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Sharp questioning in oral arguments before the Supreme Court raised serious questions about whether the “individual mandate” — the requirement that people carry health insurance — will survive.

At issue is Obamacare’s central requirement that every American buy health insurance or pay a penalty. Critics say this is an unprecedented expansion of federal power — that if the government can force people to buy insurance, it can force them to buy anything.

Supporters, including me, say the mandate is just a logical extension of federal authority to regulate this market — a market that everyone eventually participates in at one time or another. We also know that if the mandate is struck down chaos is inescapable.

Under one scenario, the court would invalidate the requirement while leaving the law’s many other rules and regulations in place.

In that event, insurance companies would have to insure anyone who asked for coverage — but they would be barred from charging premiums equal to a best guess of what the new customers will cost.

Limiting how much insurers charge can work, but only if the mandate is in place — if everyone, the healthy as well as the sick, has to have insurance. It can’t work if people can go without insurance until they get sick and only then call up their friendly insurance broker and say “Cover me.”

So, Congress would have to do something. But what? One option would be to repeal the parts of the law that the Supreme Court left standing. Finding the votes to repeal the health reform is unlikely, as the next Congress is almost certain to be closely divided.

A second option would be to do nothing. But that can’t work — not for long.

Many people would drop insurance coverage and come back to buy it when they get sick. That outcome would doom insurance, insurers, or both. Premiums low enough to be affordable would not cover insurers’ costs. Premiums high enough to cover the insurers’ bills would be exorbitant.

And what if the Supreme Court throws out the whole bill?

That would leave America, including the nearly 50 million uninsured, even worse off than we were four years ago: with higher costs, more uninsured and a political atmosphere poisoned by the failure of an all-out effort to reform a health care system everyone knows is flawed.

Health insurance costs, driven by the steady march of new technology and population aging, will claim ever larger shares of our income. Those higher costs will make health insurance unaffordable for more and more people.

It would be hard to imagine any President or Congress returning for a generation to touch the endless political grief of basic health care reform with a ten-foot pole.

Is that the future we want?

For that reason and despite its unpopularity, the best possible outcome would be for the Supreme Court to find the requirement that people have health insurance constitutional. The health reform legislation is very far from perfect. But the right thing to do is to fix it, not scrap it.

Henry J. Aaron is a senior fellow of economic studies at the Brookings Institution. Aaron focuses on the reform of health care financing; public systems such as Medicare and Medicaid; Social Security; and tax and budget policy. This piece originally appeared at the Brookings Institution.

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49 Responses for “Scrapping Obamacare Would Be an Rx for Chaos”

  1. Steven E. Waldren, MD says:

    “Make the easy choice”

    Nice precedent for the Supreme Court.

  2. Bill S says:

    According to the gov’t everybody is in the market already, so why didn’t they make it mandatory at point of sale? That is harder to contest if services are being rendered. Again, the SG insisted everyone is already in, so you’re not “waiting” for anyone.

  3. Maggie Mahar says:

    I agree. The Affordable Care Act is far from perfect, but the right thing to do is to fix it, not scrap it.

    Inevitably reform that is this large and this complicated is a process, not an event.

    Overturning the law would create great uncertainty– and chaos.

    • BobbyG says:

      I don’t think the public or most pols have the first clue regarding how much goes down with the ship here, stuff having nothing to do with the Individual Mandate.

  4. DeterminedMD says:

    Really, what Democrat representative is actively speaking out to fix it!? What, your pals Pelosi and Reid? After they had to quit giving out waivers, what did they then promote to fix.

    Oh yeah, their next elections!!!

  5. Nate Ogden says:

    I notice you never actually worked in insurance, with that in mind I guess its possible your unaware that there is right now numerous plans across the country that community rate, the same mechanism required under PPACA. So how have those plans survived for decades without a mandate?

    “That outcome would doom insurance, insurers, or both.”

    If you knew the insurance market at all you would know only the individual market would be destroyed. It wouldn’t even effect the self funded market which is 60% of private insurance. More business would move self funded and everything would continue on with no problem.

    “That would leave America, including the nearly 50 million uninsured, even worse off than we were four years ago:”

    PPACA increased both cost and the number of uninsured, repealling it would lower cost and decrease the number of uninsured. If we could actually get government to leave the market alone for more then a year or two it could solve the problem on a long term basis.

