As a single payer supporter, who also supports many other complementary reforms that we also need, let me offer some comments on where we are and where we are going:
- You can't make money insuring sick people. Not as a matter of morality, but simply economics. Taking care of sick people is too expensive (even after those other necessary cost cutting reforms) to pay for themselves.
- Adverse selection, not covering sick people and dumping people once they get sick is the main basis on which the private health insurance industry competes. That is what they did, do, and will continue to do.
Once you understand those two facts, all else follows:
- I am going to go out on a limb and predict that when the next shoe drops and Judge Vinson rules, it will not only be against PPACA but specifically that it will be carefully designed to be much broader than Judge Hudson's narrow ruling against the individual mandate. As widely noted, the last thing the insurance industry (and not incidentally that hospital lobby too) wants is to leave the limited "guarantee issue" and "community rating" that PPACA has intact, while only eliminating the individual mandate. Consider me a legal cynic, but I can't help but think that AHIP and their friends are sending their preferred language to Judge Vinson's people.
- For those who have not been following this closely, the policy argument for the individual mandate has been that it is required to avoid people not paying into the system while they are healthy, and only buying insurance once they are sick. As a matter of policy that is a real issue, and from a single payer perspective the better solution has always been "Everybody In and Nobody Out." Everybody pays into the national insurance pool via their taxes, just as they do for national security and social security and other governmental activities and services.
- The public paying taxes to the government in return for public community-wide government services is not the same as the government using it's police power to force you to buy a for-profit product from a private company. I know defenders of the individual mandate will say the government is not forcing you to buy private insurance. After all, the alternative is a fine, or tax, or maybe a fine (sorry, but disingenuous shifting of what it is and how it has been sold has marked the history of the individual mandate as it evolved from conservative think tanks, to liberalish ones, to Obama, to Congress).
- I know that this has mostly been argued, on legal grounds and on policy and political philosophy grounds, on the commerce clause. However I see strong analogy to eminent domain. The individual mandate, especially without a strong public option alternative is like the terrible Kelo decision, whereby the Supremes confirmed the use of eminent domain to transfer land from one private owner to another to further general governmental interest in economic development. As with Kelo, real libertarians and serious liberals/progressives/lefties can agree that the individual mandate is wrong. For any real liberal or progressive, the individual mandate, without at least a strong public option should be an abomination; and always was.
- I really really don't care that striking down the individual mandate, while leaving the limited guarantee issue and community rating intact, will discomfort the insurance companies, or leads to even more threats of increased premiums. This is not being nihlistic and not caring about real people having to pay higher premiums... because guess what... private insurance premiums are going up regardless in case you had not noticed. And they are still cherry picking and dumping, so the exchange plans will be subject to adverse selection anyway. This is just an additional excuse. And if conservatives want to attack guaranteed issue and community rating, I welcome that fight.
- Obviously I support single payer, expanded and improved Medicare for All. As did 55-65 percent of Americans when polled on this by non-partisan non-activist mainstream media outlets from 2003-2009. It is easy to understand and already accepted by the broad spectrum of the American public. Therefore it is off the table.
- But there are many other possible fixes and "fixes" being offered, should Judge Kennedy go Tea Party on the individual mandate (and given his erratic ideological rulings over the past several years this is a possibility, regardless of the fact that several other federal judges have ruled in favor of PPACA and individual mandate): A progressive favorite, short of single payer, would be public option or a Medicare buy-in. This could include a system of default enrollment into a basic public insurance plan (stripped and worsened Medicare for some?). A stronger employer mandate could also help actuarially balance the lack an individual mandate. Other less attractive (for progressives) options include various ways of punishing the healthy who refuse to buy private insurance: back premium penalties, higher deductible or delayed coverage for late sign-ups, limited open-enrollment periods. Nastiest of all, and therefore endorsed by many reasonable centrists, mild liberals and rational conservative, is the idea of a "multi-year waiver" whereby if you refuse to buy insurance now, you can't buy it later (or at least lose your guarantee issue and community rating and any premium subsidy) for some period of time (say five years). These latter ideas are all about preventing healthy people from waiting to get coverage until they sick. They also amount to deliberately keeping people from affordable care if they do get sick; not something I am going to endorse even if Paul Starr does. What they are not about is making sure that everybody has coverage and access to health care, and that costs at both the individual/family level and national/system level are affordable.
- For that you need single payer: The best policy remains "Improved and Expanded Medicare for All": a single universal "All America" insurance pool. There should be no issues of adverse selection. Everybody-in and Nobody-out. It would be paid for by the same progressive taxation we pay for other federal government goods and services including social security, military security and payment on the interest of the national debt. There would guaranteed and automatic enrollment. In addition to getting rid of the problem of adverse selection there would be the savings from getting rid of the private insurance companies as a wasteful unnecessary intermediary. There would be the additional cost savings benefit from monospony (single buyer, multiple sellers) in paying for services, equipment and drugs. There would be added benefits of global budgeting and strategic planning. At the end of the day, single payer is not a dream, it is only system that can actually work.