Individual Mandate Struck Down? No?

I just heard this announced on CNN. The “individual mandate,” the center piece of the legislation has, according to CNN, been struck down as a commerce clause.

Now Wolf Blitzer is suggesting they may not be fully clear on what has been decided.

Chief Justice Roberts … on part 3 … may be upheld under the taxing clause.

Entire law has been upheld …

Blitzer: “huge, huge victory for the President.”

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  • http://www.andyrowell.net Andy Rowell

    Here is what it says at:
    http://www.scotusblog.com/cover-it-live/

    10:08

    Amy Howe:
    The individual mandate survives as a tax.
    10:09

    Amy Howe:
    It’s very complicated, so we’re still figuring it out.
    10:10

    Kali:
    We are still here. Don’t worry.
    10:10

    Tom:
    So the mandate is constitutional. Chief Justice Roberts joins the left of the Court.
    10:11

    Amy Howe:
    The Medicaid provision is limited but not invalidated.
    10:13

    Tom:
    The bottom line: the entire ACA is upheld, with the exception that the federal government’s power to terminate states’ Medicaid funds is narrowly read.

  • http://LostCodex.com DRT

    This could get get quite messy if the states can opt out, as it seems right now. Very interesting.

  • http://krusekronicle.com Michael W. Kruse

    I always thought the only way to justify the mandate was to position it as a tax, but I wasn’t sure if the Supremes would reckon it as such. Appears the answer was yes. I’m a little surprised by the ruling but not much.

  • NW

    Lol! Evidently, the mandate was considered unconstitutional under the Commerce Clause by a majority of the court so Roberts decided to rewrite the law for Obama by turning it into a tax so as to make it constitutional (not exactly the job of the court). The problem with this approach is that it introduces a new moral hazard into the legislative process. Politicians would love to pass things that they promise aren’t taxes only to have the court do the unpopular dirty work of turning them into taxes when the time comes to make sure everything is kosher.

  • EricG

    CNN clearly blew it — very embarrasing, the decision isn’t that confusing. A majority of the Court upheld the individual madate under the Taxing Clause (although not the Commerce clause). The only portion of the Medicaid provision that was struck down is the one that would require States to give up *all* Medicaid funding if they do not participate in the Medicaid expansion. Nothing else was struck down.

    What is most interesting is that both conservative and liberal Justices crossed “party” lines. Conservative Roberts voted to uphold the individual mandate, and Kagan voted against the Medicaid penalty provision. I think this lends credibility to the fact that this is a fair decision.

  • EricG

    NW — -Characterization of this as a tax isn’t an after-the-fact justification — it is even collected by the IRS for Pete’s sake, as the decision notes. Robers goes into more detail — I’d suggest reading that section.

    And Roberts isn’t the type of bend over backwards to create an after-the-fact justification like that.

  • NW

    EricG,

    “And Roberts isn’t the type of bend over backwards to create an after-the-fact justification like that.”

    Don’t insult my intelligence, he just did. The mandate was neither passed as a tax nor was it marketed as a tax regardless of who collects the funds (indeed, it was strenuously denied as being one), for Roberts to fly in at the last minute and proclaim it as a tax precisely when it needed to be one is the very definition of an after the fact legal fix.

    It may not be in Roberts’s character to do this sort of thing on a regular basis but the powers that be needed it to be done this time, and so it was. That’s how real politics works, intellectual consistency is routinely sacrificed when necessary.

  • Rick

    From Politico 9/21/09:

    “Obama strongly denied that the mandate amounts to a tax increase – saying it was no different than requiring people to have auto insurance and charging a penalty if they don’t.”

  • JoeyS

    To be fair, most of the people who comment on this blog won’t see a “tax increase” in the traditional sense. It isn’t a tax that is paid de facto, but what one that you can opt out of by making sound decisions about your healthcare in the private market.

  • Fish

    It’s basically a tax on those who make enough money to buy health insurance but chose to have the rest of us pick up their liability.

    A step in the right direction, but clearly the right answer is still single-payer… as in Canada, where I’d be happy to trade 6% of my income for way better health care than I’m getting now.

    I am getting all my prescription drugs from Canada. It’s cheaper to buy them there without insurance than to buy them here with insurance. As much as 80% cheaper, in some cases.

