Obamacare's loss may be Medicare for All's gain

[Starglider]

Much as I like single-payer in theory, at this point the effect on the US federal budget would be disasterous. It is politically impossible for the Democrats to institute both universal health coverage and sufficient tax increases to fully fund it. The US deficit is already hovering around 9% GDP with strong upward pressure from existing obligations (due to the aging of the baby boomer cohort). The USD reserve status is already under assault and low treasury yields have only been maintained by a series of massive monetisation programs. By the time the Democrats could reasonably have a proposal like this ready to vote the US will be in severe fiscal crisis, and if they somehow got it passed it would likely trigger a UST crash, rate spike and subsequent massive monetisation and inflation to avoid default. In principle there should be an economic boost from redirecting all the money spent on insurance premiums to salaries and consumption, but I bet in practice companies will retain the savings of cutting coverage as profits and the savings on premiums paid by individuals will be balanced by the crash and mass unemployment in the rapidly shrinking health insurance industry. So again good in the long term but the short term hit to the economy would be a serious problem.

[HMS Conqueror]

One thing the US could do is radically cut provision. The US government already spends as much per person on healthcare as the UK, so a universal system that provided fewer scans and less coverage for cancer and other high cost:effectiveness treatments would be achievable.

Does anyone have the political power to do that? Probably not.

[TheHammer]

If the entire law were struck down, then it would be a disaster to the cause of universal healthcare. It wasn't a perfect solution, but a key stepping stone. I don't see how this idea of a galvanized Democrat push behind single payer universal Medicare is anything more than a pipe dream. When one party does get a majority in congress, you tend to get more divergent flavors of that party i.e. Blue Dog democracts, Teaparty Republicans etc. That's why the HCR that we got didn't have everything in it that Obama wanted to begin with despite the Democract Majorities.

Successful Republican demonization of health care reform was a key component to them capturing the house of representatives, or at least that is what they believe. All they have to do is say the words "Government Takeover" and immediately get their base stirred up to fight it. Further, the current focus as far as medicare seems to be to cut who is eligable, not expand it. The reason you need to take progressive steps like this that the ignorant and stupid that Republicans court so effectively actually have a chance to see that rather than "Death Panels" and "Waiting weeks to see a doctor" they actually see a benefit from the reform. Actually seeing the reforms in action have lead to an ever growing approval of the act that never would have taken place had it been killed as it certainly would have been in its most extreme form.

Hopefully the court will recognize the individual mandate for what it is, a simple tax increase with a tax credit for those who have health insurance, not unlike numerous other tax credits the government hands out to encourage certain behavior. That is something that is well within the powers of Congress and should have been the basis for the Administration arguments. Or at the very least will only toss out that provision, which would at least keep some of the reforms in place to build upon in the future. I realize the latter becomes much more complicated.

[Alferd Packer]

Well, the quickest way to acheive a single-payer model is, ironically, that SCOTUS, in its ruling, removes only the individual mandate. Since insurance companies will still have to cover preexisting conditions, vast swaths of people will only buy insurance when they have a catastrophic health emergency. Since millions of healthy people won't be paying premiums, insurance companies will have to raise premiums to astronomical levels, and even then, it won't be enough. They will instead go out of business, making it impossible to get health insurance through private companies in the United States. The public then throws a shitfit, Congress has no choice but to grant universal coverage through Medicare.

[TheHammer]

Well, the quickest way to acheive a single-payer model is, ironically, that SCOTUS, in its ruling, removes only the individual mandate. Since insurance companies will still have to cover preexisting conditions, vast swaths of people will only buy insurance when they have a catastrophic health emergency. Since millions of healthy people won't be paying premiums, insurance companies will have to raise premiums to astronomical levels, and even then, it won't be enough. They will instead go out of business, making it impossible to get health insurance through private companies in the United States. The public then throws a shitfit, Congress has no choice but to grant universal coverage through Medicare.

Nah the Health Insurance industry will simply throw massive lobbying dollars behind getting the "pre-existing condition coverage" provision removed. Which is much more likely to pass than universal medicare coverage. In a best case scenario if the mandate gets overturned would be that Congress re-writes the law in such a way that it is not subject to be challenged, i.e. a "Medicare tax" that individuals who have health insurance get a credit for.

[Alferd Packer]

Nah the Health Insurance industry will simply throw massive lobbying dollars behind getting the "pre-existing condition coverage" provision removed. Which is much more likely to pass than universal medicare coverage. In a best case scenario if the mandate gets overturned would be that Congress re-writes the law in such a way that it is not subject to be challenged, i.e. a "Medicare tax" that individuals who have health insurance get a credit for.

