a motive when it comes to deciding who or what to cover--it's the way the system skews incentives in the wrong area of life that bugs the hell out of me.  If we as a nation really believe that a health insurance company's right to profits is more important than an individual's access to health care, then I think we've become dogmatists about just how many areas of life free-market principles have to dominate, and, with regard to this matter, it's a profoundly unethical sort of dogmatism.  If that makes me an anti-federalist or un-American, then so be it.  In the grander scheme of things, I've actually been called worse.

[anvi]

I guess I'm still not clear on how this mandate swallows federalism.  What does the mandate not let the states do?

[anvi]

I'm still missing a step--sorry I'm slow, but I genuinely want to understand the argument.  My understanding up to now is that the major objection against the ACA mandate is that if gives the government too much power over individuals, since allowing this mandate to survive would give the government sweeping authority to require the individual to purchase anything in the name of government regulating its favorite market in any given week.  But this thing about federalism keeps coming up, which makes it sound like the mandate is infringing on the rights of the states, and not the individual.  I don't get that part.  Isn't the commerce clause an enumerated power of the federal government with regard to commerce between the states?  What does the mandate in ACA require the states to do?

[anvi]

Ok, sure; states can create laws binding upon their own residents regarding the purchase of health insurance.  But that doesn't negate the fact that health insurance does involve interstate commerce, since it purchases services, medicines and equipment that traverse state lines.  So long as Congress decides to pass a law regulating what is legitimately interstate commerce, that does not necessarily mean that it's abrogating a power that only the states can lay exclusive claim to.  So, then, the question regarding the constitutionality of the ACA mandate is not one about the government's authority to regulate the purchase of health insurance per se, a power that only states would otherwise lay exclusive claim to.  It's about whether pressuring (I'm going to use the word pressuring because the ACA mandate doesn't legally force anyone to make a purchase) citizens to purchase insurance when they don't possess it in the first place is an over-extension of commerce clause authority, presumably in view of the above-stated slippery-slope argument.  And any conflict about the overextension of a congressional power by its very nature invokes the framework of federalism, because powers that don't belong to the federal government might belong to the states or the people.  No?

[anvi]

Government briefs that have addressed the issue of what makes the health care market distinct from other markets, by the way, have not just pointed out that practically everyone is already actively involved with the health care market already, since, as noted above, if that were the only argument, lots of other markets are actually comperable.  In one way or another, most of us already buy water and shoes, but that doesn't mean the government can mandate that we purchase them.  The other distinctive thing about the health care market is that, under certain emergency conditions, someone may go into an emegency room, demand services at no cost without the provider having the right to refuse them, forcing all other active consumers in the market to pay the bill.  This is not analogous to other kinds of cost-shifting in other markets, and certainly in no other market can someone walk into the front door of a vender, demand a service witout compensation, and charge the bill to the general public.  Now, unless we are prepared to repeal laws like EMTILA (and I hope we are not), then that distinction will remain between the health care markets and other markets, and so regulations designed to address that unique problem (the free rider problem) of the health care markets will not impinge on other markets.

[anvi]

The idea that sick people who have no insurance can just routinely use emergency rooms for their care is false. The provisions of EMTALA only require hospitals to treat such persons if they are at severe risk of death or in active labor, and even then they need only be treated till their immediate condition is stabilized. While there are emergency rooms that treat more, it's completely legal for them to turn patients away if they don't meet these conditions, and they often do. Many people in such circumstances suffer from serious chronic conditions for long periods of time that would otherwise be treatable, but end up only being accepted for emergency room care when it's too late to successfully treat their conditions. A rather large number if American citizens lose their lives every year because of these circumstances. So the notion that we can comfort ourselves with the argument that there are only problems of economic inefficiency bedeviling our system when it comes to the uninsured is a conceit. It's a moral issue, and I think a serious one.