  • Dana Ames

    Yay!!! I am so glad!

    I think any Republican who complains about this law – the provisions of which they put forth not so many years ago – is shortsighted, to say the kindest thing I can think of.

    This is the first step to controlling health care costs, which, as I understand it, are the biggest element of our long term domestic spending difficulties. Now, hopefully on to some more in the way of sane reforms. There’s no reason we can’t ultimately do like they do in Germany, France and Switzerland – *not* “socialized medicine”, but a fair way to provide health care coverage for all their citizens, utilizing a “combination of ingredients”.

    I am stating my opinion and am not going to engage in any arguments with anyone. If others have a different opinion, that’s fine. I hope we can all agree that things can’t go on they way they have been with regard to this issue.

    Dana

  • http://LostCodex.com DRT

    NW, I don’t care if the called the money collection Steve, it is a tax.

    Imagine if all the politicians had to do was call something by a different name to get it around the supreme court. Now there would be a landmark decision. Your argument makes no sense.

  • EricG

    NW and others: So the IRS collects it, but it isn’t a tax? Hmmmm.

    JoeyS — the tax code is filled with taxes where “you can opt out of by making sound decisions . . . ” That is squarely within the typical use of a tax under the law.

  • MWK

    DRT # 12 – I’m looking outside for flying pigs, because I agree with you. This has always been a tax, but it never would have been passed as such, so they called it something else.

    NW – courts have the obligation to look at a law to see if it passes constitutional muster, regardless of what politicians say it is. This kind of decision is actually not that uncommon.

    FWIW – I actually think this decision is a good day for the constitution. A real threat to American’s liberties is through congress’ overreach of power through the commerce clause. That was limited today, which in my opinion, is a good thing.

  • Robin

    First, anyone that thinks this is going to control healthcare costs is delusional. There are no means of price controls in there. If you take a look at the stock market hospital and healthcare stocks are up, because everyone knows this will put more money in their pockets.

    Some of the guarantee issue requirements may eat into profit margins for insurance companies, but overall this does nothing to control rising healthcare costs, it just might change the distribution on who gets the tab.

    As a conservative, there are 2 things in this decision that excite me a great deal. First, it was explicitly found unconstitutional with regards to the commerce clause. I think it is accurate to say that this is the first time the Supermes have placed any hard limit on the commerce clause. The reason I thought it was unconsitutional since it was passed was that I just didn’t think the commerce clause gave congress the authority to force people into commerce against their will. The supremes agreed with that logic so any future mandates like this will have to be recognized as taxes…since mandates under the commerce clause are now clearly unconstitutional.

    Second, taking away the stick of federal funding withdrawal in the Medicaid portion is huge. The favorite method for the federal government to force states into doing things they don’t want is to say “if you don’t do X, we’ll strip funding for X and Y” now all they can say is “if you don’t do X we’ll strip the funding for X, but you still get to keep the funding for Y.”

    This will prove very important in the future when states disagree with the Feds on everything from drug legalization to gay marriage to EPA rules. I am ecstatic to see the states get out from under the threat of losing all federal funds.

  • http://LostCodex.com DRT

    At the risk of ruining my oinking streak with MWK, I want the right wingers to admit that they are now the ones who are against the constitution and the Obama administration is more supportive of it than they are.

  • Robin

    DRT,

    I take exception with that last statement. My primary concern with the mandate has always been that congress, and the president, claimed that the commerce clause gave them the right to force people into economic activity against their will. Roberts just declared that it doesn’t.

    To put it another way, Obama and congress claimed that since I will likely participate in interstate commerce for some things…they could compel me to participate in interstate commerce for things which I did not want to. That is a crazily broad reading of the commerce clause, and Roberts just rejected it, so I am happy.

    Broccoli is an overused example, a more reasonable one is firearms. If it is in the general public interest to have a well-armed citizenry (on epossible interpretation of the 2nd amendment) and congress has the power to compel economic activity…then they would also have the power to force every household to purchase a shotgun and rifle and the ammunition to load it…now they can’t.

    They can still give me a tax credit for my pistol, or penalize me through the income tax for failing to own a shotgun, but they have to be honest about it being a firearms tax.

