survived a motion to dismiss the complaint, allowing this legal challenge to be heard on its merits. And today Missouri is voting on a ballot measure similar to Virginia's statute, that purports to allow Missourians to reject the requirement of an individual mandate. I struggle to understand the thinking behind this spate of lawsuits and other state initiatives. As a legal issue, the question whether a provision in the federal legislation that would penalize people who choose not to purchase health insurance exceeds Congress's powers under the Commerce Clause, is somewhat interesting, but it seems doubtful that states are taking action for the primary purpose of exploring that interesting issue of constitutional law. As a political question, I understand the desire of opponents of health care reform to use any means available to derail this legislation. I think I even understand some of the philosophical underpinnings of this opposition--the distrust of government, the belief in markets, the desire to leave people to their own devices in making decisions that affect their own lives. It is understandable that people who believe that the government has no business providing any social services to anyone, whether Social Security, Medicare, housing assistance, food stamps or any other form of assistance, would oppose any further intrusion of government into health insurance.
But it is in the practical workings of health insurance that my understanding of this movement starts to break down. The people behind these lawsuits and statutes must recognize that without some mechanism for requiring healthy people to pay into the system, health insurance becomes increasingly unaffordable for those who need it most. In other words, if we are going to prohibit insurance companies from turning down or gouging people with pre-existing conditions, we can't allow people to wait until they get sick before they apply for health insurance. Those who oppose any requirement for making people who do not currently need coverage pay for it anyway, are either deliberately trying to create an unworkable insurance system, or they are the victims of some kind of magical thinking. The kind of thinking that would allow drivers to wait to purchase liability insurance until after they have an accident. Or that would allow homeowners to purchase fire insurance after their house burns down. We recognize (in the case of homeowners, at least mortgage holders recognize) that if we don't require drivers and homeowners to purchase insurance, whether they need it or not, the system will not work. Somehow we fail to recognize the same reality for health insurance.
The opponents of health insurance reform seem to feel that they do not have the burden of coming up with a plausible alternative. They cannot point to any other country as a model. They cannot defend our current system, which costs twice as much as most other industrialized nations, and produces worse outcomes. And they cannot construct another workable model that satisfies the goal of providing affordable coverage for all. They seem to be living in a world where the top never stops spinning.
What would happen if these measures succeeded, and Congress were prohibited from imposing tax penalties on people who choose not to buy health insurance? Wouldn't that leave Congress only with the alternative of funding health insurance out of payroll or income taxes, the way that we fund Medicare, Medicaid and the VA? No one seems to question the constitutional authority of the federal government to run a purely socialized system of medicine for the poor, the elderly and for veterans. If the government cannot enact a hybrid system for the rest of us, would there be any alternative to something like Medicare for everyone?
(magic pill illustration from photobucket)
UPDATE (8/4/10): Missouri primary voters (about 23% turnout) yesterday voted overwhelmingly (over 70%) in favor of the ballot measure that would not require people to buy health insurance until they get sick. In other news, they also voted overwhelmingly in favor of a measure that would allow everyone to have their cake and eat it.
UPDATE (8/6/10): I read today that Howard Dean thinks we don't need a mandate, and he predicts it will be eliminated once the bill finally goes into effect. That sounds like some more magical thinking to me, but wouldn't it be nice if he were right.