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Suppose the Supreme Court does rule that the health care mandate is unconstitutional? What happens then?

(I'm not saying that they will, but let's play "what if?")

The famous individual mandate is just one piece of the new health care law enacted in 2010. Take away the mandate, and here are two principal elements left behind:

-- A huge expansion of the Medicaid program. The majority of those who'd gain health coverage under the new health care law, an estimated 18 million people, would gain it from being enrolled in Medicaid, the health care program for the poor. Even before the new health care law, Medicaid was a huge program, covering one in six Americans. It's on its way to becoming bigger still, whatever happens to the individual mandate.

-- Tough new rules on insurance companies. The new health care law forbids insurers to refuse coverage on the basis of "pre-existing conditions." All applicants must be accepted, and they must be covered at the same price as the other members of the insured group.

Now let's war-game what happens post-mandate.

1. The private insurance market will crash in a spectacular train wreck.

Faced with big new costs and deprived of their expected new revenues from the mandate, insurance companies will have to raise prices. Faced with rising prices, employers will cut back coverage.

The 2010 law imposes new obligations on employers to provide health insurance but also presents employers with an option to escape those obligations by paying a (comparatively) small fine. As insurance costs surge in a post-mandate world, more employers will take advantage of that option. Their employees will join the new market for individual care, the famous health care "exchanges."

Minus the mandate, the policies on offer in the exchanges will be unexpectedly expensive. Minus the mandate, many individuals will choose not to buy. The law offers subsidies to buyers who cannot afford the full cost of the new policies. Minus the mandate, those subsidies will cost much more than expected.

2. The Medicaid program will grow.

The new health care law dramatically expands eligibility for Medicaid. In a post-mandate world, with employers dropping coverage and the individual market careening into dysfunction, Medicaid will likely grow faster than ever.

Costs of the Medicaid program are divided between the federal and state governments. As Medicaid surges, those governments will face an agonizing dilemma: Raise taxes to pay for all those new applicants or reduce coverage, leaving millions of people to clinics and charity.

3. Meanwhile, the Medicare time bomb will continue to tick.

The U.S. already has a single-payer health care system. It's called Medicare, and even today, it is one of the largest single-payer systems on Earth, enrolling more than 47 million people. As more and more of the baby boomers turn 65, the program is scheduled to expand rapidly -- to more than 63 million people by 2020 and more than 80 million by 2030.

We are headed, it would seem, to a post-mandate future that looks something like this:

Medicare will provide fairly generous government health coverage to about one-quarter of the population.

Medicaid will provide much less generous government coverage to one-quarter of the population.

The population outside Medicaid and Medicare will subdivide into two main groups:

The affluent and those whose labor is greatly valuable to their employers will be covered by an ever-more-expensive and ever-shrinking private-insurance market.

The people who can't pay themselves and whose employers won't pay for them will drop out of the private market, and either look for ways to qualify for Medicaid or wait and pray until they qualify for Medicare.

Political pressures will induce politicians to open Medicaid to more and more uninsured people. Fiscal pressures will force politicians to make Medicare less generous and more Medicaid-like.

If the Supreme Court rules unconstitutional the plan for universal coverage through private insurance, the U.S. will continue to evolve toward a government-led system -- albeit one much more expensive, and much less satisfactory, than the government systems of other advanced democracies.

Perhaps after a decade or two of discontent, somebody else will try another reform. But this time, the reform will proceed as an outright government program. There won't be any choice, if the Supreme Court of 2012 precludes as unconstitutional the private-sector alternative -- meaning that today's would-be champions of the free market will have unwittingly brought about the grandest expansion of government control since the 1930s. http://www.cnn.com/2012/04/02/opinion/frum-government-health-care/inde
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The individual mandate might prove to be the death knell for President Barack Obama's health care reform.

Politically, the polls have been clear. While most parts of the Affordable Care Act are immensely popular with the public, as recent data from the Kaiser Foundation has shown, the individual mandate is unpopular. (A CNN poll found that a bare majority of Americans oppose the mandate to buy health insurance.)

The Supreme Court heard arguments last week over whether the mandate is constitutional, and the administration is now waiting to see if the court will dismantle this key part of the program -- or possibly throw out the entire health care law.
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Although the individual mandate was born out of conservative proposals in the 1990s -- an effort to lower costs by requiring people to buy into the private market rather than creating a government program -- the presence of the mandate is also a product of the timidity liberals have displayed about their ideas since the 1990s.

As Princeton sociologist Paul Starr has written in the New Republic, during the 1990s the mandate was perceived as the "conservative alternative to the Democrats' proposed mandate on employers to pay for a share of health insurance. The Republican proposal was thought to represent a more individualistic, market-friendly approach."

Whereas liberals were once willing to defend the role of the federal government in American life and, even more importantly, defend the costs that federal programs imposed on the citizenry, liberals since the Age of Clinton have relied on developing jerry-built solutions to domestic programs that are often unpalatable politically -- and don't accomplish their goals.

For much of the 20th century, liberals argued that government was an essential part of national life and that Americans would have to live up to certain obligations to support social programs that came with the privileges of citizenry. During the New Deal, President Franklin Roosevelt was not bashful about defending the value of government.
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When Ted Kennedy championed health care, his vision was still very much akin to the "single- payer" model of other countries where the government would be the insurer of first resort.

But during the 1980s, after Ronald Reagan entered the White House and the modern conservative era began, liberals retreated into a defensive stance.

After Democratic candidate Walter Mondale suffered at the polls in the 1984 campaign when he admitted that he would call for higher taxes, most Democrats were resistant to proposing any kind of revenue increase. The shift could be seen with health care.

When President Bill Clinton proposed health care reform in 1993, he avoided the single-payer model that had been favored by older liberals like Kennedy for decades and instead opted for a complex system that aimed to create new mechanisms for offering and purchasing health insurance and stronger regulations to lower costs.

The complexity of Clinton's plan, which involved an employer mandate, left his program vulnerable to attack from Republicans who characterized it as a Frankenstein monster that would result in massive deficits.

Obama fell into a similar trap with health care. Although he was more open than many of his predecessors to championing an active government, he acted from a defensive posture. His health care proposal was even less ambitious than that of Clinton. He essentially chose a path that regulated the existing system and required all Americans to be part of it.
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Obama allowed Congress to drop the public option that would create an alternative to private insurance. The result was an extraordinarily complex system, which depended on a mandate requiring the purchase of private insurance to make sure that costs were covered. The government intervention was indirect; the financing mechanisms were murky.

It is not surprising that the individual mandate has caused so many problems. At its core, the mandate constitutes a conservative solution to the problem of costs and part of an effort by liberals to ensure health care coverage without resorting to the kinds of government interventions that liberals once championed.

Obama ultimately promoted the health care bill as a cost-cutting measure that would create greater efficiency in markets. He did not focus as much as his predecessors on the right to affordable health care that is implicit in the name of the bill.

While conservatives have attacked the program -- focusing on the mandate -- with great clarity, the president's hesitant defense of this complex system has done little to rally the public behind it. http://www.cnn.com/2012/04/02/opinion/zelizer-health-care-liberals/ind
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