  • Robin

    The conservatives arguments about the commerce clause were all found correct by the supreme court today, Roberts just found a way to get around the commerce clause.

    And in the long-run, the Medicaid portion of the ruling is going to be much more significant. The court just crippled the main “stick” the federal government uses in their dealings with states. 30 years from now people will focus on that aspect when they discuss this ruling.

  • JoeyS

    I get tired of simplistic claims that this bill will cost more money. Here is how much we are spending by not doing anything (which Republicans had 8 years to change and made zero attempts):

    In 2009 the average cost for a visit to the ER was $1,318 (Medical Expenditure Panel Survey). When folks can’t pay their bills these costs get passed on to others, which doesn’t make the bill go away. To compare, an average visit to my doctor costs me $167. One 2010 study shows that ¼ of all regular doctor visits (non-emergency) are made in the ER rather than with a primary care physician (http://content.healthaffairs.org/content/29/9/1620.abstract). That’s 88,500,000 ER visits a year. Of those, more than half are made by patients who have no insurance. That’s over 44,250,000 visits a year, with an average cost of $1,318 per visit, that gets passed on to other people and to our government amounting to a total cost of around $58,321,500,000 a year to care for the uninsured. These numbers are a gross simplification but demonstrate the cost of health care in our current system. And none of these costs go to preventative measures which would keep people healthy, ultimately saving more money.

  • MWK

    DRT – I’m no right winger, but your comment is a bit too silly to warrant a serious response.

  • http://LostCodex.com DRT

    MWK, perhaps I listen to and know too many far right wingers, but their claim all along with this has been that this is evidence that the administration is against, yes, actually against, the constitution. It is those folks whom I reference.

  • EricG

    Robin — you are correct that this is essentially a conservative decision in terms of key points of precedent it establishes. You might be reading the Medicare ruling too strictly, but then again possibly not — it will be for the lower courts to interpret for years to come.

    And you put your finger on the key question: What pressure points there will be over the States, without all Medicare funding at stake? Remains to be seen — lots of wrangling to come.

    Note, however, that it is not correct that “this is the first time the Supermes have placed any hard limit on the commerce clause.” Since 1995 they have been placing significant limits on that clause in multiple decisions, starting primarily with Lopez. The ruling today is a new limit, but it isn’t the first.

  • http://LostCodex.com DRT

    Robin,

    I can’t quite figure out what you are saying. Are you saying that Roberts disregarded the constitution and voted based on politics?

  • Robin

    EricG,

    I trust you no more about the limits than I do, it is just that everything I have seen today has called this the first real limit on Wickard.

    I also agree that the extent to which the “stick” of withholding funding has been crippled will be argued for years, and possibly decades to come. I work with Medicaid occasionally and prior to this states have had to get waivers from HHS to alter any service provision. It now looks like we have more bargaining power than we did yesterday.

  • http://LostCodex.com DRT

    JoeyS#19 is getting Oink points from me on that. The conservatives seem to have teed this up as a constitutional issue, and that they are not against the poor getting covered for health care. But now that the constitutional issue is cleared up it will be interesting to see how the framing goes.

    I am pretty certain that they will claim it is a financial issue and your analysis will come into play. But if they don’t bring that into play we will have a good idea that they are, again, blowing smoke.

  • Robin

    DRT,

    I am saying that Roberts disagreed with Obama and congress’ justification. He basically said “all those reasons that Obama and congress told you this thing was constitutional…yeah, they were completely off-base. If I went by their justifications, I would have to rule it unconstitutional. Luckily, I don’t have to pay any attention to their arguments, I don’t even have to pay attention to the arguments their own lawyers made before the supreme court. I can throw out all their justifications, because after all, the conservatives were right on the merits, but I can dust off this other justification that the administration never even bothered to bring up and save the day for them.”

    All of the arguments that the administration actually made before the supreme court were found to be unconstitutional.

    This was also the heart of Kennedy’s dissent. “Obama said it wasn’t a tax, congress said it wasn’t a tax. Even the legislation appears to say it isn’t a tax, and by the way, it operates way differently than most other income taxes. So if everyone agrees it isn’t a tax, and you agree that all of the administrations other arguments were bunk…then why should we believe that it is a tax?”

  • Robin

    Basically, Roberts upheld the mandate IN SPITE OF Obama’s justification and congress’ assertion of its authority, not because of it.

