by Robert B. Reich

Forget the symbolic vote to repeal health care. Republicans don't have the votes to override Obama's sure veto.

The real move happens later, when Republicans try to cut the money needed to implement the law's requirement that all Americans buy health insurance.

On its face it's a smart tactic. The individual mandate is the lynchpin of the heath-care law because it spreads the risks. Without the participation of younger or healthier people, private insurers won't be able to take on older or sicker customers with pre-existing medical conditions, or maintain coverage indefinitely for people who become seriously ill. The result would be to unravel the health-care law, which presumably is what many Republicans seek.

The mandate is also the least popular aspect of the law. According to a December 9-12 ABC News/Washington Post survey, 60 percent of the public opposes it. While most want to prevent insurers from dropping coverage when customers become seriously ill, they don't like the idea of government requiring them to buy coverage. The mandate not only offends libertarian sensibilities, but it also worries some moderates and liberals who fear private insurers will charge too much because of insufficient competition in the industry.

And the mandate is most vulnerable to legal challenge. In the first major ruling on the new law, announced Dec. 13, Judge Henry E. Hudson of the federal district court in Richmond struck it down, calling the mandate an "unbridled exercise of federal police powers" and an overreach of the Constitution's Commerce Clause. The U.S. government is now appealing that decision.

There's a lesson for Democrats in all this.

The federal government wouldn't be nearly as vulnerable to these political and legal obstacles had the health-care law been built upon the framework of Social Security or Medicare -- public insurance financed by payroll taxes.

Not only are these programs enormously popular ("Don't take away my Medicare!" was a rallying cry among some conservative populists during the debates over the health-care law), but they also rest on a more widely accepted relationship between the individual, the government and the market.

Americans are accustomed to paying for public insurance through their payroll taxes. Such payments aren't viewed as federal mandates that encroach upon individual freedoms, or as payoffs to private companies likely to make even more money from mandatory purchases of their products, but as well-deserved entitlements.

Indeed, the biggest problem with Social Security and Medicare is they're so popular that politicians have had a hard time trimming their benefits to match payroll-tax revenues.

For 60 years, the battle over health-care reform has been waged over these two ways of spreading costs and risks: either through payroll taxes and public insurance, or mandated purchases from private insurers.

For most of those six decades, Democrats advocated the former. Harry Truman's initial plan for adding health insurance to Social Security was defeated, but Lyndon Johnson's Medicare succeeded. Apart from George W. Bush's drug benefit, which was also based on this Democratic framework, Republicans have been on the side of mandated purchases from private insurers.

In 1974, Richard Nixon's proposed Comprehensive Health Insurance Plan would have required private employers to provide their employees with comprehensive health insurance coverage purchased from private insurers. (An employer mandate is tantamount to an individual mandate in that employees are forced to pay it indirectly, via lower wages.) Ted Kennedy simultaneously proposed universal coverage financed through Social Security taxes, essentially copying Medicare. Neither plan succeeded, but Nixon's framework redefined the idea of national health insurance from then onward.

President Obama and a majority of Democrats in the last Congress opted for the Republican model even though many Democrats preferred a single-payer system -- Medicare for all -- or at the very least a public option. Most polls showed that the public favored such an option. But the White House hoped for Republican support and wanted to ward off opposition from health insurers and pharmaceutical companies by promising them some 30 million additional customers.

The current Republican attack on mandatory coverage shows that Democrats who wanted a single-payer system should have stuck to their guns.

Perhaps they'll have another chance. If the Republican attack is successful, single-payer will be the only alternative. And it's the system Americans seem to prefer -- payroll taxes and public insurance.

 

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GOP Attack on Health Care Shows Why Democrats Should Have Pushed Medicare for All | Politics

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