Some TMI-Type Thoughts on Obamacare and the Last Chance

I used to run a lot.  And I used to be fast.  No, really, I was!

I still run when the weather’s decent, and I’m not slow . . . but let’s just say I’m definitely in decline.

And I can pinpoint the moment my decline started.  It was 8 years ago, and I was a 27 year old graduate student at the University of Iowa sitting amidst a pile of paperwork on the floor finishing some research for school (the floor is often my preferred place to conduct research, to the consternation of my wife) when I decided to quickly stand up.  I did, awkwardly, and felt my right knee pop.

I’ve never quite been the same.  Though I’ve continued to run and do other things, I can’t go as far as often or with the reckless abandon I used to.

It’s all part of getting old, I suppose.  I just never expected it would happen so suddenly.  Sigh . . . .

But, turning back to the task at hand (aren’t you wondering what that is!) . . . this last week I reaggravated my old knee injury, and it’s the worst it’s ever been.  It’s difficult to walk on it.  With rest, ice , and Ibuprofen I’m sure things will improve, but I think I’ll probably need surgery before I can return to much (if any) serious physical activity.

There’s just one problem — I’m uninsured.  Have been for the last 2 years.

My family’s uninsured.  Has been for the last 2 years.

In April 2011, I voluntarily left a good paying job at a Salt Lake City law firm that treated me well to strike out on my own in the middle of a recession.  I didn’t have a single client.  I didn’t have health insurance.  I had no idea what I was doing when it came to marketing or running a business (two years later, I have some vague ideas . . .).  I had some savings and food storage.  I had five young children and an amazing and patient wife.

View it as a leap of faith or abject stupidity.  Personally, I alternate between the two.

Things started out very rough, but have gradually gotten better.  My financial situation is improving — though we’re still struggling month to month and are far away from the point where we can afford health insurance.  Even high deductible plans would place an extraordinary strain on our meager resources.  And HSAs?  Nice idea, but for me right now, ha ha ha ha ha . . . .

We’ve been lucky so far.  We’ve avoided the emergency room and surgery–thanks in no small part to an extraordinary wife who has successfully treated numerous injuries and maladies at home — everything from small magnetic balls stuck far up a child’s nose to numerous severe lacerations and eye trouble —  when I was ready to head to the clinic or hospital.

Believe me, I don’t like walking the no-insurance tightrope.  But it is where I am right now.

I hope it’s not where I am a year from now.  Because in 2014, I — and many others like me — will have to purchase health insurance, like it or not.

It won’t be cheap.

And there are a lot of people who aren’t going to be happy about it.  The predictable result of Obamacare’s forced consumption will be premiums rising at an even greater pace than now, if you can conceive of that.  People will struggle to keep up and won’t be happy.  If my firm continues to do better, I’ll be buying insurance.  If not, I (and many like me) will be forced on to Medicaid or penalized at tax time.

President Obama and the Democrats know this.  And they’re counting on it.  They’ll want to parlay the frustration and discontentment over Obamacare 1.0 into Obamacare 2.0: National Health.  It’s been the plan from the day it became clear that, even in the dark recessionary days of 2009 and 2010, national health was a political non-starter.  The one-step program became a two-step program.

There’s nothing nefarious about it — though I personally don’t particularly like it — it’s normal political strategy motivated by a sincere desire to solve this country’s health insurance problem.

And let me tell you, folks, Obamacare 2.0: National Health is where we’re going unless someone is able to provide an workable, alternative plan for healthcare.  In fact, if no one can provide and stand up for a serious alternative vision — if all we’re left with is the choice between Pre-Obamacare 2009, Obamacare 1.0, and Obamacare 2.0: National Health . . . it should be national health.  Shocking?  Well, it’s true.

But it doesn’t have to be that way.  It’s not the choice we have to make, and it’s not the choice we should be making.

There are other choices out there in need of a champion.

GOP:  I’m talking to you.

You have one last chance to avoid national health.  You’ve already wasted 3 years trying to get rid of Obamacare via lawsuit without having a replacement plan other than “the market.”  Now, the window to avoid national health is 2013-2016, and may not even be that long.

To borrow a phrase from our President:  ”Let me be clear” — If you don’t present a workable (compelling would be nice) alternate vision for healthcare in this country before the next Presidential election . . . hello true socialized medicine.  And don’t it always seem to go, that you don’t know what you’ve got ’til it’s gone??!!

What would a workable alternative vision look like?

First and foremost, it would solve the problem of access created by out of control costs.  It would be comprehensive.  It would include serious tort reform.  It would eliminate insurance company abuse of preexisting conditions.  It might rethink the whole concept of insurance versus prepaid medical care.  But it would deal with rising costs.  It would maintain flexibility.  It might continue to rely heavily on health benefits provided by employers, or it might take a different approach.  But it would prevent skyrocketing costs.  Did I mention that it would be laser-focused on controlling costs?

Because, say it with me folks:  The problem of access is a problem of cost.  The problem of access is a problem of cost.  The problem of . . . .

That’s your challenge, should you choose to accept it.

There are lots of good ideas out there.  Put them together into a workable plan and evangelize!