    “Health insurance costs, driven by the steady march of new technology”

    If government would stop with the mandates and demanding insurance cover everything the market could sell policies that cover 2000 level care. It might cost us one to two months of life expectancy but it would be affordcable. If we went back to 1990 technology we would save billions.

    “The health reform legislation is very far from perfect. But the right thing to do is to fix it, not scrap it.”

    “It would be hard to imagine any President or Congress returning for a generation to touch the endless political grief of basic health care reform with a ten-foot pole”

    So they wont touch it to redo it but they will touch it to fix it? Unlikely.

  6. DeterminedMD says:

    And by the way, the public does not fully understand the strengths and weaknesses of this legislation, and there are some strengths. But, you can’t mandate people buy things. You can’t muscle the states to do federal biddings. And you can’t have 15 people set policy for 300 million people without accountability.

    Personally, anyone who just argues these three points are fine and dandy are idiots, tyrants, or just selfish bastards. Hmm, maybe all three!

  7. Agis says:

    The Obama administration chose to pursue the goal of increased access before pursuing the goal of cutting costs. PPACA does not, in my opinion, do enough to rein in these costs. As a result, the individual mandate has ended up costing more than it otherwise would have. People who are poor but not poor enough for subsidies will still be forced to choose between food and healthcare. http://newindependentwhig.blogspot.com/2012/03/on-health-care-reform.html

    • BobbyG says:

      “the individual mandate has ended up costing more than it otherwise would have.”
      __

      Can I borrow your time travel machine?

      • Agis says:

        Obviously, if PPACA had made a stronger effort to contain costs, this would have resulted in the individual mandate being less costly. PPACA fails in cost containment by (a) allowing for-private health insurers to administer reimbursements, (b) refusing to negotiate with big Pharma for reduced price medicines, (c) failing to set reasonable prices for all medical procedures.

        • Nate Ogden says:

          Who should administer reimbursements? And what benefits are you referring to? I administer benefits and I am not for profit private health insurer. Don’t seem to know what your talking about.

          • Agis says:

            Regardless of your opinion of Medicare, it is notable that their administrative costs are only 2%. These costs are over 20% among for-profit private insurers. When multiple private insurers distribute payments for medical claims, multiple and redundant bureaucracies will result.

          • Nate Ogden says:

            As I mention below your an idiot. Medicare is not 2% its not even close. You would need to take ignorance to a whole new level even Maggie hasn’t reached to claim Medicare admin is 2%.

            Your % are wrong
            Your comparison is flawed
            You ignore the end results and the basic question if the lowest possible admin cost is the ideal outcome.

            Your taking this argument back 10 years. No one has claimed something this stupid in that long…because it was disproven that long ago. What rock have you been buried under for all these years?

          • Nate Ogden says:

            http://timerealclearpolitics.files.wordpress.com/2009/06/admincosts1.gif

            Medicare Admin per member $509
            Private Ins Admin per member $453

            10 times more effective huh Agis?

            try 12% more expensive and far in-superior. Add $700 lost to fraud on top of that $509 admin fee. Your looking at $1209 compared to $453.

  8. MD as HELL says:

    Let the chaos begin.

  9. How about order out of chaos? Since everyone agrees that the federal government has the constituional right to tax and distribute benefits why not just extend Medicare insurance to everyone over 18 years old and produce the ‘single payer system” that the majority of providers say they want? Let the health care inusrance companies scramble for the rest and contract for the administration of the system.

    • Nate Ogden says:

      Because Medicare is alredy 40 trillion in the red. Why would we add 100 million more people to an already unsustainable system?

      As far as providers wanting Medicare when I try to pay them Medicare +20% instead of using a PPO that is not the responce I get. Trying to get a hospital to take anything under 200% of Medicare is nearly impossible.

      • BobbyG says:

        “responce”?

      • To make it sustainable. To extend the pool beyond elderly and sick patients, and to collect some real money into it, so you can pay hospitals a little more.

        • Nate Ogden says:

          How does adding more people to a broken system make it sustainable? If CMS is actively trying to push the over 65 off Medicare into private insurance how does pushing all those post 65 plus pre 65 fix their problems?

          For Medicare to assume those currently on private insurance you would see an immediate double digit jump in rates.

          That is assuming Medicare paid hospitals current Medicare allowable for these new patients. Hospitals say this is not possible and your saying you want to pay hospitals more. If Medicare paid hospitals private insurance rates you would be looking at a 20% increase in premiums right off the top.

          • How does adding healthy paying customers to private pools make them sustainable?

