When the Obama White House set out to make the liberal dream of universal health coverage a reality,it faced two obvious political obstacles. The first was the power of the interlocking interest groups insurance companies,physician associations,pharmaceutical companies that potentially stood to lose money and power in a comprehensive reform. The second was the price tag of a universal healthcare entitlement,which promised to be high enough to frighten vulnerable members of Congress.
The key to overcoming both obstacles,it turned out,was the mandate to purchase health insurance.
In arguments before the Supreme Court last [month,the healthcare mandate was defended as a kind of technocratic marvel the only policy capable of preventing the complex machinery of reform from leaking smoke and spitting lug nuts.
But the mandate is actually a more political sort of marvel. In the negotiations over healthcare reform,it protected the Democratic bill on two fronts at once: buying off some of the most influential interest groups even as it hid the true cost of universal coverage.
The mandate offered the interest groups what all entrenched industries desire: a fresh and captive market for their products.
At the same time,by requiring the private purchase of insurance,the mandate kept the true cost of the healthcare expansion off the governments books,and largely out of the Congressional debate.
So the mandate was politically brilliant,in a sense. But its brilliance was evanescent.
The reality is that the more treatments advanced medicine can offer us (and charge us for),the harder it becomes to guarantee the kind of truly universal,truly comprehensive coverage that liberals have sought for years. The individual mandate conceals these realities,but it doesnt do away with them. If its repealed or swept aside,both left and right might be able to focus on a more plausible goal: not a perfectly universal system,but more modest reforms that would help the hardest-pressed among the uninsured.
In the end,incrementalism wasnt ambitious enough to satisfy President Obama. But given the drift of last [months Supreme Court arguments,he may be wishing that hed settled for something less ideal,but more sustainable,than the bill the mandate built.