What lobbying dollars? In all honestly, the profit margins for insurance providers aren't as massive as you'd think. Modern treatments are extremely expensive, and having millions of young and/or healthy people removing themselves from the insured pool will deplete every insurance provider's cash reserves extremely rapidly. Insurance companies might simply get out of the healthcare game before they hemorrhage too much money. After all, people still need car, home, and business insurance, and it'll still be possible to make money on those.

Additionally, to change the provisions of the law killing them, the insurance companies need a filibuster-proof majority of senators on their side. If SCOTUS overturns any portion of the law, especially in a 5-4 partisan ruling, the Democrats will be incensed at the blatant judicial activism and fight tooth and nail to get Obama back in office. The Republicans, OTOH, will not be as galvanized, as Obamacare is already (partially) defeated. They'll never get the majorities needed to kill any part of the law, so all the lobbying in the world isn't going to help the insurance companies.

But yes, the individual mandate can easily be worked around through a tax and an equivalent credit on everyone's Form 1040.

[Simon_Jester]

Now that people have Obamacare, trying to take it away from them will be less popular than trying to fight the bill in the first place was. It's roughly the same thing that stops the federal government from repealing Medicaid, even when it's controlled by people who would have voted against it at the time it was passed.

That said, Alfred, lobbying is pretty cheap compared to corporate profit margins, or even the collective personal savings accounts of insurance executives. The real problem faced by enemies of the law is just that actually repealing Obamacare is going to be hard, and it's only going to get harder as more people find themselves relying on it. The only reason there's any threat to it is because there is, honestly, a serious constitutional question about whether the federal government can require you to purchase health insurance on pain of fines.

I'm not expressing any opinion on that question at the moment- I'll keep that to myself. But I think it's a little disingenuous to pretend that it isn't a question that merits a hearing in the judiciary, because the federal government never actually came out and said "all citizens must pay for X or pay for the luxury of not paying for X" before to the extent that they do with the new health legislation.

[Alferd Packer]

That said, Alfred, lobbying is pretty cheap compared to corporate profit margins, or even the collective personal savings accounts of insurance executives. The real problem faced by enemies of the law is just that actually repealing Obamacare is going to be hard, and it's only going to get harder as more people find themselves relying on it. The only reason there's any threat to it is because there is, honestly, a serious constitutional question about whether the federal government can require you to purchase health insurance on pain of fines.

I'm not expressing any opinion on that question at the moment- I'll keep that to myself. But I think it's a little disingenuous to pretend that it isn't a question that merits a hearing in the judiciary, because the federal government never actually came out and said "all citizens must pay for X or pay for the luxury of not paying for X" before to the extent that they do with the new health legislation.

I believe all males between 18-45 were once required by law to purchase a firearm from a private company. Of course, that was 200+ years ago, but it's pretty much the same idea as this.

Probably a more recent, relevant Supreme Court ruling, though, is Gonzales v. Raich, of 2005. Specifically, that ruled that the Commerce Clause allows allows Congress to prohibit people from growing medical marijuana for personal use, even in states where such is allowed. If something that isn't commerce can be regulated by the Commerce Clause, then why shouldn't healthcare (approximately 1/6th of the US economy) be subject to Congressional regulation?

[TheHammer]

Now that people have Obamacare, trying to take it away from them will be less popular than trying to fight the bill in the first place was. It's roughly the same thing that stops the federal government from repealing Medicaid, even when it's controlled by people who would have voted against it at the time it was passed.

But if SCOTUS overturns the law then the trick is getting it passed a second time. The politicians in congress all will be able to point the finger at the courts and hold themselves blameless. Further, while the law has been becoming more popular, it hasn't reached the point where there would be overwhelming public demand that it be re-enacted should the whole thing be thrown out. Instead we'll get a bunch of hand wringing that reform "still needs to happen" but very little substantial action.

Nah the Health Insurance industry will simply throw massive lobbying dollars behind getting the "pre-existing condition coverage" provision removed. Which is much more likely to pass than universal medicare coverage. In a best case scenario if the mandate gets overturned would be that Congress re-writes the law in such a way that it is not subject to be challenged, i.e. a "Medicare tax" that individuals who have health insurance get a credit for.

What lobbying dollars? In all honestly, the profit margins for insurance providers aren't as massive as you'd think. Modern treatments are extremely expensive, and having millions of young and/or healthy people removing themselves from the insured pool will deplete every insurance provider's cash reserves extremely rapidly. Insurance companies might simply get out of the healthcare game before they hemorrhage too much money. After all, people still need car, home, and business insurance, and it'll still be possible to make money on those.

Profit margins are a trick. The same trick oil companies try to use to get us to feel sorry for them. When you are raking in hundreds of billions of dollars it doesn't matter if your "profit margin" is small because your profit in raw dollars is still huge. The insurance companies wouldn't take such a huge hit from the loss of healthy people since the bulk of health insurance is provided as an employment benefit anyway, so essentially it would go back to how it was pre-2009.