President Obama’s not the only one who can capitalize on the frustration about to be created by Obamacare 1.0.  You can, too.  And even if we ultimately end up at a variant of national health, the country will be better off for having been given a real choice.

Stop whining, get wonking, and then start selling!

 

John Roberts and Election 2012

Fiscal cliff . . . blah, blah, blah . . . dysfunctional government . . . blah, blah, blah.

I know it’s important.

But I just can’t bring myself to talk about it, other than to say that the posturing is idiotic and that it is more obvious than ever that everyone who is “serious” about solving [INSERT PET CRISIS HERE] is apparently only serious about doing it on their own terms, which is an approach that always works well.

Blah, blah, blah . . .

Oops, even I slipped into it there for a second — sorry!  You don’t really want to here any more about that, right?

OK . . . how about I talk about Chief Justice John Roberts instead?

I am, after all, a lawyer.  Sigh . . . .

I saw the following headline this morning that got me thinking:  John Roberts is the Person of the Year.

If the approaching new year has you looking about for “most influential” types, then look no further than the Chief Justice, a lawyer’s lawyer, who, intentionally or unintentionally, almost certainly had more influence on Election 2012 then all the millions of dollars in hounds-of-hell SuperPACs he unleashed on the unwitting public via Citizens United (which, interestingly, I haven’t heard a peep about since early November . . .).

While people were awaiting the Court’s decision on Obamacare, both sides were a bit ambivalent on the political consequences.  After all, if conservatives lost at the Supreme Court, they could run against both an unpopular law and activist judges.  As for President Obama, if he lost he could run against both the wealthy and an antiquated, out-of-touch, white male judiciary (+ Clarence Thomas).

In fact, the best political outcome for both sides was probably a loss, right?  Right??!!  Just look at the expanded list of villains!!

Ha ha.

All that ambivalence was just a bunch of posturing.

The reality was that both sides really wanted an Obamacare win.  And President Obama really needed an Obamacare win.

If you can remember all the way back to late June this year, you’ll remember that it wasn’t a great time for the President.  The economy wasn’t doing well . . . for the fourth summer in a row . . . and there were few signs of improvement.  There was the debt ceiling debacle.  His image as a pragmatic compromiser was being, well, compromised.  His list of accomplishments — despressingly short already given (probably unfair, but largely self-inflicted) expectations — was posed to grow even shorter.  Although liberals were still sanguine about the election, Republicans were licking their chops, sure that the President’s signature domestic policy accomplishment was about to be dismantled by the Supreme Court.  ”Just what has he done the last four years?,” they would say.  ”Passed an ineffective stimulus bill and an unconstitutional healthcare law?”  ”Saved Solyndra and wasted all his time trying — unsuccessfully, thanks to us — to subvert the Constitution by undermining the quality of your healthcare?”

And what would President Obama’s response have been?  ”Well, when it comes to jobs, we’re *almost* back to where we started?”  ”Blame it all on the Wall Street, Congressional Republicans, and the Supreme Court?”  Ouch.  Though we might all have been saved some of the rhetoric about birth control . . . or not.

Would the election have turned out differently?  I don’t pretend to know.  But even if the result was the same, the election surely would have been different.  And I think there is a decent chance that things would have turned out differently.

Maybe that’s all wishful thinking. :)

But I struggle to think of anyone else as politically influential in 2012 than our Chief Justice.

In his own version of the Switch in Time that Saved Nine, John Roberts fundamentally changed the anticipated direction of the electoral conversation and, I think, had more influence on Election 2012 than anyone else.

I don’t think John Roberts is an activist judge (if that phrase has any meaning at all).  I don’t think he aspires to be a political power player.  I think he’s pretty much the ultimate lawyer’s lawyer.

In fact, I’ve been pretty open about the fact that I think our Chief Justice’s Obamacare decision was motivated primarily by a desire to keep the Supreme Court out of politics rather than to inject it into the middle of another Presidential election — whether you think that’s a legitimate judicial consideration or not.

But that’s the long-game, and sometimes you have to take some short term hits to get where you ultimately want to be.

So, whether he wanted it or not, John Roberts has my vote for most politically influential of 2012.

Now that he’s no longer kept in suspense, he can get back to scheming over how to incense half the country over affirmative action.

And with that, I return you to the fiscal cliff . . . .

Election 2012: Morning After Thoughts on the National Election

Has the Republican Party lost its way?  Did it get beaten so badly because of Tea Party craziness?  Or was it, yet again, too moderate?  Did it get beat because it’s party of angry old white men?  What lessons should the GOP take away from this drubbing?

Here are some of my brief thoughts.

(1) This was not that much of a drubbing.  It was predicted to be a close election.  It was a close election.  The country remains evenly split.  Republicans and Democrats should both keep that in mind.  Enough of the American electorate responded to President Obama’s primary message, which was, “better me than him,” for him to win.  Certainly not a mandate for four more years of the same.

(2) Candidates, candidates, candidates!  Right now, the GOP has a problem with its candidates, and I’m not talking Mitt Romney.  Democrats picked up seats in the Senate due to some incredibly inept Republican candidates, not a Democratic groundswell.  Whatever the reasons — whether it’s Tea Party extremism or the party getting too comfortable with certain seats, I’m not sure.  But the GOP has lost too many races that it should have won over the last 4 years.

