On the Affordable Health Care Act

John Robert Behrman is an economist, retired, and was formerly State Democratic Executive Committeeman for SD-13, including the Texas Medical Center.

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The Supreme Court, including Chief Justice Roberts, has stepped back from the brink by not gutting the Affordable Care Act (Obamacare). I guess I should be happy.

But the still conservative majority on this court may have simply recognized that they risked more public support for the President and a move closer to a single-payer system with another radical, split decision. The court majority still have the complexity and unpopularity of the new law working for them. They know that Washington concession-tenders cannot make a relatively simple disability insurance program work for Iraq and Afghanistan veterans.

Democrats at every echelon of government (other than the Supreme Court) have to make this aw work despite (a) its constitutional near-death experience, (b) the very nature of health insurance policy sales racketeers they partnered with, and (c) the actual complexity, from state to state, of our motley institutions of public health and medical care. That is what we have: public health and medical care. “Healthcare” is oxymoronic lobby-jargon. The fact that our party’s national policy elite -- bundlers and consultants -- believe in “healthcare”, the “Latino vote”, the Easter Bunny, and so on portends how hard this will be and how perilous the present situation still is.

Here’s a suggestion:

Oregon and Washington State should opt out of Obamacare, as the president has invited them to do. They can create a system of public health and medical care that is fiscally and actuarially sound. Moreover, this would support them in worldwide competition for jobs and capital for the region: Seattle, Portland, and Tacoma. These two states would even have four senators in Washington, D.C., one of whom, Ron Wyden, actually knows what he is talking about in these matters.

So Oregon and Washington should be proud and can lead the nation.

As a legacy of WWII shipbuilding, aircraft factories, and nuclear ordnance, these two states have comparatively strong institutions of public health and medical care, including Kaiser-Permanente and Group Health of Puget Sound health maintenance organizations, as well as very reputable medical schools. These are embedded in other healthy industrial and commercial institutions. Moreover, public health authorities in these states have to deal with two of the most hazardous occupations in America: fishing and logging. In sum, Oregon and Washington are comparatively proficient in public health and medical care. Their patriotic, liberal, and scientific institutions are not unduly burdened by legacies of “scientific racism”, although they may have been somewhat tainted before and during WWII by anti-immigration bias and eugenics.

In short, these two states have the economic and technical scope and scale –- also every political and economic incentive –- to do a fine job of national health insurance built on other wholesome civic and professional institutions they have. This is something our federal, not our national, system of politics and government can accomplish in a highly regionalized global economy.

Moreover, the success of Oregon and Washington should be a signal to Texas Democrats. We could be the national leader in combining energy, industrial, and environmental policy as soon as 2014. We were once before, “back in the day”. We could swap some tips: Oregon and Washington are not leaders in combining energy, industrial, and environmental policy, quite the contrary.

In the midst or aftermath of huge wars, progressive policy has been dumped by a prestigious, victorious government in Washington on small or backwards states. Lyndon B. Johnson could even play Otto von Bismarck, and did so, by creating Medicare, barely and just before losing the war in Vietnam. However, even though “Obama got Osama”, the old flood-down paradigms of “Military Keynesianism” and post-war progressivism will not work for our beleaguered President or utterly marginalized state party today.

We have to try something new, even if it is actually old.

This post is dedicated to the memory of my childhood friend, the late Cicele Bostrom. Raised in Houston and Gonzales, Texas, she became President of Group Health of Puget Sound and a distinguished member of the Washington State Board of Medical Licensure. The flow of labor, capital, and culture between US states and our overseas trade partners that she epitomized is more progressive than the trickle-down of pork and patronage from state or national capitals.

Our so-called conservatives don’t know that and the so-called liberals have forgotten it.

It stands.

I'm still not quite ready to believe that Justice Roberts joined the liberal wing in the majority. I would not have ascribed a 1% chance of that happening.

Excerpts follow from the SCOTUS(live-)blog.

SCOTUS holds that mandate violates the Commerce Clause, but is constitutional under legislative branch's power to levy and collect taxes.

In his opening statement in dissent, Kennedy says: "In our view, the entire Act before us is invalid in its entirety."  

Amy Howe: 

In Plain English... The Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. There were not five votes to uphold it on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power. That is all that matters. Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose new funds if they didn't comply with the new requirements, rather than all of their funding.

I'll assemble various reactions later today.

Update: A fairly hilarious Twitter aggre-reaction. The first Tweet there is in response to CNN's initial webpage update, quickly pulled down, that said the ACA was rejected. And Republicans in Congress Tweeted that the law had been struck down, and then deleted them once they figured it out had it explained to them by a fifth-grader.