          • Nate Ogden says:

            so Medicare is going to cherry pick and only take the healthy ones?

            After paying claims there is 5% profit for insurance, add another coupel percent medical could save eliminating some marketing expenses. Lets be real generous and say Medical could reduce cost 10% over private insruance which would be roughly $350 per year.

            Medicare loses $700 per year to fraud. That best case scenerio $350 savings is now a $350 guaranteed loss.

  10. Maggie Mahar says:

    Hub Mathewson

    The problem with trying to convet to a single-payer system is that many people like the private insurance they have– which in some cases is actually better than Medicare–and don’t want to give it up.

    I, for instance, have insurance witih no annual limits and no lifetime limits on coverage. Medicare imposes limits on how much it will pay it. If you go over the limit (which is not that hard to do) you most spend most of your savings–and perhaps sell your home– before you qualify for Medicaid. And then you will probably have to switch doctors becuase many docs don’t take Medicaid.

    My insurance also has no deductible. The out of pocket costs of Medicare
    have soared, and most people are surprised, when they turn 65, to find out how expensive it is. Even if you are paying for Medicare Advantage to supplement Medicare, you can easily have a $35 co-pay to see a specialist.

    The people who are lucky enough to have really good private insurance are
    generally wealthier and healtier than the majority of Americans. Either they work for a large company with deep pockets and generous insurance, or they
    are able to pay $6,000 or $7,000 a year , out of their own pocket, for a plan that covers just one person.

    They would not want to switch to Medicare for all. (Probably, under the law, you could force them, but I doubt you could ever get the votes in Congress.)

    So Medicare for all would wind up covering the poorer and lower-middle-income people who are sicker than the rest of us. This would make it an expensive pool, and the coste of Medicare would become more than taxpayers could finance.

    Yes, Medicare’s administrative costs are lower, but according to CBO, that means that a family plan under Medicare would cost about $1500 less. Meanwhile, the cost of buying MediGap or Medicare ADvantage to fill in the many holes in Medicare would probably eat up that $1500.

    Finally, Medicare is so expensive (much more expensive than insurance in
    European countries) because there is so much waste– thanks to the lobbyists, it covers a great many procedures, tests and products that provide little or no benefit to the patient.

    Over time, the Affordable Care Act can squeeze out at least some of that waste, and then I hope we will have a public option that offers better care for less. Who knows, we migiht even swith to a single-payer govt system, but it’s worth noting that countries in Europe all have a private/public hybirid system.

    Private insurers are regulated–but they are part of the system. Only the UK and Canada have single-payer, and outcomes suggest care is not as good as in France, Germany, etc.

    • Nate Ogden says:

      Doesn’t the $700 per member Medicare loses to fraud exceed the entire administrative cost of private insurance per member?

      • Nate Ogden says:

        point being my administrative cost would be much lower if I just paid every bill anyone sent me.

        It’s a very slippery slope to claim Medicare admin cost are lower. Apples are cheaper than oranges, but what does that mean?

    • Agis says:

      In Switzerland, basic health care is available to all. People who want “better than basic” can pay for a plan that includes things like private hospital rooms etc. This solution could your concern about some people having private insurance that is superior to what they would receive in a public system. Some people could still have so-called “Cadillac” plans, but everyone would have basic health care.

      • Nate Ogden says:

        Switzerland is a few million white people. Do you see Utah or Idaho having nearly the crisis as other states?

        • Agis says:

          If you are implying that a “white only” country and (essentially) white only states can manage health care effectively, that position is so despicable that it hardly deserve a reply. France is an example of a multicultural society with one of the best health care systems in the world. States with low population densities will not have the same conspicuous problems (e.g., number of people with expensive-to-treat chronic conditions) as other states.

          • Nate Ogden says:

            Let me get really despicable, if it was all Asians it would be even more cost effective.

            I read you link through you screen name and am now 100% certain your an idiot and don’t know what your talking about.

            Regardless of where they leave different races have different health predispositions. If you put a population of pure Africans in a Swiss or any other model they would have different outcomes then a pure Asian population. Nothing despicable about facts unless you have something against the truth.

            genetic illness, body type, etc etc all are predisposed, nothing racist about it, its just reality.

            On top of that add culture and your comparison was even dumber. Exercise, eating, priorities are just a few examples of non system related effects on healthcare spending.

            if we traded salty fried food for steamed rice we would all be healthier and spend less on healthcare. That is not a symptom of our system.