(3) Despite the close election, Republicans do have a serious issue with minority appeal and demographic realities.  As a result, I suspect we’ll finally see bipartisan immigration reform before 2014.  However, Republicans have lost ground on the issue that’s going to be hard to make up.  They really need to do some serious outreach.  There are Hispanic voters that would fit well in the GOP, but it’s going to take time, words, and action to make them feel comfortable enough to join up or come back.

(4) Republicans need to make peace with the idea of serious healthcare reform.  Obamacare isn’t going away; there will be no repeal.  It was ultimately a losing wedge issue this time round, it will be more so in future years.  The other thing about the Republican stand on healthcare is that it hurts the party’s minority appeal.  The issue going forward becomes how to mitigate the negative impacts, of which there will be many. The GOP needs a serious alternative healthcare approach.  Now!

(5) The GOP foreign policy does sound like the 1980s part II.  Although I don’t believe for a second that Mitt Romney really conceived of Russia as the United States’ primary foreign policy threat, the GOP needs a foreign policy that is more than Israel, Iraq, + military spending.

Before my fellow Republicans despair that we’re entering a new era of Democratic dominance and all is lost, let’s keep in mind one thing: The Democrats have their own problems.  Pretty big problems.  In his effort to win this election, President Obama repeatedly villainized wealth and openly engaged in the type of class warfare we haven’t seen since before Reagan.  I think some damage was done to the Democratic Party as a result.  President Obama and Congressional Democrats have some time to try and rehabilitate their image.  An improving economy will help.  The significance of the Democratic “firewall” of rust belt swing states is also subject to coming demographic realities.  Continued unconditional support for unions is going to hurt elsewhere and the political benefits will be reduced as the rust belt becomes less electorally significant.  Democrats cannot continue to offer, as their only solutions for an obvious entitlement crisis (1) reduced military spending, and (2) more entitlement programs.  Both parties need course corrections.

Finally, let me wax philosophical on a couple things.  First, the Tea Party.  My few regular readers will know that I’m no great fan of the Tea Party.  But for me, the problem with the Tea Party has always been about the penchant for constitutional politics, not the stances on the major issues of our time, which are debt and entitlement reform.  The Tea Party energy is a positive thing for the Republican Party; it just needs to be re-directed to where it counts.

Second, Mitt Romney.  I was a Jon Huntsman supporter during the primary.  I still like Huntsman.  But I like Romney as well, and I’ve always thought he would be a tremendous President.  I think that Romney represented Republicans well.  I think he represented the Mormon Church well.  I think the door is now wide open for a Mormon President — of any political persuasion.  Mitt ran for office with a deck stacked against him in many ways.  Evangelicals were suspicious of his religion.  Republicans were suspicious of his record.  Democrats attacked his wealth.  If he flip-flopped to navigate the minefield, I forgive him.  He did a good job.

Anyway, my random morning after thoughts on the national election.  Utah thoughts coming soon . . . .

A (Relatively) Unbiased Take on Night 1 of DNC 2012

Here they are, handful of readers, my unsolicited thoughts on the first night of the Democrats’ 2012 National Convention!

Major themes:

  • President Obama has improved everything but the economy.
  • It takes a village, shared sacrifice — put best by Julian Castro when he said that, “We understand that freedom isn’t free.  But neither is opportunity — we have to invest in it.”
  • Mitt Romney is an economic terrorist who hates everyone except white males.
  • We love Obamacare (and abortion rights)!

Worst speakers:

  • Ted Strickland. Obnoxiously hack-ish…and he managed to yell for 10 minutes straight (the only breaks being a few self-congratulatory chuckles).
  • The NARAL lady.  I get that you think that women can’t trust Mitt Romney…but you scare me…
  • Lincoln Chaffee.  Somehow managed to reinforce every negative stereotype about independents in a speech no one could stand to listen to.
  • Kathleen Sebelious (sp?).  Numbing delivery really ruined what was a decent, and substantive, speech.
  • Kal Penn. Just a bit too weird with the forced cool.

Best speakers:

  • Deval Patrick. This is what Ted Strickland should have been.  Attacking, fiery, inspirational to the crowd he was speaking to. Oratorical skills that remind me of Obama, but with a definitely harder partisan edge.  Trouble for his future is that his economic record also mirrors Obama…
  • Julian Castro. In my opinion, despite Michelle’s effort, the best speaker of the night for the Dems. I’ve already said I loved his “opportunity isn’t free” moment.  His “actually” line in reference to Romneycare was also one of the great lines of the night.  Took credit for the TX economy, but hey, why not?
  • Michelle Obama.  I don’t remember her 2008 speech, but I suspect she’s developed her talents during the last four years.  She did a great job.  Not much else to say.

Michelle v. Ann:

  • Both had crowds primed to love them, Michelle more so than Ann.  Both did well.  I’ve heard some people say that Ann seemed a bit more sincere . . . certainly she’s not as polished as Michelle, who, at times, seemed a bit more rehearsed.  Overall, I thought Michelle did a better job speaking, but Ann’s speech is probably more likely to have an impact on voters than Michelle’s.  How’s that for splitting the baby? :)

Obamacare:

  • It became clear to me tonight that it was *really* important for Obama in 2012 that the Supreme Court upheld Obamacare.  How in the world would Democrats answer the “better off” critique if it had been struck down?