Update II: Lyle Denniston of SCOTUSblog:

Salvaging the idea that Congress did have the power to try to expand health care to virtually all Americans, the Supreme Court on Monday upheld the constitutionality of the crucial – and most controversial — feature of the Affordable Care Act. By a vote of 5-4, however, the Court did not sustain it as a command for Americans to buy insurance, but as a tax if they don’t. That is the way Chief Justice John G. Roberts, Jr., was willing to vote for it, and his view prevailed. The other Justices split 4-4, with four wanting to uphold it as a mandate, and four opposed to it in any form. 

Update III: Fox News' losing efforts to declare ACA unconstitutional. Their only recourse now is to impeach... Chief Justice Roberts.

Update IV: "(T)he ‘Scalia Freakout’ ended up being the big tell about this morning’s ruling."

Update V: Mitt Romney just had his reaction televised, and you would have thought his dog had died. Well, maybe his dressage horse. Then again, maybe his wife. OK, his political fortune. Seriously, I've seen more joy expressed in eulogies.

Harold Cook has a sly take:

So to review: the Supreme Court concluded that health care reform is constitutional, including the individual mandate (although SCOTUS apparently characterized it as a tax). The Republicans will try to spin the hell out of the "tax" part, even though it's only a tax for those Americans who fail to do what is required under Mitt Romney's health care plan.

The individual mandate only exists because it was the mechanism Republicans said they liked, and the mechanism their own Presidential nominee said is essential. Then the Republicans immediately decided that their own plan was terrible, evil, and unconstitutional, because it happens to be signature legislation of a President they hate, and Republicans sued to have it overturned.

So remind me again - what aspect of affordable health care to Americans can Republicans take credit for? Zero. Less than zero. They even fought like hell against their own funding mechanism to ensure its failure. Fortunately, they have apparently failed.

Those 14 original Republican Attorneys General who sued to overturn the plan? They'll spend the rest of the day complaining, and rename "Obamacare" to "the Obamacare Tax," all without presenting a new idea of how they would have made health care affordable.

Vast and Spurious

Before the Republicans' big bad day kicks off, let's all take note of the fact that the Bureau of ATF agents allegedly involved in a Mexican gunwalking conspiracy told Fortune magazine that it didn't happen.

Never happened.

This "Fast and Furious" bullshit that conservatives have been screaming about for a couple of years turns out to be a fairy tale. A myth. An urban legend.

But they never let the facts get in the way of a lynching before. Why start now?

Has Fox News mentioned anything about it yet? As the Most Interesting Man in the World has said: "I don't always watch comedy masquerading as a news broadcast, but when I do... it's on Fox."

Just thought I'd help get this development out there before the political world explodes in a few hours over health care.

As we wait for tomorrow's decision on health care...

Here's a little light reading.

HOUSTON – Last year, Luis Duran drove almost 200 miles to San Antonio to have a colonoscopy because he didn't want to wait six months for an opening at a county clinic.

A few days later, the doctor in San Antonio – a friend of a friend who had performed the screening for free – called to break the news that Duran, 51, had advanced colon cancer and needed immediate surgery.

"I kind of broke down," recalled Duran, a machine operator whose employer had terminated his health policy.  "I said, 'Doctor, I don't have insurance, and I don't have much money, but I won't refuse to pay. Please help me.'"

They say everything is bigger in Texas, and the problem of the uninsured is no exception. The Houston metropolitan area has one of the highest rates of uninsured people in America, and a health safety net imploding under the demands of too many people and too few resources.  Almost one in three residents – more than a million people -- lack health insurance, and about 400 are turned away every day from the county hospital district's call center because they can't be accommodated at any of its 23 community or school-based centers.

Those seeking care at the public hospital's ER, meanwhile, arrive with blankets and coolers full of sandwiches and drinks in anticipation of waits that may go 24 hours or longer.

"If the Affordable Care Act is overturned, the rest of the country should take a good look at the situation in Texas, because this is what happens when you keep Medicaid enrollment as low as possible and don't undertake insurance reforms," said Elena M. Marks, a health policy scholar at Rice University's James Baker Institute for Public Policy and a former city health official.

No, they are NOT all Ill Eagles.

With its fiscally conservative philosophy and cash-strapped state budget, Texas does not offer Medicaid coverage to childless adults unless they are pregnant, disabled or elderly. Parents of children covered by welfare are eligible for the state-federal health program only if they make no more than $188 a month for a family of three.

At the same time, the proportion of Texas workers with employer-sponsored insurance is almost 10 percentage points lower than the national average of 61 percent, in part because of the state’s high concentration of jobs in the agricultural and service sectors, which often lack benefits.

"They're hourly wage earners, nannies, [people] working in lawn care services or dry cleaning or real estate, or people working two part-time jobs and neither will pay for health care," he said. "Many are small business owners who are well-educated and well-dressed."

Any Republicans you know think this is a problem? And if they do, can any of them acknowledge that something needs to be done about the problem without blaming undocumented people for the problem?

Update: "We need to accept the principle that sometimes the poor will die just because they are poor."