My (very non-expert) two cents on PPACA
The Supreme Court’s recent ruling on the federal individual health care mandate (National Federation of Independent Business v. Sebelius) was necessarily ideological; the validity of the law with respect to the Constitution can hinge on points such as whether health insurance as mandated in the Patient Protection and Affordable Care Act (PPACA) can be interpreted as a tax. But the Court’s ruling should not be thought of as an approval or affirmation of the idea of universal health care but solely of the PPACA’s particular approach to implementing health policy.
Somewhere along the way, as I think sometimes happens in politics, the debate about federally mandated health care insurance became an ideological debate and lost sight of what should be the real goal of health policy, which is to improve healthcare outcomes. Unfortunately the necessarily ideological points of the Supreme Court ruling don’t help the issue; as far as I can tell (being a person of left-wing sympathies), the aspect of the PPACA that gets right-wingers fired up is that it is a tax and they don’t like taxes, in a religiously axiomatic way.
I dislike these fervid anti-tax stances. As I believe has been said by famous economist Milton Friedman, “To spend is to tax.” A true anarchist may support a zero tax rate because he supports zero government, but everyone else should have some level of taxation that he is willing to support in order to keep his desired level of government running. The taxes are a means to the government’s ends defined by our laws and policies, and I think people who attack taxes rather than expenditures take the wrong approach. Rather than opposing enactments because they are taxes, we should be making judgments on whether their contents are worth the taxes that will be necessary to support them.
I think it’s perfectly fair for people to disagree about whether the costs of the PPACA merit the benefits. Here reasonable left-wingers and right-wingers may differ in their personal opinions of the value of healthcare; one person may believe that an annual expense of up to $400 per person is justified to provide a certain level of universal health coverage, whereas another person may consider the justified amount to be $200 per person. (In March 2012 the CBO estimated the cost of the PPACA to be $1.1 trillion over the next 10 years, which assuming an average US population over that time of 325-350 million comes out to $314-$339 per person per year). For any reasonable person there is some cost that is low enough and some cost that is too high.
The point that people should not disagree on, though, is that any improvement in healthcare efficiency – any policy which can improve the quality of healthcare treatment for the same amount expended – is a desirable outcome. For the same reason that we cheer on the development of more potent drugs, innovative surgical techniques, scientific breakthroughs in biochemistry and genetics, etc., we should also cheer on any government policy that delivers better healthcare for the same cost.
The right-wing response is generally to say that the least government involvement results in the most efficient outcomes, but this is a policy guideline and not a mathematical law. It’s well-known that the US spends the most money in the world per capita on healthcare; this is not inherently problematic, but it does suggest the question of whether we are getting the best healthcare bang for our buck. And there’s nothing incompatible with supporting government action in one sector of the economy while advocating a hands-off approach in others. This sounds obvious but I think the casually educated free-market pundit has a tendency to shoehorn every industry and every economic situation into whatever toolbox or philosophy she learned in undergraduate economics 101. Understanding basic economic principles is important but reality does get more complicated.
The big challenge for the left is to keep itself honest about the true goal of healthcare reform, which is to get a healthier populace per dollar spent. It is not my opinion that universal health insurance is an end in and of itself. I think some leftists embrace and rally around the “X for Everyone” mindset but I think that’s far better achieved through the market if possible; rather than mandating “X for Everyone” and supporting it with taxes, let’s get good X so affordable that anyone can buy it. At least I continue to think that’s the ideal way to do things whenever you can, for commoditized products, and I definitely think that inadequate concern for efficiency, or excessive concern for equality over efficiency, leads to serious long-run institutional frailties in most economic situations.
Health insurance is not necessarily a commoditized product for which we can rely on all-private markets (I think comparisons of the individual mandate to requiring people to buy some random product like a car is totally fallacious). But maybe the individual mandate in general, or the individual mandate as implemented by PPACA, isn’t the right answer either; leftists need to be honest with themselves when monitoring its ongoing success or failure and not be content with just saying that we’ve now achieved universality and let’s rest on our laurels, not lose sight of the goal of improving outcomes.