    Conservatives won the legal argument, but Obama won the policy battle on a technicality. (A technicality he vehemently opposed when suggested by George Stephanopoulos)

  • Robin

    All those quotes are me talking in my own head by the way, not actual quotes from anyone outside my cranium.

  • Robin

    I did see this as a constitutional issue, and on that front I am pretty happy with the ruling. I didn’t want congress to have the commerce clause powers they were claiming…and now they don’t.

    I do think that this is an expansion of congress’ taxing powers, and it will be interesting to see if they use them. I mean, I always knew that congress had the right to give me a credit or deduction based on my personal activity, but now they have the right to also hit me with a tax penalty based upon personal decisions.

    So I could already get a tax credit for purchasing an electric vehicle, and now I can be assessed a tax penalty for purchasing something that gets <20 mpg (just an example of what they could do).

    I never imagined I would be this happy with an outcome I disagreed with. I'm practically bubbly.

  • Tom F.

    In terms of rewriting the law, there is a well established principle on the Supreme Court where the justices are to find ANY way that a law could be constitutional, even if the law itself justifies itself in terms that would be unconstitutional. Therefore, the Supreme Court “rewriting” the law is actually doing exactly what it is supposed to do.

    Can I just say that this decision was immensely satisfying for me. Not because of upholding Obamacare, but because the court didn’t vote on ideological lines. This makes me have more respect for them as principled rulers, and when I consider decisions that I didn’t like (Citizens United, for example), I am way more apt to consider that maybe there were good legal arguments that led people like Roberts and Kennedy to vote in favor of that decision.

    In short, it is one step away from political life where the law is simply a function of who is in power, and a step towards a politics where there are principles beyond the brute exercise of power.

    Robin- I think you are probably right on the commerce clause, although most of the legal analysis I’ve heard from legal scholars suggests that this isn’t anything new on the commerce clause. The new thing would have been Obama’s argument, which I will grant was lame. On the other hand, the “stick” of the federal government is limited but still allowed, as I read it, as it seems that the government simply didn’t give enough time to the states to adjust.

    It seems that congress and the president have the right to influence economic activity through taxes, but not coerce through other legal means. However, nothing in this ruling suggests that it would be illegal for the state to make these taxes exorbitant, so still pretty broad powers (but that’s why law are written by elected officials, who can change them, and yes, if the country decides to, repeal them.)

  • Robin

    Last attempt:

    1. If you are a conservative who just wanted President Obama to fail…you will be sad today.

    2. If you are a conservative who thinks ACA is disastrous policy and the wreckage it will cause is more important than the broader constitutional picture…you will be sad today.

    3. If you are a conservative who thinks that constraining the federal government and giving power back to the states is more important than individual policies…you will be happy today.

    4. If you lean progressive and care more about this specific policy than any precedent it sets…you will be happy today.

    5. If you lean progressive and care more about legal precedents than specific policies…you will be unhappy once you realize what Roberts actually wrote.

  • http://LostCodex.com DRT

    Robin, FWIW, nearly anyone I debate with ended up saying it was unconstitutional as their primary rant, so now they will have to come up with a new reason.

  • Robin

    DRT,

    I hope you understand what I was saying above. I feel like we lost the battle (it is now constitutional) but we won the war (we were right, they tried to act unconstitutionally, but Roberts informed them they passed a tax without knowing it).

    Also, the new number one argument your conservative interlocutors will have for hating it is that it is now a huge tax increase for some people.

  • http://LostCodex.com DRT

    Robin, I hear that, but I look at it that they passed a law to try and give people without insurance coverage and to decrease the cost overall and succeeded. And it gives me more faith in our founders that can do something that is reasonable and good and have it be constitutional.

    If it would have been struck down because they did not frame it up with the correct magic words then that would have been quite a shame.

  • Robin

    I was always more concerned about the precedent. Now that that is out of the way I find myself kind of ambivalent. I still think it is a bad law with good intentions, but I think it will get tinkered with over time until we can live with it.

