Win or lose at the Supreme Court, the GOP is likely to suffer at the ballot box as long as health is a central issue in future campaigns.

Romney health care speech - Rebecca Cook : Reuters - banner.jpg


Over at his relatively new Daily Beast digs, David Frum argues that Republicans are in trouble if they lose the Supreme Court challenges to the Affordable Care Act. He says that if the law is ruled constitutional, then "healthcare comes roaring back as a campaign issue," and a potent one, for "because of the prolonged economic downturn, more Americans than ever have lost -- or are at risk of losing -- their health coverage." What are Republican candidates going to tell those people?

Says Frum:

If Republicans lose in the Supreme Court, they'll need an answer. "Repeal" may excite a Republican primary electorate that doesn't need to worry about health insurance because it's overwhelmingly over 65 and happily enjoying its government-mandated and taxpayer-subsidized single-payer Medicare system. But the general-election electorate doesn't have the benefit of government medicine. It relies on the collapsing system of employer-directed care. It's frightened, and it wants answers.

"Unconstitutional" was an answer of a kind. But if the ACA is not rejected as "unconstitutional," the question will resurface: if you guys don't want this, want do you want instead? In that case, Republicans will need a Plan B. Unfortunately, they wasted the past three years that might have developed one. If the Supreme Court doesn't rescue them from themselves, they'll be heading into this election season arguing, in effect, Our plan is to take away the government-mandated insurance of millions of people under age 65, and replace it with nothing. And we're doing this so as to better protect the government-mandated insurance of people over 65 -- until we begin to phase out that insurance, too, for everybody now under 55.

Meanwhile, at The New York Times, Ross Douthat argues that conservatives may be in political trouble in the presidential race if they win at the Supreme Court and the individual mandate is struck down:

The unpopularity of the president's health care bill is a settled reality of American politics. But as liberals have long hastened to point out, not every provision of the bill is unpopular. If you isolate the legislation's various components, many of them poll reasonably well.

The individual mandate, though, tends to be far less popular than the legislation as a whole .... If the Supreme Court invalidates the mandate, the justices' traditional "presumption in favor of severability" will probably ensure that the rest of the legislation remains intact -- which might reassure moderate voters that the health care bill wouldn't actually trample their liberties, because the courts are on the case. Stripping away the law's most unpopular component might make the rest of it marginally more popular. And setting a clear limit on liberalism's ability to micromanage Americans' private decisions might make voters feel more comfortable voting to re-elect their micromanager-in-chief.

There's a third possibility: the Supreme Court strikes down the Affordable Care Act in full. And if that happens? It sure seems possible that health care would emerge as one of the biggest issues in campaign 2012, and President Obama would be able to best Mitt Romney, who is so twisted around in pretzels on the subject that nearly anything he says can be attacked as hypocritical. And there would remain the general failure of the GOP to articulate a health-care agenda that voters like (besides the prescription drug benefit and promising not to cut Medicare).

None of this is to say that they shouldn't fight the law. If it results in a precedent that puts a hard limit on the federal government's power, reversing the absurd, tyrannical decision in Wickard v. Filburn (the state should not be able to prevent you from growing food on your farm) and the egregiously intrusive decision in Gonzales v. Raich (growing medical marijuana for your own use is not interstate commerce, and is more properly governed by state law), it'll be a victory for ... well, for libertarians, and conservatives will feel good about it too, until the precedent thwarts some future excess of theirs. In any case, health care sure seems like a political loser for the GOP.

And that isn't likely to change.

As James Joyner writes:

The combination of unsustainability [sic] high growth in health care costs and the enormous competitive disadvantage that puts on American business means that our current system of quasi-private, insurance-based medicine will collapse of its own weight. Like it or not -- and I mostly don't -- Americans will wind up with some sort of government-centric model, likely one that provides basic coverage at a fixed price with some option for private supplemental coverage for those who can afford it.

And as Ezra Klein explains:

At the moment, our understanding of the genome remains relatively crude, and our ability to predict future health risks based off of genomic sequencing is limited. But we're getting better at it. For instance, women in families with a high rate of breast and ovarian cancer can have themselves tested for alterations in the BCRA1 and BCRA2 genes. If they test positive, it means their risk of developing breast or ovarian cancer is significantly higher.

As we sequence more genomes, mine more data, and conduct more studies, we'll find a lot more of these connections. Eventually, genomic testing will be a powerful predictor of future illness. And it raises the potential that young people will get themselves tested and then purchase insurance based off the result. So those with a clean genomic result might go for a cheap catastrophic plan, while those with a high risk of developing pricey illnesses will opt for more comprehensive insurance.The result would be, in insurance terms, an "adverse-selection death spiral," as the healthy opt out of expensive insurance, the sick opt into it, and premiums spin out of control.

Already 85 percent of Americans want government to force private insurers to sell policies to anyone even if they have a pre-existing condition. Is it even plausible that anything like a free market in health care is going to survive the political, economic, and technological developments of the next decade? As a purely political matter, I wouldn't want to be the party fighting for that proposition. On the other hand, the sort of health-care reforms I'd like to see are relatively market-friendly. For complicating information see Avik Roy's characteristically astute post

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