Additionally, to change the provisions of the law killing them, the insurance companies need a filibuster-proof majority of senators on their side. If SCOTUS overturns any portion of the law, especially in a 5-4 partisan ruling, the Democrats will be incensed at the blatant judicial activism and fight tooth and nail to get Obama back in office. The Republicans, OTOH, will not be as galvanized, as Obamacare is already (partially) defeated. They'll never get the majorities needed to kill any part of the law, so all the lobbying in the world isn't going to help the insurance companies.

But yes, the individual mandate can easily be worked around through a tax and an equivalent credit on everyone's Form 1040.

I don't know that I have as much faith in congress as you do. If people's premiums start to go up, or they lose their insurance then you'll see that provision fold pretty damn fast.

[Sea Skimmer]

Probably a more recent, relevant Supreme Court ruling, though, is Gonzales v. Raich, of 2005. Specifically, that ruled that the Commerce Clause allows allows Congress to prohibit people from growing medical marijuana for personal use, even in states where such is allowed. If something that isn't commerce can be regulated by the Commerce Clause, then why shouldn't healthcare (approximately 1/6th of the US economy) be subject to Congressional regulation?

Because growing marijuana is an activity, while not buying health insurance is not. Two different things. Also the supreme court already ruled more the once that activity that is not interstate in nature can be regulated if it is necessary to uphold a wider scheme of interstate regulation. This is how numerous drug and firearms laws were upheld long in the past.

[Grumman]

Well, the quickest way to acheive a single-payer model is, ironically, that SCOTUS, in its ruling, removes only the individual mandate. Since insurance companies will still have to cover preexisting conditions, vast swaths of people will only buy insurance when they have a catastrophic health emergency. Since millions of healthy people won't be paying premiums, insurance companies will have to raise premiums to astronomical levels, and even then, it won't be enough. They will instead go out of business, making it impossible to get health insurance through private companies in the United States. The public then throws a shitfit, Congress has no choice but to grant universal coverage through Medicare.

Quickest, perhaps, but completely unethical. If the government needs to resort to such tactics to do what it wants, that should be a pretty clear indicator that it shouldn't be doing it.

[Simon_Jester]

...Who says this is deliberate?

Obama and friends obviously think there's no constitutional problem with their own law. If the Supreme Court does, and the result is chaos for the insurance industry... well, to be honest, I think the insurers made their bed and should be forced to lie in it.

The fraction of Americans who think something is very wrong with American health care is growing, and isn't going to stop growing. Sooner or later, the actions of a democratic government have to reflect that sort of trend- America does not exist for the benefit of health insurance providers. If the Supreme Court strikes down the only method anyone can think of that the insurers like (everyone has to pay them, in exchange for them actually taking care of people), then the state will ultimately wind up coming up with another way the insurers will like less.

[kc8tbe]

On pre-existing conditions, you might find this article interesting:
Basically, it argues that the economic reason why pre-existing conditions are blocked isn't because those people are too expensive to insure, but because they are too smart to insure.

In other words, they know their projected healthcare costs better than most people, having experienced much more of it.

With this knowledge, they can calculate the projected cost of out-of-pocket payments vs insurance premiums. If the premium is less expensive, they'll do it. If not, they will just pay out of pocket.

The insurance companies do this same math, but on the other side. They want to make a profit, so only if the premium is more expensive will they want to make the sale.

If you raise premiums, it doesn't actually make the company more money, because these people will just do the math again.

It makes beautiful sense, but I never considered it this way until I saw that article.

No, this does not make sense unless you are so fabulously wealthy that you can afford to spend upward of $1 million on your own healthcare. Although most insurance plans cover (and under Obamacare are required to cover) routine preventative care, i.e. your annual checkup, under the maxim of "an ounce of prevention is worth a pound of cure", this isn't the true reason for insurance. Sure, paying for my annual doctor's visit out of pocket would be less expensive than a co-pay + insurance premium. But that insurance premium also buys me coverage if I develop something unexpectedly expensive, i.e. cancer.

[kc8tbe]

What exactly is your point? Earlier you claimed:

Basically, it argues that the economic reason why pre-existing conditions are blocked isn't because those people are too expensive to insure, but because they... can calculate the projected cost of out-of-pocket payments vs insurance premiums. If the premium is less expensive, they'll do it. If not, they will just pay out of pocket.

While consumers of health insurance may in fact behave this way (I would be interested to see data), it is a stupid way to behave. To use the example from the article:

A patient who expects his expenses to cap out at just a few thousand dollars won’t sign up [for health insurance]—for him, the coverage isn’t worth it.

Only an idiot budgets for insurance based on expected costs. I mean heck, I don't expect my house to burn down this year, but I buy house insurance anyway because otherwise I'll be really screwed if it does.

