In what could be a telling ruling today, a conservative Bush appointed Republican federal judge ruled against the PPACA (aka: the health care reform we got). What makes this potentially telling, and as I have been predicting, this ruling strikes down the individual mandate and along with it guarantee issue and possibly community rating.
While some reports will no doubt emphasize the individual mandate part, and others that he left health reform intact overall, in fact that is not the importance of this ruling. Unlike either the prior Virginia ruling (much broader) or the Florida ruling (narrowly striking down just the mandate), this ruling acknowledges the policy tradeoff in the plan ever since it was proposed by Republicans in the 1990s: The insurance companies get the guaranteed market expansion they want, with the individual mandate using the police power of the state to force Americans to buy their inherently defective private for-profit product; while the public gets the benefit of the right to be able to buy some sort of insurance policy at some sort of hopefully affordable cost.
Were the individual mandate to be struck down narrowly, while truly leaving the rest of health care reform intact, including guarantee issue and community rating, then there would be the issue of so-called "free riders.” People holding out on buying insurance until they were sick or at least at self-perceived higher risk. This would make insurance too expensive for the for-profit insurance companies, and us. Indeed health care is too expensive to ever be paid for just by sick people. That is why "health savings accounts" also don't work. That is why insurance companies compete mostly by avoiding sick people. You can't make a profit covering sick people.
Of course, single payer solves this by having everybody pay in through progressive taxation, just as we do for all other government services. And covers everybody automatically. Everybody in. Nobody out. As we are seeing with Perry's struggles, Medicare is popular. And "Medicare for All" is the simple to explain, economically best solution, supported by about 60% of Americans. A single universal "All America" insurance pool. There should be no issues of adverse selection. There would guaranteed and automatic enrollment, with no waste due to eligibility determination, enrollment and disenrollment games. 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.
Meanwhile, tea party rhetoric aside, there was never going to be any chance whatsoever that the plutocracy and kleptocracy were going to allow just the mandate to be struck down. At best, we would get PPACA intact as is, but whittled away at by constant attack, and ultimately achieving neither universal complete coverage, nor cost containment. Alternatively, if the Supreme Court does strike down most or all of PPACA, then this judge's ruling today could be a model for their argument.