Bad Switzerland:

  • Money in a Swiss bank account has never created an American job?  Well, I suppose that money in any bank account doesn’t create jobs . . . but I bet there were a couple uncomfortable Democrat Swiss bankers tuning in (or speaking?) last night.

That’s just my quick first take on night one.  Your thoughts?

Obamacare and Chief Justice Roberts

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Who is Chief Justice Roberts?

Is he the methodic, calculating, conservative revolutionary, that Obama had the foresight to oppose for confirmation to the Court based on his inability to discern what was in the now-Chief Justice’s heart?  Is he the pragmatic conservator of the Court’s institutional capital at the expense of the Court’s obligation to make authoritative constitutional pronouncements?  Or is he yet another conservative appointee driven ever left by mysterious unidentifiable substances in the Washington D.C. water supply?

And what to make of the Court’s decision today upholding Obamacare as a valid exercise of Congress’ taxing power?

Is it an unmitigated disaster that spells inevitable socialistic decline for America — assuming of course Mitt Romney and Orrin Hatch can’t team up on Democrats using the Senate Finance Committee and Oval Office? ;)  Is it a secret long-game win for conservatives masterminded by the Chief Justice at the expense of the unwitting liberals now praising his name?

So many questions to answer, so little time.

Rather than bore you with a treatise, I’ll just give you a few of my thoughts after reviewing the opinions (and trust me, this will be long enough).

1.  This decision is an unqualified loss for conservatives.  Though Roberts may have something of a long game in mind here (see point 4 below), it’s really hard to spin this as a win for conservatives.  Overall, the thrust of the opinion is, “you can find a way to uphold congressional action, even when it’s an unprecedented extension of federal power.”

To be fair, Roberts did throw conservatives some bones in his opinion. For example, it’s clear that he purposefully reached the Commerce Clause issue unnecessarily, in order to send a message about mandates.  His explanation to the contrary was unpersuasive (to me, anyway):

JUSTICE GINSBURG questions the necessity of rejecting the Government’s commerce power argument, given that § 5000A can be upheld under the taxing power. Post, at 37.  But the statute reads more naturally as a command to buy insurance than as a tax, and I would uphold it as a command if the Constitution allowed it. It is only because the Commerce Clause does not authorize such a command  that it is necessary to reach the taxing power question.  And it is only because we have a duty to construe a statute to save it, if fairly possible, that § 5000A can be interpreted as a tax. Without deciding the Commerce Clause question, I would find no basis to adopt such a saving construction.

So it’s a tax only because it’s not a penalty?  Pretty weak . . . and that means he reached the issue to send a message.  Whatever his reasons for upholding, he obviously wanted to make clear that federal efforts to mandate conduct as a way of bootstrapping in to Commerce Clause authority are non-starters.

And one has to acknowledge that Roberts did refuse to countenance an extension of Congress’ spending/commandeering power.  Ultimately, however, it’s hard to see how that does much for federalist types when the practical thrust of his opinion is that even statutes that are written as exercises of the Commerce Clause authority, and exceed that authority, are nonetheless constitutional taxes (even when not denominated that way and denied publicly).  This allows Congress to avoid the political consequences of enacting taxes while pretty much giving Congress the type of unbridled legislative authority rejected under the Commerce Clause.

2.  Robert’s opinion will not make it procedurally easier to repeal Obamacare politically.  Today’s decision may very well have the effect of galvanizing conservatives for the upcoming elections (apparently it’s been a monetary windfall for Mitt), but those claiming (and I’ve seen a few posts on this today) that Justice Roberts judicially declared Obamacare a tax in order to ensure that, under the Democrats own congressional rules, efforts to repeal would be immune from filibuster (that captures the substance if not the precise form of the argument), clearly didn’t read Justice Roberts careful parsing of the difference between statutory and constitutional tax status:

Congress’s decision to label this exaction a “penalty” rather than a “tax” is significant because the Affordable Care Act describes many other exactions it creates as “taxes.”  Where Congress uses certain language in one part of a statute and different language in another, it is generally presumed that Congress acts intentionally.

Amicus argues that even though Congress did not label the shared responsibility payment a tax, we should treat it as such under the Anti-Injunction Act because it functions like a tax. It is true that Congress cannot change whether an exaction is a tax or a penalty for constitutional purposes simply by describing it as one or the other. Congress may not, for example, expand its power under the Taxing Clause, or escape the Double Jeopardy Clause’s constraint on criminal sanctions, by labeling a severe financial punishment a “tax.”

The Anti-Injunction Act and the Affordable Care Act, however, are creatures of Congress’s own creation. How they relate to each other is up to Congress, and the best evidence of Congress’s intent is the statutory text. We have thus applied the Anti-Injunction Act to statutorily described “taxes” even where that label was inaccurate.

The desperate efforts of conservatives to label this decision a “win” for them remind me of Democrats attempts to rationalize President Obama caving to Republicans on the debt ceiling as grand liberal strategy.