  11. DeterminedMD says:

    “…we will have a public option that offers better care for less.”

    Excuse me, but does the adage “you get what you pay for” apply to anything that Democrats, or for that matter equally what republicans have offered when they were the only game in town?

    I love the denial and delusion that these defenders and apologists continue to sell in promoting and, really the way some people are talking now that their pipe dream of the legislation being approved by 7 or 8 Justices prior to this week is now dissipating, now trying to rudely and cruelly demean as the odds of PPACA surviving the Supremes’ vote in three months are not Vegas easy bets.

    Again, if this legislative effort was so wonderful and embraceable since March 2010, why did no Republicans sign on after some time and why are parts now being discarded? Here’s the lesson America, don’t let people in positions of authority tell you to blindly trust them and expect results to be uncontestibly wonderful and without consequence.

    You get what you pay for, if the insurance is cheap, then so will be the care.

    How many of you go to the auto shop advertising an oil change for $1.99?

    Thought so.

    • Lots of people who don’t read blogs would go.

      The reason we cannot have universal health care in this country is because we need to create it without disturbing the rich and powerful, both on the left and on the right.
      The rich on the left would be just fine with everybody (other than themselves) enjoying the plentiful cornucopia of knockoff medicine at Walmart, and the rich on the right would be just fine with everybody lining up for charity, or dropping dead naturally.

      • DeterminedMD says:

        Nah, I disagree with your perspective, the rich on either side of political perspective want people to drop dead, because let’s face it, rich people are as narcissistic and selfish as addicts can be and don’t give a rat’s ass about anyone else but themselves and their cronies.

        Universal health care can only come to fruition if the sizeable majority of Americans accept the fact that people will die prematurely because, wait for it Ms G-A, the FINITE resources that are health care will deny some who appropriately deserve the access will still in the end be denied. And what honest, caring, invested community individuals will instinctively accept that premise?

        Hey, I see people every day who are invested and will follow through with standards of care as asked, until such standards should fail if proven otherwise, but can’t access it financially or prioritize it realistically. Our culture is unfortunately about limits and Darwinian principles. But, who wants to accept the truth? Just ask the usual suspects telling us PPACA is unfairly being judicially reviewed!

    • Agis says:

      No Republican voted in favor of the legislation because of party discipline. I daresay some of these Republicans had been supporters of the Republican-sponsored health care reform proposal of 1993 that is nearly identical to PPACA. I am no fan of PPACA, but I recognize that Republicans are putting partisan politics ahead of solutions.

      • DeterminedMD says:

        Yeah, partisan politics was some of it, but it was lousy legislation from the get go, so you look a bit good not being forced to vote just to benefit the few. As long as this alleged 2 party system of hate stays in place, the public is tarnished!

  12. Maggie Mahar says:

    Nate–

    Private insurance loses as much to fraud as Medicare–if not more.

    Private insurers ackowledge that they can pass the cost on to customers in the form of higher premiusm. (I write about this in my book, Money-Driven Medicine.)

    Medicare can’t pass the cost on to anyone
    unless it can persuade Congress to raise Medicare taxes, deductibles or co-pays which is never popular politically. So Medicare takes fraud pretty
    seriously– though it doesn’t have as money as it needs to investigate
    fraud.

    Medicare administrative costs ARE lower–but not as much lower as
    many claim.

    The big problem in that in our fragmented system we have so many small doctors’ practices and small hospitals that insurers’ must bill
    separately. (In countries with fewer hospitals that are larger, administrative costs are lower. And when doctors are banded together into large groups, the costs of billing are much lower– economies of scale.)

    Finally, all of our providers wind up filling out different forms for different insurers. It’s not at all clear why the insurance industry couldn’t standardize forms. One thing docs like about Medicare is that it’s just
    one form, and pretty easy to fill out. What’s covered and what isn’t is pretty cut and dried.

    • Nate Ogden says:

      “Private insurance loses as much to fraud as Medicare–if not more.”

      BOLD FACE LIAR you could not be any more incompetent in your writing. You have reached the point you just wholesale make up arguments without even trying to be honest. Then have the gale to claim writers should be truthful. You can’t find any piece of data to even come close to backing up that claim.

      “Medicare can’t pass the cost on to anyone”

      Really so tax payers don’t have any liability for Medicare?

      “So Medicare takes fraud pretty seriously”

      Keep digging, these fish stories keep getting better and better.

