Losing on Health Reform

When the Supreme Court issues its ruling on the constitutionality of the Affordable Care Act, we'll begin a new chapter in this saga, one that will probably (well, maybe) involve sorting through how the law's implementation will work once the individual mandate is struck down. But we've reached the point where there's no denying that the fight over public opinion has been lost, and that ground may never be regained no matter how hard the Obama administration or progressives might try.

Perhaps it was inevitable. The administration passed an extraordinarily complex piece of legislation that sought simultaneously to solve a multitude of problems, each in its own way. At its heart was a compromise, an idea taken from conservatives to solve a problem created by the very fact that everyone was so insistent that we maintain the patchwork of private, employer-provided insurance, and this conservative idea provided conservatives the vehicle to get their allies on the Court to strike down the law. Neat how that worked out.

As for all the other things the law does, no matter how appealing they were one by one, the complexity combined with an ignorant public and an extraordinarily well-funded and shockingly dishonest campaign to destroy it made for an impossible sell. As The New York Times reports today, the anti-ACA forces spent $235 million in ads attacking the law, compared to only $69 million in ads spent in the law's favor. The latter are mostly from the Department of Health and Human Services, which have all the emotional content of your average public service announcement. The former, on the other hand, were full of fear-mongering and lies, convincing people that they'll be put in front of death panels and be prevented from getting care. It was no contest, and in the end the people who stand to benefit most from the law are the most ignorant about it.

I suppose in the wake of all this that conservatives are very proud of themselves. I know they've convinced themselves that the individual mandate is the worst infringement on personal freedom since the Alien and Sedition Acts, and if (once) it is struck down, Americans will be able to breathe the sweet air of liberty once more. And the millions who will continue to go without coverage if the ACA is struck down? The people who will continue to get tossed off their insurance once they get sick, or go bankrupt when they reach their coverage caps? Screw 'em. A small price to pay for sticking it to Barack Obama.

It's very possible that the Court will strike down the mandate and the accompanying ban on exclusions for pre-existing conditions, since the former is what makes the latter possible. That will be a very, very bad thing, since eliminating pre-existing condition exclusions does so much to give all of us the security we now lack (until we turn 65 and can get into Medicare). Nevertheless, that outcome would be very good for very many people. It would still give millions of low-income people access to Medicaid, and give millions of others subsidies to get private insurance. It would still save seniors money on their prescriptions, since the ACA closed the infamous "doughnut hole" in drug coverage. It would still begin a move away from the fee-for-service system that causes so many distortions and so much wasted money. Insurers are about to refund $1.1 billion dollars to customers because of requirements in the law. In short, lots of good things will still happen. The public won't give the administration or the Democrats credit, but in the end, that's much less important than that we do what we can to alleviate the gargantuan amount of suffering our awful health insurance system causes every year. In future years, people may hold on the benefits they receive from the ACA with all the intensity of the senior citizen yelling at her representative to "Keep the government's hands off my Medicare!" And if the Court's decision means we took two steps forward and once step back, at least that was one step forward.

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