[This is a sort of prelude to Part 2 of 2 of Anecdotal Evidenz: The “trash in the ER” argument; and my dealings with CPG (1993-94). It is rather hastily done--which may be OK, since several of the points here are not as relevant with regard to future eventualities as is the Part 2 blog entry that is to come.
On the other hand, it may seem like a polemical hair shirt and a kind of "moot court" effort. Anyway, the Part 2 entry won’t come until after April
13, and in the meantime, I plan to post at least two other entries, “Movie
break” types: one on two movies starring Winona Ryder; and a 1976 film titled The Front, which stars Woody Allen but
was not written or directed by him, and co-stars Zero Mostel and Herschel Bernardi.]
As things developed in recent weeks, after the big set of oral arguments at the Supreme Court on the Obamacare law the week of March 23, it became clear my own strategy in telling my anecdote should change. I realized that, in a way, it doesn’t matter whether the individual mandate should be removed from the law—struck down by the court—with the rest of the law standing, as I would prefer; or whether the whole law is certified, complete with the individual mandate. Why doesn’t it matter? And why does the answer mean I have, for myself, a Plan B, for what little it’s worth (as the Administration seems not to, if the law is struck down)?
Whether or not the individual mandate is struck down, a sizable percentage of the U.S. population, not currently covered by health insurance, will have to deal with some entity to get insurance coverage (unless they choose not to, and opt to pay the relevant penalty on their tax returns). For many, this will mean dealing with private insurance companies, which can run into a mixed bag of possible results, as the insurance companies conform with the law or not (or conform somehow with the letter but not the spirit of it).
And there’s the problem. The Obamacare system, if upheld, is not a single-payer insurance situation that everyone is expected to be part of. Not everyone is being asked to do something to get covered by Medicare, or something like it. When people have argued about how, in some sense, the uninsured have been irresponsible not to get insurance (see below for more concrete examples), Obamacare does not mean that if they do, they will be paying into the same pool that covers everyone. There will be, instead, and as before, a patchwork system of health insurance coverage: some by Medicare, some by Medicaid, and some by a plethora of private plans (and some among these people will get subsidies to pay for insurance, as provided for by the Obamacare law).
This rough sum doesn’t include the factor of
state-administered assistance, and whatever else is outside a federal
single-payer-type program.
This fact of there being a patchwork of coverage, one way or the other, has been unappreciated by those who argued, seemingly heatedly or in high dudgeon or the like, that the uninsured should get insurance.
Let’s get this criticism out of the way—let’s look at some recent articles that apparently bespoke disappointment in the fact that the Supreme Court was less likely than some had thought to uphold the Obamacare law (all or most of it), willy-nilly. And I will briefly respond to each.
1.) In the article “Court scoffs at Congress over health care law,” an Associated Press article in the New Jersey daily The Star-Ledger (April 1, 2012), section 1, p. 2: “Solicitor General Donald Verrilli Jr. repeatedly invoked Congress’ power under the Constitution to take aggressive action to deal with health care, which makes up 17 percent of the U.S. economy [OK, won’t argue with that], and with the problem of 50 million people who lack insurance [OK, will assume number is correct] but whose health costs are being passed on to taxpayers and those with insurance.”
Hold on. False as stated. All those 50 million people are getting health care whose costs are covered by government or others’ private insurance? NO! We don’t even need to know exact numbers (though percentages would be interesting) to know that (1) some haven’t been (recently) sick and hence haven’t required care that cost something; (2) those who were sick with minor (or even some with more major) illnesses could pay for their own care (such as myself, with minor care from a private practitioner); and (3) others got care from any of a variety of sources (including emergency rooms, but not only this), and
this was paid for in a variety of alternative ways: either this care was covered by the government, by (in effect) someone else’s insurance, or by fundraisers or some other creative means.
2.) There was a column in the same paper, “A supremely unconvincing court,” by John Farmer, a legal professional and whose writings on other topics I have agreed with and admired (such as something recently concerning the Dharun Ravi case). In the Obamacare column, he writes: “And the numbers of the uninsured—and the burden they impose on society—will continue to grow” (The Star-Ledger [April 1, 2012], section 2, p. 3).
What? “…the burden they impose on society…”? How much of a burden? And this by all of them? See my response to the earlier quote, above.
3.) Then we have the article “Federal mandates long a part of health care[:] From Medicare to hospital maternity stays, government regulations are commonplace,” an Associated Press article in The Star-Ledger (April 2, 2012), p. 8. This combines a sort of opinion piece with a sketchy wide-ranging survey. In its effort to argue that the individual mandate “isn’t the first federal mandate involving health care,” it notes, “There is a Medicare payroll tax on workers and employers…” and later says, “Workers must pay a tax to finance Medicare, which collects about $200 billion a year.”
Wait a minute. Medicare is a government program. It is like Social Security; in part, we all pay because we may not need, depending on our age, to collect its benefits now, but we should be able to when we retire and start collecting Social Security at age 65 or 67 or whenever.
Repeat: Medicare is a government program. Requiring people to pay taxes into it, as a sort of “mandate,” in order to have its benefits distributed, is a typical government mechanism of the social-service type we have seen for many decades. That is not what the individual mandate is when it requires people to buy insurance from any of a number of sources, especially if these are private companies. In a sense, the individual mandate, for many (who don’t get subsidies), would be a sort of unfunded mandate, and there are enough people in different connections who criticize that sort of thing (including those in state government who balk at federal demands for a certain new function without money behind them).
That last article even quotes Supreme Court Justice Anthony Kennedy making a very apropos point: “Kennedy said Congress could have created a Medicare-style program for the uninsured, run exclusively by the government without the involvement of private insurers.” Very much to the point.
People have argued about whether the individual mandate is “severable” from the rest of the Obamacare law. I think it is. Even The New England Journal of Medicine thinks so—see here.
My prediction: the Obamacare law will either be fully upheld, or not, or have only the individual mandate struck down, or not, by a 5-4 vote, with several dissenting opinions.
***
Horror story that is one basis for my “Plan B”
But let’s leave aside all this arguing about the nature and rationale for the individual mandate. Let’s assume the Supreme Court upholds it. What then?
Will everyone who tries to get health insurance from a private insurer, even with the Obamacare federal prohibition on excluding people on the basis of preexisting conditions, really be able to get insurance? Or will there be snags and absurd situations? I have my doubts.
It is a look at specific horror stories in this connection that really points up the problems with the individual-mandate aspect of the Obamacare plan. Oh, yes, the overall plan could be making a lot of strides toward improving the health care system. But it is not, in all its parts, a single-payer system, by any stretch. When we go to my story about the CPG insurance situation, we will see why the reliance on private insurers is destined to cause problems, maybe (15+ years after the CPG situation) some new types. Maybe not to a wide swath of the population, but to enough individuals, and with enough absurdity about these instances, that we might be able to say, The more things change (with health care in this country), the more they stay the same.