3.  Roberts tax opinion is more persuasive than conservatives want to admit.  Although all the focus leading up to the case was on the Commerce Clause, Roberts’ opinion boils down to this:  constitutional authority to legislate depends on the substance of the legislation and not congressional magic words.  That’s a familiar principle, and persuasive in a number of contexts.  The effect of my contract depends on the written language and the intent of the contracting parties, not on the use of precise words to accomplish specific functions.

Should this be any different?  Well, we do have this sense that Congress should be allowed to use the tax designation as both a sword (justification for enacting authority) and a shield (insulation for political consequences of raising taxes).  But since when has Congress been estopped from legislating?  It’s also a bit surprising that Roberts went different ways on the Anti-Injunction Act and Taxing Power (see quote language above) . . . one felt that if the Court reached the merits of the case it would do so based on the finding that Obamacare was not a tax and therefore would be forced to decide the issue on Commerce Clause grounds alone.  But Roberts neatly worked around that dilemma by  holding that the individual mandate was indeed a tax, just not a tax to which Congress intended the Anti-Injunction Act would apply.

4.  Even though this is a loss for conservatives, there is something of a silver lining.  Between Roberts’ opinion and the Joint Dissent, there is a 5-member majority in support of unusually strong language on Commerce Clause federalism.  The language is so strong, in fact, that it likely forecloses any attempt at “compelled commerce” regulation in the near future.  This means that, if, down the line, conservatives are able to chip away at the rather deferential constitutional construction of a tax and/or expand on the Chief Justice’s anti-commandeering rationale, the field for Congressional action will have been limited.  It seems like Roberts’ opinion might also spawn some new Republican political strategy, like citing judicial authority to justify characterizing every regulation as a tax, or inserting punitive penalties into regulatory laws to sabotage them constitutionally . . . maybe I’m just reaching here, but no question congressional Republicans are committed and creative :)

5.  Roberts v. Scalia.  In case anyone doubted the sincerity of his commitment to judicial restraint (especially after Citizens United), Roberts’ opinion should allay that doubt (for now).  While Scalia’s commitment is, first and foremost, to originalist interpretation, Roberts’ jurisprudence is (in my opinion) guided to a significant extent by his beliefs about the role of the Court vis-a-vis the political branches and, to a lesser extent, preservation of its institutional capital.  I really think that this is the best way to look at his decision.  Which is the better approach?  I’ll leave that for you to decide . . . . ;)

6.  Another “switch in time”?  Although there is already a healthy ongoing debate over this, it does look (to me) as though Chief Justice Roberts changed his vote relatively late in the process.  It is hard for me to avoid the conclusion that the Joint Dissent (Scalia, Thomas, Kennedy, and Alito) was written by Scalia as a majority opinion.  It contains numerous references to “the dissent,” despite itself being a dissent.  It is also written, like a majority opinion, using the plural “we,” as opposed to the singular “I.”  Here’s an example:

The dissent claims that we “fai[l] to explain why the individual mandate threatens our constitutional order.” Ante, at 35. But we have done so. It threatens that order because it gives such an expansive meaning to the Commerce Clause that all private conduct (including failure to act) becomes subject to federal control, effectively destroying the Constitution’s division of governmental powers. Thus the dissent, on the theories proposed for the validity of the Mandate, would alter the accepted constitutional relation between the individual and the National Government. The dissent protests that the Necessary and Proper Clause has been held to include “the power to enact criminal laws, . . . the power to imprison, . . . and the power to create a national bank.”  Is not the power to compel purchase of health insurance much lesser? No, not if (unlike those other dispositions) its application rests upon a theory that everything is within federal control simply because it exists.

Why were these references left in?  It could because of a last minute switch . . . but I doubt it.  Justice Roberts had to have time to write his opinion, and the Justices and clerks who write Supreme Court opinions are some of the very brightest people around — these edits could have been made no matter how late the change.  So, were they left in purposefully, as a signal to the world of a betrayal by the Chief Justice?  Well, I kind of doubt that as well . . . .  But whatever the explanation, it’s certainly interesting.

7.  Let’s get political!  Thus far in the battle over Obamacare, both sides have alternated being overly optimistic.  Prior to oral argument, quite a few Democrats were contemptuous of the merits of the legal challenge.  After oral argument, conservatives were prematurely dancing on Obamacare’s grave.  Liberals rejoicing today should take into account that it looks (if my sense if correct) like Obamacare was headed down to defeat and was saved only by a last minute defection (that was, in all likelihood, not wholly based on the merits of the case).  Furthermore, there is still a long way to go in the war over national health insurance in America, despite today’s decision.  And, while the Supreme Court will have more of a role to play, Roberts’ opinion, consistent with his commitment to circumscribing the judicial role, ensures that, going forward, this battle will be fought primarily politically from here on out.

Anyway, I’d love to hear your thoughts, whether on the opinion or my own commentary.  Type away — I can take it :)

Dan Liljenquist and State Level Medicaid Reform

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If you’ve ever attended one of his “fiscal reality” town hall meetings, you’ll notice the passion with which Senator Dan Liljenquist talk about entitlement reform.  He’ll tell you it’s what pulled him out of the private sector and into politics.  You can hear the excitement in his voice when he talks about how Rhode Island — the bluest of all blue states — enacted sweeping pension reform legislation this past year to forestall a fiscal collapse.  And you feel his real frustration when he speaks about the fact that a “mid-level bureacrat” is holding up Utah’s Medicaid waiver request over small proposed co-pay increases.

