The Supreme Court’s marathon on health-care reform means that the pundits are going to be going all health care, all the time this week. And if reports from the court’s arguments this morning are to be trusted, and the Supremes toss Obama’s health program out the window, then we’re going to be talking about this all year.
But before the legal weeds engulf us, it’s worth stepping back to recall the wider issues at stake.
Faced with the programs and rules that make up a moderate, private-enterprise-friendly health-care reform program like Obamacare, the Red State id is throwing an individualist tantrum. Like the Tea Partiers shouting “Hands off my Medicare” to the government that runs the program, today’s conservatives are deeply confused, and they are flailing in every direction at once. Mandates are unconstitutional! Save Medicare by ending it! Down with the death panels! Beware bureaucrats bearing broccoli!
This fight seems to be about mandates and dollars. But what’s at stake is even more basic: Are we ever again going to be able to apply big collective solutions to our big collective problems?
Health care in the U.S. is a large, complex system that will eventually break down unless we repair it. In this, it resembles other large, complex systems in desperate need of reform, including our energy system and our financial system.
Large, complex systems share a common sort of intractability. You can’t transform them with a single lever; they rarely change unless they’re pushed from many directions at once. Otherwise, they absorb blows and buffer stresses and resume where they left off — as the oil companies did after the Deepwater Horizon spill and the banks did after the housing collapse. They’re resilient! Or incorrigible.
So if you accept the reality that our system of health care and health insurance is on an unsustainable course, you also have to accept the reality that there’s no simple patch to apply or magic wand to wave. (Well, OK, single-payer universal health care might come close, but it’s not exactly a shoo-in.) The change we need is actually a whole set of changes, in pricing and practices, in incentives and transparency, in information systems and patient education.
A lot of those changes are a part of the Patient Protection and Affordable Care Act, as Obamacare is formally known, and many of them are already working to bring down health costs and improve quality of care. You don’t hear much about that because the opponents of health-care reform have zeroed in on the “individual mandate,” and that has become the flashpoint for right-wing fury and the focus of the legal challenge to the law.
The individual mandate says that everyone has to buy health insurance. This provision is the complement to Obamacare’s requirement that insurers offer policies to everyone regardless of their health problems or “preexisting conditions.” It’s a simple idea straight out of an economics textbook: Insurance marketplaces don’t work unless there’s a good mix of low- and high-claim consumers; the former’s premiums fund the latter’s payouts. Without the ban on “preexisting condition” exclusions, you get a market where the insurers can cherry-pick their customers and freeze out people who need the most help. (This is essentially the lousy state of affairs at present for anyone who isn’t over 65 or covered by an employer.) Without the individual mandate, you get a market where the insurers go bankrupt.
The mandate is the brainchild of conservative think tanks. It’s essentially a business-friendly law: After all, it insists that people buy something from particular businesses! Yet for the Red State mind it has become almost as unpopular a symbol of Big Government meddling as lightbulb laws.
The transformation of the individual mandate from free-market brainstorm to Tea Party target helps explain why Mitt Romney, who passed his own mandate in Massachusetts, has had to contort himself into pretzel twists this election season. Don’t get sidetracked by the argument that states can do it, only the feds can’t; that may matter to constitutional lawyers, but why should the rest of us care?
The right’s backflip on the mandate suggests what underlies opposition to health-care reform: It’s not the details that conservatives object to, but rather the very concept of health insurance as a collective right. They do not want a system of mutual moral obligation; “we take care of each other” must give way to “every man for himself.” As supporters of health-care reform kept adopting conservative ideas like the individual mandate, conservatives had to keep moving their goalposts; deep down, though, they’d rather not play this game at all.
But we will keep playing it, because we have no choice. And once we’re done with health care — for the moment, at least! — we’re going to have to keep playing, over and over again. As we struggle to tame each of the complex systems our civilization has built — with climate-altering energy production first in line — any win will depend on group action and collective responsibility.
Where will we come out? I’m cautiously optimistic still. We will act because we have no choice. The individualist tantrum will end in exhaustion, as all tantrums do, while the grown-ups clean up the mess.