One weird problem in national policy debates is that it's almost impossible to run genuine experiments.
Since policymakers can't try out two sides of an issue on different groups of citizens, only one approach ever gets implemented. But the other idea actually benefits from remaining forever theoretical: Safely ensconced in abstraction, the untried approach — no matter how bad — can perpetually claim to be the greener grass.
So as perverse as it sounds, the Supreme Court's decision today to preserve ObamaCare did the Republicans a huge favor.
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The guts of King v. Burwell concerned a technicality. According to the plaintiffs, the actual wording of the law implied that only health care exchanges established by state governments should receive federal subsides. (ObamaCare allowed the federal government to establish an exchange if a state government refused, and many did.) The justices disagreed, but their logic need not concern us here. What does concern us are the consequences if they had found otherwise.
Coverage would have been far more expensive in the federal exchanges, letting many buyers escape the individual mandate through the hardship exemption. Since making insurers take all comers could jeopardize the companies' finances, the individual mandate requires everyone, even the healthy, to buy coverage. And the subsidies ensure people can afford to comply. Without them, the individual mandate would have been effectively destroyed, and the insurance market would have entered the "death spiral" that ObamaCare was designed to prevent.
In short, had the plaintiffs won, we would have been left with a giant national demonstration project: one collection of states enjoying stable, functioning health care insurance markets under ObamaCare; the other collection grappling with the pre-ObamaCare status quo, except considerably worse.
This alone would have probably driven most states to knuckle under in short order and establish their own exchange. But there would have also likely been some holdouts, giving conservatives an opening to test their own ideas in some states.
To the extent conservative alternatives to ObamaCare exist — and the GOP certainly hasn't been able to settle on one — they largely revolve around the claim that ObamaCare doesn't "really" provide a market in insurance. Conservatives would like to do away with both the regulations forcing insurers to take all comers, which would then allow them to eliminate the individual mandate. Without the regulations, and with "real" competition, conservatives figure the costs of insurance would come down, allowing them to cut the generosity of the subsidies.
Peter Suderman, a libertarian and long-time opponent of ObamaCare, summed up the idea pretty well, writing on Monday that a better system "would expand coverage and access to care by making it truly cheaper for everyone instead of increasing the cost and adding subsidies."
The thing is, when someone is denied health care, the cost is at once zero (it never happened) and entirely too high (people are denied care when they can't afford it, or their insurer can't afford it on their behalf). Conversely, the big expenses that truly drive the cost growth in American health care are made possible because that care is, in turn, too cheap. The question of distributing health care is the same as distributing gasoline or food or rocking chairs: There's only so much to go around, so rationing decisions must be made. The pre-ObamaCare status quo rationed health care by giving to the well-off in abundance, and giving little to nothing to the poor.
There is no way to right that injustice without costs going up on someone — namely, those who previously enjoyed abundance. It's a matter of simple math. You can redress the matter through the government, and distribute care through something like single payer. Or you can redress it by trying to shift the flow of resources through the competitive private markets themselves, which is what ObamaCare does. (Everyone who abhors "rationing" forgets that rationing is exactly what markets are supposed to do.)
But shift it you must. And that is the fundamental fact that every conservative alternative must contend with and yet cannot. The horizon upon which every one of their proposals has converged has been the same: A world in which everyone bears their own risks to the greatest extent possible. The young, the healthy, and the well-off enjoy the fruits of their good fortune, while the old, the sick, and the poor struggle alone under the consequences of their misfortune.
Had King v. Burwell gone the other way today, that is what we would likely have gotten: the ObamaCare world and the right-wing world, allowed to jointly operate side-by-side, for everyone to see. We would have gotten our experiment in the real-world consequences of both visions. Instead, that right-wing world will remain safe and immortal in its theoretical abstraction.
If you think the American people have any sense or moral decency, you have to conclude conservatives and their Republican champions in Congress dodged a massive bullet today.
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