Liljenquist has built quite a name for himself as the state level entitlement reform guy nationwide.  It’s what he does, and, thus far, he appears to have done it in impressive fashion.  So these days, he’s the guy that other people talk to when they want to do it, too.

But despite all the notoriety, I suspect there are quite a few people, especially here in Utah, that don’t understand what exactly it is that Liljenquist has done when it comes to entitlements.  So I wanted to put up this post summarizing the nature of Liljenquist’s Medicaid reforms here in Utah, and then offer some brief thoughts on the future of state-level Medicaid reform (and how it may tie in with Liljenquist’s future political plans, which may be the worst kept secret in Utah).

What’s Been Done

Liljenquist’s reform efforts were prompted by some alarming numbers.  In the case of his Medicaid reforms, it was the accelerating growth of Medicaid as a percentage of Utah’s budget.

Medicaid, though jointly implemented by the federal government and the states, is a federal program.  And the federal government sets uniform eligibility requirements for state Medicaid programs, while each state (with significant federal funding assistance, of course) is left to meet those requirements with its state level programs.  The continually soaring cost of health insurance — whether employer-funded and privately purchased — together with the difficult economy has led to a rapid rise in eligibility for benefits.  As a result, states are being forced to budget ever larger shares of their shrinking (or stagnant) revenue streams to meet the increased demand.  And Obamacare, when fully implemented in 2014, will expand eligibility even further.  These days, Medicaid expenses are growing fast enough, and becoming large enough, that they legitimately threaten to crowd out other important state services, including public education.

So, what to do?

Well, the federal government could grant limited waivers to Medicaid eligibility requirements for states who need them.  But it won’t.

Kathleen Sebelius (President Obama’s Secretary of Health and Human Services) has made clear that states cannot expect any flexibility with Medicaid when it comes to eligibility; the current federal administration is not about to let Utah, or any other state, reduce eligibility requirements, even (and maybe especially) in the middle of a recession.  And the two most reviled statutes in recent memory (at least from the right side) — the stimulus and Obamacare — both contain provisions protecting Medicaid eligibility.

Although Utah cannot control the number of people who are eligible for Medicaid benefits from the state level, Sebelius has suggested that states — as they have been in the past — will be given some flexibility when it comes to the nature of benefits themselves, and that’s the starting point for Liljenquist’s proposals.

The essence of Liljenquist’s reforms involve limiting costs by (1) tying Medicaid expenses to budget growth and (2) changing treatment incentives.  These two components are designed to reduce total cost as well as to make expenses predictable in relation to each year’s revenue (which obviously fluctuates due to a number of different factors).

According to Liljenquist, Utah’s current Medicaid model — a combination of managed care and fee for service — incentivizes overtreatment by hospitals and physicians, and, more importantly, irresponsible overuse by Medicaid recipients (e.g., unnecessary trips to the emergency room).  Liljenquist proposes moving Utah’s Medicaid system to a managed care+ philosophy designed to encourage more cost effective treatment.  Here are the highlights:

  • The state would allocate what amounts to block grants of its Medicaid funds to groups of healthcare providers known as Accountable Care Organizations (“ACOs”) on a statistically calculated (based on disease rates and risk profiles) per patient basis.
  • Each patient would be assigned what’s called a “medical home,” and a healthcare provider would be assigned to manage that patient’s care.  Patients would have a limited ability to choose their initial ACO and would have an option to switch ACOs once per year during an open enrollment period.
  • The ACOs would profit from Medicaid to the extent they facilitate effective and responsible treatment for their patients; since Medicaid payments would no longer be tied to specific treatment services provided, Liljenquist’s reforms would reduce the incentive to over treat for profit.
  • The state would offer some incentives, such as reduced co-pays or even cash rewards, for ACOs and patients who take advantage of preventative treatment options.
  • The system seeks to avoid the potential incentive to under treat patients by requiring that ACOs maintain a quality of treatment equivalent with that provided under the current system.
  • Compensation for services provided would remain in line with compensation under the current system; any expected savings would be generated by a relative predominance of more preventative and cost-effective treatment options.
  • The state would infuse some predictability into Medicaid funding by tying it to budget growth going forward.  In years where there is a surplus, the surplus would be put into a rainy day fund.  In years where enrollment growth exceeds expectations, benefits would be reduced across the board according to a predetermined schedule.
  • The state would seek modest increases in co-pay requirements for certain health services for those on Medicaid.

The Utah legislature’s fiscal analysts office estimates that the proposed reforms would result in savings of $770 million over the first seven years they’re implemented.

Liljenquist’s reform effort is just beginning, and can’t be implemented without permission from the U.S. Department of Health (USDHHS) and Human Services.  The specific reform bill, S.B. 180, passed unanimously by the Utah legislature during the 2011 session, required the Utah Department of Health to develop the specific details of a reform plan, and submit a request for waiver to USDHHS, which it did on July 1, 2011.  The waiver request is available online, for those interested in getting down into the details.  If the waiver request is granted in time, the initial reforms are set to be implemented in July 2012.