  • http://www.educatingbrian.com Brianmpei

    Coming from across the northern border so please forgive my question if it seems clueless – I am. So for healthcare people pay an insurance premium in the U.S. – yes? And now everyone who doesn’t already have healthcare in the U.S. will have it by paying a tax rather than a premium – which seems like what we do up here – based on their income – yes? So people with healthcare will be unaffected but those without healthcare will now never have to be afraid of being bankrupted by major medical expenses or worse, turned away from treatment for lack of insurance or cash. Yes? If that summary is accurate, I’m missing the bad part of this deal. Fill me in please!

  • http://azspot.net Naum

    Fabulous *New Yorker* piece by Atul Gawande — healthcare as a “wicked problem”, thoughtful…

    Two decades ago, the economist Albert O. Hirschman published a historical study of the opposition to basic social advances: “the rhetoric of intransigence,” as he put it. He examined the structure of arguments—in the eighteenth century, against expansions of basic rights, such as freedom of speech, thought, and religion; in the nineteenth century, against widening the range of citizens who could vote and participate in power; and, in the twentieth century, against government-assured minimal levels of education, economic well being, and security. In each instance, the reforms aimed to address deep, pressing, but complex societal problems—wicked problems, as we might call them. The reforms pursued straightforward goals but required inherently complicated, difficult-to-explain means of implementation. And, in each instance, Hirschman observed, reactionary argument took three basic forms: perversity, futility, and jeopardy.

  • nathan

    the people in the legislative and executive branches may have made mistakes when it comes to their political rhetoric and their own arguments for the constitutionality of the law.

    but the magisterium of the court did the court’s job. They clarified, in light of the body of relevant sections of the constitution, their judgment on the law. They smacked down the constant over use of the commerce clause (I’m looking at the folks on the the Left), but also made clear that, in their judgment, other provisions in the constitution apply.

    That’s why we have a Court. That’s the system we have.

    We can’t demagogue the Constitution when it suits us (I’m looking at you Tea Party) OR import insane Austrian economic commitments into it when it suits us (I’m looking at you revisionist Libertarians), but whine when the Court does it’s job and exercises its final constitutional judgement.

    It might not be what you like, it might not be what you agree with, but the Constitution isn’t some document that serves only one particular political ideology. Hence we live with the horror of Roe v. Wade, Citizens United, etc. alongside the goodness of Brown vs. Board of Education, Miranda vs. Arizona, Coffin v. US, etc. etc.

  • http://LostCodex.com DRT

    Brianmpei,

    Instead of saying “……, yes? ……., yes?” You really need to live up to our stereotype here and say “…….., eh? …………, eh?”. Now, isn’t that better?

    The bad part, as much as I can tell from my friends like Robin, is that they feel like they are supporting the poor people with the law, but when it was buried in their premiums it was not so obvious.

  • Robin

    Brianmpei,

    (1) Some people will now be on Medicaid (100% government provision) (2) some people will be forced to buy insurance, but will have it subsidized based on income, (2) and some people will have to buy on the open market, without a subsidy.

    The insurance rules are also changing, the new rules appear very similar to me to New York State (guarantee issue, community rating), so I will use New York as the comparable. A family policy in New York averages $12,000 per year. This is the amount the third group above should probably expect to pay annually for their insurance.

    This doesn’t affect people who already have insurance, so the main potential losers are people who make a decent income, felt like they didn’t need insurance, and now will have to pay ~$12K per year or pay a penalty. Obviously group 2 could be negatively affected as well, depending on the subsidy they get and whether or not that subsidy lowers the cost enough to make the product attractive to them.

    The last group (negatively) affected is people who will lose their insurance because their employer drops coverage, and who now have to be part of one of the three groups above. The list of required benefits for employer-provided coverage under ACA is fairly generous, much more generous than many employers provide. Employers must decide to up their plans and contributions, or drop coverage and pay a fine for doing so. For many companies it will make financial sense to drop coverage and pay the fines, leaving their employees to go on Medicaid, or buy subsidized or unsubsidized coverage on the private market.

  • Robin

    DRT,

    I’m trying to understand the last paragraph of you last comment. I am supporting the poor and unhealthy with my premiums because I am in an employer plan. But for the most party in Kentucky, individuals with private plans are not supporting those groups. We do not have guarantee issue or community rating, so individual insurance rates depend very heavily on personal circumstances. In states like New York, everyone really is in the same pool so everyone is subsidizing everyone else, but in some states that is not the case.

