In three weeks or so, the Supreme Court will rule on health care. Republicans have been discussing what they might do in the event that poor, beleaguered John Roberts manages to withstand that vicious assault of the liberals and to lead a majority that strikes down the individual mandate. This one is a classic, folks. After spending three years lying their eyes out about the bill and tearing this country apart over it, it now turns out that they may well want to keep several of its provisions. And of course they want to keep the easy and fun stuff and get rid of all that bad-bad-bad stuff, but what they don’t understand—or more likely do understand but refuse to acknowledge—is that the good doesn’t work without the "bad." It’s breathtaking and ignorant—whether breathtakingly ignorant or ignorantly breathtaking I’m not quite sure. Call it the audacity of dopes.
Two weeks ago, John Boehner was insisting that “Obamacare” must be repealed lock, stock, and barrel. Some other Republicans wanted the slightly less radical approach of keeping some aspects of the law. A few days ago, some in the House warmed to this idea. Now, TPM is reporting that Senate Republicans are hopping on the piecemeal train.
The idea is to preserve the language that requires insurers to cover people with preexisting conditions, because everyone likes that; to continue to permit young people up to age 26 to stay on their parents’ insurance, because that’s helpful, especially in a rocky economy; and to press forward with eliminating the Medicare prescription drug “donut hole,” whereby seniors have to pay 100 percent of medication costs within a certain price range.
The last two are fine. But that first one is the gobsmacker. You cannot just make insurance companies cover really sick people. Sick people are expensive people, and insurers’ costs will shoot to the heavens, and those costs of course will be passed along to everyone else. Is there a solution to this problem? Yes. The solution is to get more people in the insurance pool—especially more healthy people, who don’t cost a lot to cover. Then, insurers have more money to use paying for the care of the sick people. But since you can’t just wish for more healthy people to buy insurance, you have to figure out some way to get them to do so. And hence ... the individual mandate. It broadens the pool and brings premiums down. It’s how you manage to pay for all those people who need radiation and chemo and dialysis.
There are alternatives to the mandate, which I needn’t go into now because the mandate is what we have. Without the mandate, you have millions of sick people being added to insurance rolls but no healthy ones. What happens? You develop “high-risk pools,” in the argot, and Harold Pollack, a leading health-care expert from the University of Chicago (who advised the Obama campaign) says that high-risk pools don’t work: “Except as a temporary stopgap measure, the track records of high-risk pools is quite poor. Experience in state programs indicates that high subsidies are required to keep premiums affordable for this (by definition) high-cost group. Many states have ended up capping the program, charging high premiums, or both.”
As it happens, the ACA has started temporary high-risk pools, designed to try to help some people before the law fully takes effect. Pollack studied them and wrote up the results in the Journal of General Internal Medicine last year. He found that the program’s funding didn’t come close to matching the need. In other words, lots of money is required to serve these people properly—money that would come from premiums imposed by the individual mandate.
The Republicans’ “answer” to this is their answer to everything like this, tax-free saving accounts. But health-savings accounts, if they work at all, which is a serious question, work only for healthy people who break a leg tossing the Frisbee. Nobody can sock away $25,000 for an operation or $100,000 for end-of-life care; the very idea is crazy. The GOP would also subsidize care for high-risk people. But Pollack notes that these subsidies would have to be billions of dollars a year. Republicans aren’t throwing that kind of money around at anything. Except at ships the Navy doesn’t want and tax cuts really rich people don’t need.
It’s just a shockingly unserious approach to a very serious problem of roughly 4 million uninsured Americans who have cancer, diabetes, emphysema, and the like. Republicans don’t give a happy crap about any of these people. They have no interest whatsoever in trying to solve a public problem. See, this is the Democrats’ burden, and when you come down it, the true difference between the parties these days. Democrats are actually concerned with trying to address a public-policy problem in a responsible way. You can disagree with their way, but they’re at least trying to do something positive in the country—help those 4 million as best they can. This involves difficulty and choices because nothing meaningful in life doesn’t. It also requires the people to stop being selfish apes for five minutes and look at the larger picture.
The Republicans, on the other hand, are complete nihilists. They don’t care about solving any policy problems. They care about two things. They care about politics—advantage, winning, humiliating Obama. And they care about ideology, their drunken and medieval belief that the market can fix everything. But wait; it’s not even really a belief. They’re dumb, but they are not that dumb. They don’t fully believe it. Like Romney accidentally acknowledging to Mark Halperin that huge budget cuts cause recessions. It’s just the garbage they say because it sounds good. No pain! Nothing is complicated! Be selfish!
There is some question as to whether the Republicans will unite behind the three planks I mentioned. Because only the “moderates,” the sell-outs, really want to do it. “Real” Republicans, the Tea Party people, want to kill every aspect of the bill, strike its name from the very records of history. So we’ll see what they do. And of course it all depends on the Supremes tossing the mandate out, which they might not do.
But if this chain of events unfolds, you can bet on Paul Ryan and others going out there to talk about their “reform” of the high-risk pool problem with all the pious sincerity they can muster. And if, God forbid, the Republicans win the presidency in November? Then they’d enact some patchwork thing with about 1/20th of the money actually required, and millions would remain uninsured. But most Americans would never be the wiser because 4 million people just isn’t that many to begin with. That’s how the GOP will hope to get away with it. Here’s hoping little Johnny Roberts is as delicate a flower as conservatives fear he is.