Where Do We Go From Here?  And What’s the Future for State Level Medicaid Reform?

Liljenquist’s proposed reforms are an attempt to work within the present system, frustrating as that system may be for reformers.  And Utah’s new approach does seem promising.  Of course, only time will tell whether the projected cost savings are realized and whether the quality of treatment for patients on Medicaid remain high.  But what Utah is proposing to do, while not wholly innovative, is a significant step forward in deal with the problems created by partially-funded federal mandates that result in unpredictable expenses.

But ultimately, thanks to that pesky Supremacy Clause, state level Medicaid reform can only get you so far.  Furthermore, you can never be certain that the reforms will be enduring, as they are subject not only to Congressional changes in course (see, e.g., Obamacare), but also to a somewhat unpredictable bureaucracy, subject to changes in approach based on the four-year Presidential election cycle.  Finally, there is the oft-cited concept as the states as laboratories of democracy for federal policy; the irony in this case is that if state reforms are successful in providing effective care at a reduced cost, they might serve as models for National Health 2.0 — “Hey, Utah’s got this great approach to effective cost, statewide government funded health care, let’s try it nationwide!”  Indeed, when I started investigating Liljenquist’s proposal, I thought to myself, if this works are well as they say it’s going to, it sounds like something that could go national and be, relatively speaking, cost effective.

All this reminds us, simply, is that Medicaid, despite the promise of state reforms, is a federal program, and real, fundamental change must happen at the federal level.  The drivers of the Medicaid problem are eligibility and benefit standards, and, as a result, the basic components of real, substantive reform involves dealing with questions of eligibility and tiered-benefits, not just increased effectiveness in treatment and care delivery (which treat the symptoms).

The premise of Medicaid is about setting creating a safety net and setting a basic floor for those who can’t afford health care coverage.  I think that’s a good thing, and I think that it’s probably something that should be done on a national level.  This is, after all, all about people and not about states — and a person is a person, no matter what state they live in.  But if Medicaid is going to continue to be implemented and significantly funded by the states, the overall national structure needs to provide, at minimum, necessary flexibility for states with vastly different budgetary needs and obligations and populations with different health profiles.

That can’t be done from a state legislature, no matter how many great ideas you’ve got.  The future of Medicaid reform is not at the state level.  Liljenquist knows that, and I suspect it’s a big part of what’s informing his future career plans.

D.C. Circuit Upholds Obamacare

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Watching Obamacare wend its way through the federal courts is great sport for court-watching types like myself.  It’s fascinating to watch some very, very intelligent and thoughtful federal judges wrestle with the significant constitutional questions posed by the individual mandate — questions that strike at the heart of some of America’s most basic constitutional principles:  separation of powers, federalism, and due process.

This morning, the United Staes Court of Appeals for the District of Columbia Circuit released an opinion upholding the constitutionality of Obamacare’s individual mandate.  The opinion was authored by Judge Silberman (appointed by President Reagan), joined by Judge Edwards (appointed by President Carter), and dissented from by Judge Kavanaugh (appointed by President George W. Bush).

Judge Silberman and Judge Edwards reached the merits of the plaintiffs’ challenge (i.e. actually decided their Commerce Clause argument), while Judge Kavanaugh would have dismissed the plaintiffs’ challenge for lack of subject matter jurisdiction pursuant to the Anti-Injunction Act.

For those of you keeping score on Obamacare, this puts the federal appellate decisions at 2-1-1 in favor of upholding Obamacare (6th and D.C. Circuits vote to uphold, 11th Circuit votes to strike down, and 4th Circuit punts on subject matter jurisdiction grounds).

Anti-Injunction Act

I won’t spend much time on the Anti-Injunction Act argument. Suffice it to say the argument there is essentially one of timing.  The Anti-Injunction Act prohibits any efforts to enjoin the collection of taxes prior to when the tax has gone into effect.  Essentially, Judge Kavanaugh was of the opinion that, under the Anti-Injunction Act, no challenge to Obamacare’s individual mandate could be brought before the individual mandate was enforced.  Judge Silberman (joined by Judge Edwards) rejected the Anti-Injunction Act argument, concluding that (1) the purpose of the Anti-Injunction Act was to prohibit suits designed to compromise the government’s ability to raise revenue, and (2) the purpose of the individual mandate was not to raise revenue to but to enable the functioning of the government’s national health care effort.  For a detailed discussion, read the opinions.

But it is significant to note that this is essentially a 3-0 rejection of the plaintiffs’ challenge to Obamacare (Kavanaugh, though not reaching the merits, would have dismissed their suit under the Anti-Injunction Act).

