The Law of the Land

The Patient Protection and Affordable Care Act is now the undisputed law of the land following yesterday’s Supreme Court decision narrowly upholding the Congress’s power to impose a mandate to purchase healthcare insurance under its taxation powers while more broadly rejecting the Congress’s ability to punish states that reject the expansion of the Medicaid burden that the law would impose on them. Some progressives have sniped derisively at “Tea Party governors” who would refuse to accept the expansion of Medicaid for which the PPACA provides. I strongly suspect that they will be very surprised and dismayed at the Democratic governors who do so. The states have fiscal problems enough without accepting significantly more of an expense that rises faster than their revenues do.

Nancy Pelosi, Speaker of the House of Representatives when the PPACA was enacted, famously remarked that we would need to wait until the law was enacted to learn what was in it. If only that were the case! As I pointed out yesterday enough of the law will be promulgated in the form of regulations many of which have not been written yet and some of which won’t be written until after the law goes into effect fully in 2014 that nobody can really say what’s in it. The best we can say is “we’ll see”.

When we do know what’s in it, I suspect that more people will come to the conclusion I did when the law was enacted: it’s simultaneously excessive and inadequate. It doesn’t result in everybody having healthcare insurance, it retains multiple, competing healthcare systems, it doesn’t slow the increase in costs let alone reduce them as I believe we need to do, and it expands the bureaucratization of an already too bureaucratic healthcare system.

But we’ll see.

13 comments… add one
  • Icepick Link

    It doesn’t result in everybody having healthcare insurance, it retains multiple, competing healthcare systems, it doesn’t slow the increase in costs let alone reduce them as I believe we need to do, and it expands the bureaucratization of an already too bureaucratic healthcare system.

    But other than that it is a complete success.

  • steve Link

    I cannot speak for the politicians, but for health care policy people I think the ACA was always seen as the first step. We now need step two, which would concentrate on costs.


  • I have always thought that was a far-fetched plan. If you look at the history of healthcare reform in the U. S., once having engaged in a major reform we have not immediately jumped in with another. We wait about a generation.

  • steve,

    The problem with that is that costs are the root of the problem. Coverage is expensive because health care is expensive. If healthcare was cheap(er) the problem of the uninsured would be much easier to deal with. And a comprehensive reform that replaced fee-for-service would largely obviate the need for the PPACA. Perhaps you mean it’s a first step politically. I think Dave’s right that there won’t be any more substantive reform for several years at least.

  • michael reynolds Link

    Like Steve, I see this as step 1. It’s very hard to get anything accomplished, ever. Expecting the thing to be done perfectly places an impossible burden and ensures that nothing ever gets done at all. And remember that nothing is exactly what had been done pre-Obama, and exactly what the GOP preferred.

    So we moved from nothing to something. We put a stake through the heart of libertarian fantasies and established health care as a right and a responsibility. We don’t have Berlin, but we do have some beaches in Normandy and that’s a lot more than we had before.

    If costs keep rising then we’ll have to adjust, but now we’ll adjust within a system that begins from the assumption that people have a right to coverage and an obligation to pay for it. That narrows the options by excluding the Galtian non-solutions as well as the “Let it be” option so that we are closer to some lasting solution.

  • jan Link

    I think step 1, as Steve calls it, will act as either a distraction or an inhibitor for step 2 to happen, in either a timely manner, if at all. In MA, for instance, the mandate was applied by Romney as a remedy to ease not only access to HC (attempting to lower the numbers of uninsured in the state), but also to deal with the free riders of HC. Decreasing medical costs were not a component of their legislative actions. And, it still hasn’t been addressed…..

    Also, as stated earlier, if you have a consumer who doesn’t need to consider the cost of treatment in accessing it, then cost effectiveness will not be a component in either their frequency of medical treatment (even for minor problems) or implementation of personal habits in maintaining more optimal health (not smoking, exercise, weight management). In other words, free access does not compute to incentives for lowering costs. And, more efficiency in devising other medical models, IMO, will lead to greater impersonalized practices in medicine, rather than a measurable decrease in medical costs.

  • jan Link

    Furthermore, step 1, is such an enlargement of bureaucratic intrusions, that some of the hypothetical benefits will get lost in the maze of implementation. I forget how many new bureaucracies, IRS people etc. are going to be involved in this step 1 for better medical access. But, it’s enormous! And, again, we still don’t know all the intricacies of the bill. Such a mystery, IMO, will turn into misery for some of the very people it is supposed to help.

  • All I can say is “we’ll see”. steve and Michael apparently believe that either fortified by the triumph of the PPACA or driven by desperation we’ll immediately launch into more healthcare reform (and another and another in continuing approximation). My view is that healthcare reform is such a dispiriting experience for most politicians that they won’t be eager to do it again soon. That’s what’s happened over the last half century. Maybe this time will be different.

  • michael reynolds Link

    My vote is for desperation. And I don’t think Washington ever does “immediate.” I think we’ll look to the Euro crisis for inspiration – desperate and last-minute. ‘Cause we’re America, and that’s how we roll.

  • TastyBits Link

    Winner – Mitt Ronmey
    $4,000,000 in 24 hours

    Winner – Wall Street
    Dow up

    The winners have pulled out the 100% snag-free dacron polyester trousers, platform shoes, and silk shirt. It looks like they have hit the dance floor.

    “Do the Hustle”

  • Icepick Link

    TB, the markets are up today because the Europeans have once again saved CIVILIZATION AS WE KNOW IT by ensuring that the banksters won’t go broke for at least another month.

  • TastyBits Link

    I found someone almost as good as Nigel Farage. I caught a clip of Daniel Hannan. “Europe is giving itself a transfusion – from one arm to the other.”

    “Do the Hustle”

  • steve Link

    @Dave- History also shows us that no country has ever done anything about costs w/o universal care. The ACA, while not universal, is as close as we are likely to get for now.

    I think costs will be much more difficult to fix. We either dont really know how to control them, or are unwilling to embrace things we know will work. I dont really see us working on Medicare until the bond market says we have to. I am not sure we can fix Medicare w/o addressing private insurance.

    The current bill allows for states to experiment. I hope some do, but given that few have tried, I am not hopeful on that front. A lot of GOP hopefuls could be integrated with the ACA. I think selling across state lines will just make docs richer, but it could be tried as maybe I am wrong. Tort reform could be, and should be, tried, but I dont expect it to save a lot of money. It wouldnt be that much of a reach to eventually modify the ACA into a Swiss or German like plan. The ACA already allows for pretty high deductibles, but if the GOP wanted I dont see they couldnt increase the (estimated) $12,000 deductibles in the bronze plan even higher. The tax exemption could be accelerated and include the entire cost of insurance, not just part of it.

    Other than GOP hurt feelings, I am not sure what would keep this from being modified to include costs savings measures, and I have not even touched upon the ones I would prefer, which would include some market based approaches.


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