For example, a diabetic might realize that it is cheaper to spend $8,000/year on insulin out of pocket than it would be to pay for a $10,000/year health insurance plan that covers insulin. The expected costs makes going without health insurance seem like a good idea. But what if our diabetic unexpectedly develops a leukemia with high odds of cure using a $100,000 - $1 million bone marrow transplant? Most people couldn't possibly afford such a procedure out of pocket. Bang, you're dead. The extra $2,000/year for health insurance would have protected our diabetic from this catastrophic risk.

[SirNitram]

That said, Alfred, lobbying is pretty cheap compared to corporate profit margins, or even the collective personal savings accounts of insurance executives. The real problem faced by enemies of the law is just that actually repealing Obamacare is going to be hard, and it's only going to get harder as more people find themselves relying on it. The only reason there's any threat to it is because there is, honestly, a serious constitutional question about whether the federal government can require you to purchase health insurance on pain of fines.

I'm not expressing any opinion on that question at the moment- I'll keep that to myself. But I think it's a little disingenuous to pretend that it isn't a question that merits a hearing in the judiciary, because the federal government never actually came out and said "all citizens must pay for X or pay for the luxury of not paying for X" before to the extent that they do with the new health legislation.

I believe all males between 18-45 were once required by law to purchase a firearm from a private company. Of course, that was 200+ years ago, but it's pretty much the same idea as this.

Probably a more recent, relevant Supreme Court ruling, though, is Gonzales v. Raich, of 2005. Specifically, that ruled that the Commerce Clause allows allows Congress to prohibit people from growing medical marijuana for personal use, even in states where such is allowed. If something that isn't commerce can be regulated by the Commerce Clause, then why shouldn't healthcare (approximately 1/6th of the US economy) be subject to Congressional regulation?

Amusing, this ruling(IIRC, written by Scalia), was a key argument by Obama's lawyers in this. However, I have lost faith in SCOTUS to actually give a shit about such things as precedent and similar.

As for the theory brought up by Destructiontor, it's plausible, but I'm not that optimistic.

[SpaceMarine93]

On the agenda - how do we break up the monopoly of Insurance Companies on US healthcare?

[Patrick Degan]

Seems the Supreme Court is fucked no matter how they rule on this issue. If they attempt to strike down just the individual mandate and keep the remainder of the law intact, they'll be forced to do so by the most tortured readings of both the Commerce Clause and legal precedents stretching back nearly 80 years and extending right up to the Gonzales case. But then they open the door to skyrocketing insurance costs and the destruction of the profitability of the entire industry and the companies won't like that one bit. Ironically, it's easier for them at this point to actually have the present law in place and completely intact, especially as it staves off for at least another three decades a drive for universal coverage. Likely they'd —to protect their own profitability— be clandestinely behind any drives at state and even Federal level to circumvent such a ruling for which the Court would have further destroyed its own institutional credibility while giving Obama plenty of ammunition for his reelection campaign, given existing public anger toward this Court over Citizens United. OTOH, if the Court strikes down the whole law, they not only guarantee Obama's reelection along with the possibility of an ironclad turnover of Congress into Democratic hands in the wake of such blatant judicial activism, but in doing so they would throw a huge shadow on a whole body of regulatory law which has been based around a broad interpretation of the Commerce Clause, which would cause governmental and legal chaos with ripple effects extending to large sectors of the economy in turn, and again the health insurance industry face the prospect of their profitability evaporating away. Striking down the whole law would be insanity and there have to be at least two of the conservative justices that aren't at all comfortable about such a prospect. And then, if they rule to uphold the AHCA in toto, the Court winds up under ever-increasing Republican political attack, and likely Obama is reelected anyway with the public vindication of his reading of constitutional law combined with the fact that the provisions of the law are actually benefiting more and more Americans as they kick in on schedule. SCOTUS may have to eat that shit sandwich as the only viable option for not possibly destroying the health insurance industry while also not turning commerce law into total chaos and vote to uphold. Expect in that case a very florid and elaborate dissenting opinion by Scalia, possibly joined by Kennedy, to attempt to undermine the credibility of the ruling —particularly if it comes down 5-4. The wildcard factor is the degree of partisanship of this Court and how far it would actually eclipse common sense, and the idiotic questions put forth by Scalia and Kennedy in oral arguments don't exactly inspire confidence.

[Grumman]

On the agenda - how do we break up the monopoly of Insurance Companies on US healthcare?

The first and most important step I suggested during the lead-up to this law was to take the current tax deduction for employer-sponsored health insurance and extend it to non-employer-sponsored health insurance. This would remove the 20-30% head start given to one specific insurer, as well as making it easier for the self-employed and employees of small businesses to buy health insurance.