The worst case scenario at that point is that insurance companies will have to go to 50 state-based exchanges to document precisely how much the cross-subsidy costs before passing it along in the form of higher rates. A transparent public accounting of the transferred costs for the free-riding uninsured would be a good thing.
Repealing the mandate will also moot the federal court challenges to reform filed by 20 or so Republican state attorneys general and private groups. The mandate is the only element of the law that makes it vulnerable, and given the judicial activism of the Roberts court, why chance having the whole bill voided for a non-essential provision?
Another provision the Democrats could add on to their “repeal” bill would be elimination of the tax on high-cost plans, which doesn't go into effect until 2018. There will be plenty of time to debate health care tax reform once the exchanges are up and running.
Repealing those two measures will take all the steam out of Republican efforts to kill reform. While picking on the mandate and the Medicare "cuts" were nothing more than election season demagogy, Republicans were not dishonest when they said they philosophically oppose the overall thrust of the bill. They remain committed to a vision of reform articulated by Sen. John McCain during the 2008 election. They want employer vouchers, insurance plans that cover catastrophic care only, and high co-pays and high deductibles -- all of which are designed to make health care more market driven by making consumers have "more skin in the game."
In my view, it's an impoverished view of how to hold down health care costs because it will have disastrous health consequences. People left to their own devices do not have the time or sophistication to sort out what preventive and routine services are most consequential to their long-term health.
More significantly, it will fail at holding down costs. People in emergency situations or facing chronic or serious illnesses (the 80 percent of all health care expenditures attributable to just 20 percent of the population) are in no position to act other than as passive consumers of decisions made by their providers. Most of those decisions are wise. Some are pound-foolish from health care system perspective. You're sick. Your doctor is telling you what to do. Do you want to make those decisions based on your own personal pocketbook considerations?
Reform of the health care delivery system, which is begun in the reform bill, remains the best hope for getting health care costs under control while simultaneously improving overall health. Transferring success in the pilot projects contained in the law to the broader system is the most humane way of achieving the $500 billion in Medicare savings contained in the legislation.
The mandate and the tax on high cost plans have nothing to do with any of that. In the spirit of compromise, they should be the first things to go.
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