      Medicare paid dead physicians 478,500 claims totaling up to $92 million from 2000 to 2007. These claims included 16,548 to 18,240 deceased physicians. (U.S. Senate Permanent Committee on Investigations, 2008)

      Nearly one of three claims (29 percent) Medicare paid for durable medical equipment was erroneous in FY 2006. (Inspector General report, Department of Health and Human Services, 2008)

      Medicare administrative costs ARE lower–but not as much lower as
      many claim.

      But, as you might expect, when you compare administrative costs on a per-person basis, Medicare is dramatically less efficient than private insurance plans. As you can see here, between 2001-2005, Medicare’s administrative costs on a per-person basis were 24.8% higher, on average, than private insurers.

      So, contrary to claims of Alter, Krugman, and President Obama, moving tens of millions of Americans into a government run health care option won’t generate any costs savings through lower administrative costs. Just the opposite.

      “all of our providers wind up filling out different forms for different insurers.”

      BS how can any one be so ignorant and get paid for talking on the subject. HCFA 1500 UB 92 are 90% of all claims. And that is when most claims were billed on paper. Majority of claims are now submitted electronically and there are zero forms. Its not 1990, its time to wake up and stop your constant lying and misinformation.

      Do you even have an honest bone in your body? None stop lie after lie from you. And it only takes 30 seconds on yahoo to prove your full of it.

      Milliam Study

      Conclusion. Medicare at first glance appears to have lower administrative costs than the private sector. But there are several caveats that make untenable an easy comparison between Medicare and the private sector — as private sector critics like to do. Most of what are considered administrative costs in the private sector are not
      captured by official Medicare accounting. So the investigators in this study tried to estimate how much it would be from other parts of the federal budget. Second, there is an assumption that administrative costs are bad. The fact is that only inefficient administrative costs are bad. Insurers regularly scrutinize claims forms and
      check with health care providers if they find an error, discrepancy or what they believe to be an unnecessary treatment. That raises administrative costs, but it also lowers claims costs. That is a benefit for those insured because it helps keep premiums lower. Moreover, that regular scrutiny has an impact on providers’ behavior, helping to discourage the small percentage who might try to game the system to increase their
      income. In other words, efficient administrative oversight alters behavior, and the cost is almost certainly recovered in lower premiums.
      Finally, because Medicare on average pays out more per claim, it distorts the administrative cost ratio. If both the private sector and Medicare paid out roughly the same on a per-claim basis, private sector hard administrative costs would likely be close. However, thethe issue is not and should not be which segment, private sector insurers or
      government-run plans, has the lowest administrative costs. The issue should be whichdoes the best job of providing quality health insurance coverage for the best price. When one looks at all of the money pouring into Medicare, even with the price controls imposed by the government, the answer has to be the private sector.

    • Nate Ogden says:

      Medicare administrative costs ARE lower–but not as much lower as
      many claim.

      http://timerealclearpolitics.files.wordpress.com/2009/06/admincosts1.gif

      2005 Medicare cost to admin per member $509.00
      Private insurance cost to admin $453.00

      Medicare 12.3% higher. Do you know what the word lower means?

    • Nate Ogden says:

      Private insurance loses as much to fraud as Medicare–if not more.

      So Medicare takes fraud pretty seriously

      http://abcnews.go.com/blogs/

      But there’s a bigger point – the connection between “low” administrative costs and staggeringly HIGH levels of fraud and waste. As Michael Cannon at the Cato Institute and Regina Herzlinger at Harvard Business School have pointed out, much of the 10 to 20 percent of private insurance administrative costs goes to preventing fraud. Private insurers, you see, care about whether or not they lose money. Medicare, with its unlimited claim on the public purse, does not. It’s only taxpayer money, after all.

      The results are predictable, but breathtaking nonetheless: an estimated $68 billion (with a B) in outright Medicare fraud every year (About $3 billion in Miami-Dade county ALONE.) On top of that, according to well-respected Dartmouth researchers, roughly a third of Medicare’s total $400 billion annual spending goes to procedures which were medically unnecessary.

      That’s, on average, 68 billion every year. Imagine a private insurance company surviving with loss figures like that. But as Stossel points out, without an incentive to eliminate fraud and abuse, it continues year after year after year, with politicians and Medicare administrators tut-tutting but never really doing anything about it.