  • JohnM

    Robin,
    I want to be as happy about it as you are, though I’d fear floating clear out of orbit ;) and I hope you’re right, both about the effect of the legal precedent and about tinkering with the law until we can live with it. However, I wonder how happy conservatives should be about one more manipulative tax. It’s not the tax part that bothers me, it’s the using taxes to punish behavior and using punitive measures to raise revenue. Yes I know, we’ve been doing that forever, but one more rotten fish doesn’t make the pile smell any better. Still, I want to agree with you and Chief Justice Roberts.

    Brianmpei, #36 – “So people with healthcare will be unaffected”. Well now. We shall see. I hope it’s like that, but I’m not confident anybody really knows what this is going to do.

  • http://LostCodex.com DRT

    Robin, if you tell me I am barking up the wrong tree I will believe it because I am not an expert here.

    But, my thought and knowledge says that we all pay for a level of care for the uninsured through our current premiums due to regulations governing the delivery of emergency types of care. And in essence we are paying a substantial and likely fully absorbed cost for that, though the recipient is not getting the full benefit since they are forced to use a back door, so to speak.

    Is this incorrect?

  • http://LostCodex.com DRT

    JohnM,

    I may be wrong, but I look at this as a classic free loader issue. That the dollars are being spent regardless of the individual action so there are many who simply free load, or must free load in the current environment.

    If we do this above the board as opposed to the current below the board approach (emergency care), for the same dollars we can have a more effective and efficient application of health care to the group in question, and average out the expected cost an impose it on those that are simply shooting craps on their health prospects.

  • Robin

    DRT,

    I would say that in states with community rating and guarantee issue, you are fully subsidizing those groups. Elsewhere, it depends. In Kentucky the state picks up the tab for part of those people and some of it is just absorbed by the hospitals.

    My wife works for HCA, the largest hospital chain in the country. I checked hospital stocks today and most of them went up 8-10% immediately after the ruling. You see literal spikes at 10 AM. Obviously hospitals were eating costs of care for some of those groups, and now that they won’t have to worry about that anymore their stock prices are ticking upwards.

    I also just read an interesting take on Andrew Sullivan’s blog that I hadn’t considered yet. Several states provide Medicaid (thru Federal waivers) to people making over 100% of the Federal Poverty Level. With the new law, they can now drop those people from the Medicaid rolls and let them enter the exchanges like everyone else. Because those groups will be subsidized at 100% they will still have coverage, but the state won’t be picking up 33% to 50% of the costs. This could be a huge hit to the federal budget, but it could give the states quite a bit of breathing room. I’m going to check how far up we allow people to stay on Medicaid.

  • Robin

    DRT,

    Regarding #44 there is a free rider problem, but also a utilization issue. Now that care is covered, for some people at 100%, there is a large probability they will utilize much more medical care than they did in the past. My wife works in the ICU and ER and frequently tells me stories about women who will come and wait in the ER for a pregnancy test because Medicaid pays for it, rather than buy a $1 pregnancy test from the dollar store.

    People who couldn’t afford insurance and didn’t qualify for Medicaid will now be eligible for and receive much more care, for better (hopefully improved outcomes) and worse (much higher overall medical spending).

  • http://LostCodex.com DRT

    I want to add another thought as an employer (I own a small company with employees).

    As margins are tight on small businesses, one of the considerations I have is regarding the health coverage we supply, and the type of people we hire. It is almost totally irresistible to not discriminate based on age and sex when you know that that 50 year old fat guy or young child bearing age woman is going to cost you more than double what a single, healthy stud is going for these days. We need this act.

  • http://LostCodex.com DRT
  • http://LostCodex.com DRT

    Robin#46,

    I see your concern about using too much care as valid. But, I believe that the cost of catastrophic care far outweighs the marginal excessive cost you discussed.

    I raise you my sister in-law, that was actually participating in a health care panel to Obama last week on the automation of health care, and she has been a NICU nurse for some time in Colorado, and the money that can get throw around there is amazing.

    She too is not a fan of the welfare queen etc, but there is a legitimate need here too and we can’t let our jealousy around someone getting something for free or causing us to pay more to outweigh the humanitarian benefit that is to be had here. Just because someone is getting over on the system does not make the system bad! It gives me optimism that when I am in a bad situation that some can look the other way and let me get away with a bit more. There is a big administrative burden to tighten it all up so no one can get a piece of my pie.

