Okay, I didn't tell anybody this either here or on my blog, but my optimistic self had predicted a 6-3 decision in support of the individual mandate, with Roberts and Kennedy joining the liberal members of the Court. Kennedy's siding with the three off-their-rockers in dissenting AND saying they would have thrown the entire thing out, well, I could never have predicted. But Roberts voting to allow the mandate -- and on tax grounds -- I did hope for. Kudos to Talking Points Memo and reporter Brian Beutler for suggesting this outcome (I had noticed it during oral arguments but had forgotten it until I read Beutler's piece, which was quite prescient).
My pessimistic side had assumed we were doomed. We may yet be, but not today. Today we rejoice and enjoy watching the Republicans and Mitt Romney twist themselves into pretzels. As Paul Krugman says, today is "double scotch time." Make mine wine, but I will toast come happy hour.
As for pretzel time, Rand Paul and Jim Inhofe declared fuck the Supreme Court, we're going to refuse to follow the law anyway. Mitt Romney says -- in spite of the fact that his healthcare achievement in Massachusetts relied on an individual mandate -- he will repeal the ACA on day one. All the other conservative talking heads, and some liberal ones as well, are harping on the "lie" that Obama said the ACA wasn't a tax. A little digging reveals that Obama didn't say it wasn't a tax, he said it "wasn't a tax increase." Check it out.
All those referring to Obama's saying that it was not a tax, are referring to that ABC interview. In it, Obama declares that the ACA is not a tax increase. Now, I get that part of his argument is that regardless of whether or not you elect to buy insurance or pay a penalty -- collected by the IRS -- the overall impact of the ACA is that your costs for health care will go down, while coverage for the American citizenry is broadened. And I essentially agree with him.
There's a simple way to dismiss this tax argument: no responsible adult needs to pay the penalty; all they need to do is obtain healthcare coverage. End of story. And the 85% of Americans already covered by health insurance don't even enter into the uninsured penalty zone anyway.
But to argue sensibly with the conservatives is a waste of time, unless you enjoy pretzel watching.
I prefer to move on to what the SCOTUS decision made me consider. Now that the law will come into effect by 2014, how can savvy state politicians take advantage of the situation for their home states by preparing early for the law?
The answer hit me like a brick, and I hope that it stands up upon closer examination. Here's what I recommend to, say, Jerry Brown, my California governor:
1. As required by the ACA, each state in the nation needs to set up health insurance exchanges, which are to be the marketplace where the uninsured, as of 2014, can acquire affordable health insurance.There you have it: a series of steps for creating a state health insurance exchange, in stages, that will bring down costs as slowly or quickly as a state might decide, as long as it is fully in place by 2014.
2. A smart way to make a state's health insurance exchange truly affordable is for it to be based on an already functioning and affordable system. Most states already have such an exchange available to its public sector employees, where they can choose from a variety of healthcare packages. (I participate in such an exchange. I did, first, as a public-school teacher, and do so now, as a retired teacher who isn't yet of Medicare age. I'm 63.)
3. So, as soon as is practicable, Jerry Brown -- in my example -- should find a way, either through legislation or state agency policy, to declare that all state employees are now de facto participants in the health insurance exchanges.
4. All local government agencies, whether towns, cities, or counties, should be invited to join in the state exchange, in order to create an even larger negotiating pool, placing participants at a better competitive advantage with the health insurance providers.
5. Next, all private-sector businesses should be invited to join.
6. Lastly, all uninsured private citizens should also be allowed a mechanism for participation.
I would further recommend that the state require a small fee, say $10, to participate in the exchange, with a $20 reinstatement fee if someone leaves the pool or allows his participation to expire (to discourage flightiness). This fee would have little impact on individuals but would easily finance the bureaucracy needed to run the exchange.
Everything I know about economics says that the sooner a state or public entity participates in such an exchange, the sooner the state's healthcare costs go down. This allows states, municipalities, counties, businesses, and even individuals to make their healthcare costs affordable. Seems to me states could radically reduce their budget shortfalls.
What am I missing here? Seems like a no-brainer.