    • Nate Ogden says:

      http://online.wsj.com/article/SB10001424052702304760604576428300875828790.html

      Almost all discussions about Medicare reform ignore one key factor: Medicare utilization is roughly 50% higher than private health-insurance utilization, even after adjusting for age and medical conditions. In other words, given two patients with similar health-care needs—one a Medicare beneficiary over age 65, the other an individual under 65 who has private health insurance—the senior will use nearly 50% more care.

      You can’t make up that difference. Under no feasible scenario on earth is Medicare more efficient or cheaper then private insurance.

    • Nate Ogden says:

      Private insurance loses as much to fraud as Medicare–if not more.

      http://money.cnn.com/2010/01/13/news/economy/health_care_fraud/

      Increasingly, criminal groups are hacking into digital medical records so that they can steal money from the $450 billion, 44-million-beneficiary Medicare system — making the government, by far, the “single biggest victim” of health care fraud, according to Rob Montemorra, chief of the FBI’s Health Care Fraud Unit.

      Even the FBI says your a liar Maggie.

      So Medicare takes fraud pretty seriously

      One key reason having Medicare information is a virtual “goldmine” for fraudsters, according to Montemorra, is the system’s “pay and chase” system — under the law, Medicare must send out payments within a very short time period.

      He said private insurers are better at preventing fraud — although not immune from it — because they’re so much smaller.

      What is that Maggie, the FBI says private insurance is better at preventing fraud.

  13. Maggie,
    You sound like you have great health insurance which you buy and have the money to do so. Why couldn’t people who have the money to do so buy supplemental insurance under a Medicare single payer system and enjoy similiar benefits?

    Blaming high care medical costs under Medicare partially on the inlfuence of lobbyists raises the interesting notion that private insurance companies would be less vulnerable to lobbyists’ (stock holders’) influence. Do you really believe that?

    I cerainly agree that the ACA, current Medicare, and private insurance will have little effect on medical care costs.

  14. DeterminedMD says:

    I gotta just say this, thank god this case finally went in front of the Supreme Court this week, because the issue needs to be put to rest.

    Unless these 9 people take the cowardly way out and punt it down the road to others to take the heat. Wait a minute, that is the standard operational procedure that is D.C.!

    But, the ultimate truth is not quickly resolved, is it!?

    • BobbyG says:

      6-3 to Uphold. Maybe only 5-4, but maybe 6-3.
      __

      “…Virtually everybody agrees that a vote to strike down the Affordable Care Act would be five to four—a bare majority. And it would be a bare partisan majority, with the five Republican appointees overruling the four Democratic appointees. The decision would appear nakedly partisan and utterly devoid of principle. Appearances would not be deceiving.

      The second distinction is even more more significant. Today Brown is a nearly universal icon of social progress, while Roe remains an object of great controversy. But, for better or for worse, both cases represented efforts to change the everyday reality of American life. With Brown, the justices were tearing down barriers to racial equality; with Roe, the justices were eliminating laws that prevented access to abortion.

      But in this case, nobody has said they want to stop government from providing universal access to health care. On the contrary, the plaintiffs have stated that a program like Medicare, in which the government provides citizens with insurance directly, would be clearly constitutional. They’ve also stated that a scheme of compulsory private insurance would be constitutional if somehow the government could make people buy it when they show up at the hospital—suggesting, as Elena Kagan stated, that the only problem with the Affordable Care Act is temporal.

      Most amazing of all: The plaintiffs have conceded that a universal health insurance program would be constitutional if, instead of penalizing people who decline to get insurance, the government enacted a tax and refunded the money to people who had insurance. As Sonia Sotomayor noted, functionally such a scheme would be exactly the same as the Affordable Care Act. Both the plaintiffs and some of the skeptical justices have also indicated that the Affordable Care Act would be constitutional if the law’s architects had simply used the word “tax” to describe the penalty.

      Think about that for a second: If the justices strike down the Affordable Care Act, they would be stopping the federal government from pursuing a perfectly constitutional goal via a perfectly constitutional scheme just because Congress and the Preisdent didn’t use perfectly constitutional language to describe it. Maybe labels matter, although case law suggests otherwise. But do they matter enough for the Court to throw out a law that will provide insurance to 30 million people, shore up insurance for many more, and help to manage one-sixth of the American economy? It wouldn’t seem so.