    This require big picture thinking and people need to get off their jealousy and let some people even take advantage of them, in the interest of it being more fair and benevolent overall.

  • Robin

    DRT,

    You misunderstood me. I didn’t invoke her as a welfare queen, I could care less, but as an example of how getting something for free changes your utilization patterns. People who were eligible for 0 care will now be eligible for great deals of care, and they will use it. That care will cost money, and we will pay for it.

    You can’t just assume that the guy with no insurance isn’t going to change his healthcare utilization now that he has coverage. That’s like saying the homeless guy living on the street isn’t going to change his eating patterns if you give him a free pass to a chinese buffet.

    I’m also confused about you as an employer. I thought you had been unemployed for 6 months.

  • Robin

    To clarify, the reason I brought up that whole scenario is you insinuated that people are already getting care below board and we are footing the bill, now they will just get it above board and better prices.

    I believe they are getting some care below board, but now that everything is above board they will get much, much more care. If it is a significant amount more we will pay for it through either higher premiums or larger subsidies.

  • http://LostCodex.com DRT

    Robin, fair enough. I come down on the side that they will get preventative care and also start using lower cost options, which will decrease the cost overall enough to cover the additional coverage.

    The reason I believe this is twofold. First, it is what the administration says.

    Second, it is my experience with my own coverage. My insurance coverage has deemed that it is in their interest to give me more preventative care, much more, rather than pay the price for not giving that care. I think we will see that play out across the board, but I could be wrong.

  • Robin

    That is where the financial question will be decided. I will just close with this. Utilization depends a lot on insurance design. My insurance has a $100 co-pay for ER visits that gets refunded if you get to the hospital.

    They don’t want people rushing to the ER for every minor incident so they set up a steep co-pay, but they also don’t want people avoiding the ER if they are really sick, so they refund it if you get admitted (i.e. you really needed to go to the ER).

    Small program designs like this will determine what the total bill ends up being. My belief, currently, that this is going to cost more than the status quo is based on the fact that most of the regulations in the ACA seem designed to discourage things like I listed above. They are against things like high deductible HCA accounts, etc. There is very much a sense of “everything should be covered at $0 cost” in the ACA. If the insurers end up having wider latitude to bake disincentives into their products then you could be right.

  • http://LostCodex.com DRT

    Robin, thanks for talking. I guess this comes down to how much and what kind of risk one is willing to take. I find the potential cost for higher premiums to outweigh the potential benefit to the lives of the poor.

  • http://LostCodex.com DRT

    oops, I mean the opposite of what I said. Shalom

  • Tom F.

    Robin, I can’t tell exactly where you are among the options 1-5 today, but I’m hoping that you are a 3.

    I would put myself as a 6- I lean progressive but I’m far more happy that the court made the decision on legal grounds than on ideological ones, and I’m willing to take my lumps when they come as long as they’re based on constitutional and not ideological grounds. (Besides, as said, not that big a lump for me, since it always seemed to be a tax to me anyway. The Economist argued this as well back a few months, and their logic convinced me as well.)

    So if you’re a three and I’m a six, than we both get to be happy today. How rare in politics that people on different sides of the spectrum get to do this! Praise God for wise lawyers who can make wise decisions. Also, I’m sure with this court it won’t be long before conservatives get a decision that goes there way, so our positions may be reversed in no short time. If you aren’t a three, and therefore unhappy, know that I don’t take any pleasure in your unhappiness. Although I have to admit, hearing Rush Limbaugh explode was definitely too gratifying. Still need to work on some stuff I guess! :)

    Blessings,

  • John Inglis

    Given the public arguments Obama and his administration made regarding the constitutional basis for his plan, but especially the commerce clause arguments made by his lawyers, it appears that he did lose the constitutional issue he was putting at play: i.e., that the commerce clause permits this sort of federal intervention. On that Obama was clearly wrong. However, if only the goal is considered, the goal of universal health care provision per se, then that sort of federal intervention and program was found to be constitutional.

    There are different constitutional issues at play, which DRT glosses over, but which Robin unpacks.


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