Tuesday, December 29, 2009

The Obligatory Healthcare Post

The school year is over, as is Christmas, so it is really time for me to start posting again before school resumes. So, healthcare has passed the Senate and awaits reconciliation. My comments on the subject:

No, this isn't perfect. You don't get everything you want. Deal with it. Instead of a single payer, we get something like the Swiss healthcare system, in which everyone is required to purchase health insurance, insurance companies are required to offer the same basic services to everyone regardless or age or condition, and the government offers subsidies for people who can't afford premiums. To throw the whole system out and stick with the status quo because it isn't everything you wanted is a classic exercise in cutting off your nose to spite your face. Senators Feingold and Sanders understand this; so should the left blogosphere.

Whatever emerges out of conference committee will not have a public option and will disallow federal funds for abortion. That's the price of getting it passed. Deal with it. As for other contentious issues, the houses will doubtless find some sort of compromise on expenditure formulas. I do not pretend to know enough to judge the relative merits of the different financing systems. I am mostly interested in two issues. The long-term survival of the system could depend on either.

The first is whether exchanges should organized by the federal government or the states. As a law student, I can confidently say by the federal government. Why? Certain conservative have long denounced the whole system as an unconstitutional extension of federal power. Mockers have answered, so what do you plan to do about it, nullification. The obvious answer is no, a Supreme Court challenge. If the federal goverment requires states to set up exchanges, the current Supreme Court might, indeed, find that provision unconstitutional. In the case of New York v. United States, the Supreme Court has held that the federal government may not "commandeer" states do administer programs it sets up, but must do so itself. Requiring states to set up interchanges sounds very much like unconstitutional "commandeering" and could very well be struck down. And without interchanges, the whole system will fail.

The other critically important issue is when the whole thing is implemented. The delay in implementation is basically an accounting gimmick to conceal the true costs of the bill because Blue Dogs are afraid to vote for anything too expensive, but accounting gimmicks are not a good method of fiscal responsibility. To delay relief to someone in need of health coverage now for the sake of an accounting gimmick is lousy policy. It is even worse politics. In the end, if there is one thing the public hates more than deficits, it is any serious attempt to get rid of them.

But above all else, the benefits under the system would do well to vest before the 2012 election if Democrats want the whole reform to survive. Republicans will pull out all the stops and unleash all hysteria in the 2010 elections. Undoubtedly they will pick up seats. They may very well repeat 1994 and win majorities in both houses. But barring truly extraordinary events, it is unlikely that they will win 2/3 majorities in both houses. That means Obama will be able to veto any attempt to repeal the health care bill.

Granted, passion on the subject will probably die down after a while when the bill passes and nothing catastrophic happens. But if the benefits do not vest by 2012, Republicans can always ramp up the hysteria in that year by warning that the bill is about to take effect and only we can stop it. Consider what the 2012 election could sound like. Republicans will warn that if the Democrats win, healthcare reforms will vest next year lead to the end of liberty as we know it, complete government takeover of healthcare, Communist tyranny, death panels, euthanasia of seniors, T-4, Soviet tanks in the streets, cats and dogs living together, etc. Democrats will warn that if Republican win they will block health care reform from vesting and you won't get all those benefits we promised you back in 2009. It isn't hard to see which is the stronger argument.

By contrast, if the exchanges are actually up and running in 2012, it will be extremely difficult for Republicans to convince anyone that liberty has ended, death panels are murdering seniors, Soviet tanks are occupying the country, cats and dogs are living together, etc. Instead, Democrats will tell people that Republicans want to take away their health insurance. It will be a tad bid awkward for Republicans to tell people who have purchased policies with government subsidies that their doing so has ended liberty as we know it, and that if we don't take away their insurance, the country will degenerate into a Communist tyranny. More likely, they will issue unconvincing and easily refuted denials that they ever saw the whole thing as a problem.

And if this doesn't convince Democrats, consider an alternative scenario. Republicans take power in 2012 and do nothing at all to stop the exchanges and subsidies from vesting. When people without insurance start buying coverage, Republicans will take credit for the program and say it proves they are so much better at delivering healthcare than Democrats. Don't put it past them.



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