      Of course, the conservative justices who would invalidate the Affordable Care Act may not hold the law in especially high regard. Samuel Alito, in particular, suggested during oral argument that he had serious problems with younger, healthier people subsidizing, via their insurance premiums, the medical expenses of older, sicker people—which just happens to be the defining feature of Medicare, Social Security, and every other social insurance scheme on the planet.

      Alito is entitled to his opinion about what makes for good legislation. But he’s not entitled to impose that opinion on the country and his colleagues aren’t, either. Their job is to determine whether a law is constitutional, not whether a law is wise. And the more significant the law, the more unambiguous their judgment ought to be.”

      http://www.tnr.com/blog/jonathan-cohn/102204/supreme-court-roberts-kennedy-health-mandate-legitimacy

  15. Maggie Mahar says:

    Hub Matthewson–

    I really can’t easily afford the isurrance. I spend about 15% of my income just on health insurance for myself.

    But for me, it’s a priority. (And I’m not suffering from any major chronic disease that I know of.. But if I suddenly am diagnosed with a serious long-term disease, I don’t want to lose my home. And I don’t want to leave my husband with no savings.

    In Europe, people are accustomed to spending 10% of their income for health insurance. It’s only in the U.S that empoloyer based insurance has led us to think that someone else should be paying for our healthcare.

    But while I can’t really afford this insurance, i’m luckier than most people.
    My husband and I earn somewhat more then the average middle-income joint income in this country (around $65,000 , joint ) Half of all all households earn less than that, joint. Half earn more. This is why I use this number to define middle-income

    You write: “Why couldn’t people who have the money to do so buy supplemental insurance under a Medicare single payer system and enjoy similiar benefits?”

    The answer is that families in the bottom half of incomes in this country couldn’t afford supplemental insurance. Many are raising children. They can’t make health insurance for themslves (or even their children) theier top priority.

    You add: “Blaming high care medical costs under Medicare partially on the inlfuence of lobbyists raises the interesting notion that private insurance companies would be less vulnerable to lobbyists” under the Affordable Care Act?

    Yes, the Affordable Care Act reduces Medicare’s annual payments to hospital by 1% a year–pushing them to become more efficent, reduce waste, and avoidable preventable errors.

    The legislation also gives the Secretary of HHS the right ot lower Medicare fees for “overvalued services” (which provide little benefit for patients ) while also raising fees for “undervalued services.”

    Private insurers have already said they will follow Medicare’s lead. They, too, wil pay less.Why wouldn’t they want to pay less?

    They know that Employers and individuals will no longer choose private insurance plans that charge more while over-paying.

    Medicare has already cut payments for diagnostic imaging, and we know that more cuts are coming for certain specialists’ services that medical reserach shows offer few benefits. More and more, Medicare and private
    insurers will only be covering certain procedures for certain patients–in cases where medical science shows that they will beneift.

    You can excpect to see the fees for angioplasties for paients suffering from “stable heart disease” and fees for low-back surgery for patients suffering from localized low back pain to fall. These are just two examples.
    Fees for surgeries or procedures that might gave the average cancer patient an extra two or four monhts of low-qualiy life also are likely to drop.

    Fees for palliative care, counseling patients on how they can help manage their own chronic diseases, and many types of preventive priamry care are likely to rise. But beause these doctors are now paid so much less,
    net, net, Medicare (and private insures) will realize significant savings.

    President Obama also has indicated that at some point in the not too distant future, Medicare will stop overpaying for a great many drugs if they
    don’t provide benfits that justify the very high price. The VA is already doing this–wiith great success.

  16. DeterminedMD says:

    “The VA is already doing this-with great success”. Yeah, what a great formulary, treating our veterans who fight wars for the politicians who started them by nickeling and diming true heroes with 30 year old generic drugs while the politicians access the newest and most innovative options.

    You gotta love these defenders who just echo these false hopes and dreams by their party loyalists who don’t practice what they preach.

    You know what, this week is revealing the game is up with PPACA. Hope and change, we just didn’t know the words between: “hope you’re ready for more of the same, forget change”. Just the ‘forget’ word is really two letters shorter with none of the same letters after ‘f’. You get it!

    Well, unfortunately Nevada really didn’t have much of a choice for real change in 2010, and SanFrancisco, well, they’ll vote for the idiot chick even after she is dead, but you never know when people wise up and surprise you. The problem is with the current occupant of the White House, there are no real alternatives there either.

    My advice, keep the Legislative branch under separate rule from whatever loses less to keep the Executive Branch in November. I guess we have to wonder if there will be more time after 2012 ends, eh?

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