Wednesday, January 19, 2011

Six More States Join the Anti-Mandate Suit

The Associated Press reported today that Iowa, Kansas, Maine, Ohio, Wisconsin and Wyoming, all with Republican Attorneys General, have joined the Florida suit that claims the individual mandate is unconstitutional.

At this point, 25 states, all but one with Republican leadership, are suing the mandate provision!

This is a fascinating piece of U.S. politics. My guess is that when historians and political scientists delve into the issue 10 - 20 years down the road, the suit and the Republican repeal effort in the House of Representatives, will look like a combination of: (1) the latest manifestation of what Richard Hofstadter called the "paranoid style in American Politics" (see here for a post on Hofstadter), triggered by the fact that the individual mandate is an intrusive piece of legislation; (2) theological belief that market solutions are always best; (3) reluctance to embrace the communitarian values the law embodies; and (4) a hefty dose of cynical political opportunism.

There's no way to contain runaway health costs without bringing the entire population into the risk pool and, one way or another, creating an overall budget for health care that we - the body politic and our health institutions - must learn to live within. The highly complex health reform law is an effort to do that without paying for health insurance collectively through taxes. If the Supreme Court ultimately rules against the mandate, or if a Republican sweep in 2012 leads to its repeal, we'll have to look for a new way to broaden the risk pool and create a health care budget.

If the mandate bites the dust, I would predict that politicians may turn to the kind of proposal Ezekiel Emanuel made in Healthcare, Guaranteed. Emanuel envisions a tax supported system that provides individuals with vouchers for purchase of insurance. While a tax is as intrusive as a mandate, we're accustomed to paying taxes, but not to being penalized for not making a purchase. A dedicated health tax may be more politically acceptable than the mandate mechanism. And vouchers that individuals use to purchase health insurance from independent entities make use of market mechanisms. This would reduce concern about "federal takeover" of healthcare and "creeping socialism." (See here and here for Maggie Mahar's excellent 2008 discussions of Emanuel's proposal.)

The process we're seeing is a combination of ethics (a civilized society should ensure that all citizens have access to good health care), economics (a prudent society doesn't let one sector consume disproportionate resources), and politics (the way the problem is addressed must be compatible with public beliefs and values). There's no way this can be a tidy, settle things for once and all, process!

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