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The Merits (i.e., Commerce Clause, Federal Police Power, and Such) 

Each of the plaintiff groups challenging Obamacare has taken a bit of a different tack in challenging the individual mandate.  The plaintiffs in the D.C. Circuit case brought a facial, as opposed to an as-applied, challenge to the mandate.  A plaintiff bringing a facial challenge to Obamacare’s individual mandate is required to demonstrate that the mandate is unconstitutional in all, as opposed to only some, of its applications.  Here’s how the plaintiffs attempted to meet their heavy burden:

As is apparent, appellants have brought a facial challenge to the individual mandate. Appellants recognize that a facial challenge theoretically must establish “that no set of circumstances exists under which the [law] would be valid.”  United States v. Salerno, 481 U.S. 739, 745 (1987). But unlike the plaintiffs before the Sixth Circuit, appellants were careful to avoid conceding there were any valid applications of the law.  Cf. Thomas More, 651 F.3d at 556, 561-62, 564 (Sutton, J., concurring). Instead, appellants’ theory of the Commerce Clause would invalidate virtually all conceivable applications of the mandate.

Since, according to appellants, Congress only has the power to regulate individuals who are affirmatively acting in ways that affect a market, and for the duration of their activity, Congress also categorically lacks authority to compel individuals to maintain participation in a market into the future. No one currently active in the health insurance market will necessarily be active in 2014, when the mandate goes into effect, or remain active in that market in perpetuity, absent the mandate. Nor do appellants here concede that Congress could impose a mandate to require individuals to purchase insurance when they arrive at a hospital for treatment and maintain that insurance indefinitely.  The requirement to maintain coverage into the future, under their theory, dooms the mandate in its entirety.

Although the court admitted it was intrigued by the plaintiffs’ arguments, it ultimately rejected them, reasoning that the plaintiffs’ argument about activity/non-activity was just as novel as the individual mandate itself and had no basis in either in the text of the Constitution or past Supreme Court precedent:

The mandate, it should be recognized, is indeed somewhat novel, but so too, for all its elegance, is appellants’ argument. No Supreme Court case has ever held or implied that Congress’s Commerce Clause authority is limited to individuals who are presently engaging in an activity involving, or substantially affecting, interstate commerce.

We look first to the text of the Constitution. Article I, § 8, cl. 3, states: “The Congress shall have Power . . . To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes.” (emphasis added). At the time the Constitution was fashioned, to “regulate” meant, as it does now, “[t]o adjust by rule or method,” as well as “[t]o direct.”  To “direct,” in turn, included “[t]o prescribe certain measure[s]; to mark out a certain course,” and “[t]o order; to command.”  In other words, to “regulate” can mean to require action, and nothing in the definition appears to limit that power only to those already active in relation to an interstate market. Nor was the term “commerce” limited to only existing commerce. There is therefore no textual support for appellants’ argument.

As to Wickard v. Filburn, specifically, Judge Silberman had this to say:

Whether any “particular person . . . is, or is not, also engaged in interstate commerce,” the Supreme Court expressly held, is a mere “fortuitous circumstance” that has no bearing on Congress’s power to regulate an injury to interstate commerce. Id.

Wickard is very much in that vein. In Wickard, it mattered not that Filburn’s annual wheat output was trivial in relation to national production. Nor did it matter that Filburn was being penalized for behavior that had only the most tenuous impact on interstate commerce in of itself, since Filburn never intended the wheat to be used for commercial purposes, never sold it, and used it only to sustain his home farm. It was also irrelevant that the wheat quota could compel even those farmers with no intention of selling any wheat, in any market, to enter the interstate market. All that mattered were the overall dynamics of the wheat market–in other words, generalizations about likely, future economic behavior. If farmers like Filburn all exceeded their quotas, the mechanics of the wheat market made it inevitable that the interstate market would be impacted–either by the likelihood that the high price of wheat Congress was trying to maintain would induce some unspecified number of farmers to sell wheat at market after all, or the probability that farmers who had enough wheat for their own use would stop buying wheat at market. Either way, these economic forecasts–and not any affirmative acts by people like Filburn–were enough to sustain the law. 317 U.S. at 117, 126-28.

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Often times, the most interesting parts of these Obamacare opinions come toward the end when the court provides some insight into how it views the case from a broader perspective.  Judge Silberman’s opinion is no exception.  Here are a few of the more interesting paragraphs:

Appellants’ view that an individual cannot be subject to Commerce Clause regulation absent voluntary, affirmative acts that enter him or her into, or affect, the interstate market expresses a concern for individual liberty that seems more redolent of Due Process Clause arguments. But it has no foundation in the Commerce Clause.

[I]t is irrelevant that an indeterminate number of healthy, uninsured persons will never consume health care, and will therefore never affect the interstate market. Broad regulation is an inherent feature of Congress’s constitutional authority in this area; to regulate complex, nationwide economic problems is to necessarily deal in generalities. Congress reasonably determined that as a class, the uninsured create market failures; thus, the lack of harm attributable to any particular uninsured individual, like their lack of overt participation in a market, is of no consequence.

Finally, appellants’ position would not preserve state sovereignty.  A state that requires all its citizens to purchase health insurance is making them “active” in the interstate market; if the state thereby cedes control over its health care policy to the federal government, its experimentation is tantamount to a relinquishment of its own power.  Thomas More, 651 F.3d at 561-62 (Sutton, J., concurring); cf. Veazie v. Moor, 14 How. 568, 574 (1853).

That a direct requirement for most Americans to purchase any product or service seems an intrusive exercise of legislative power surely explains why Congress has not used this authority before–but that seems to us a political judgment rather than a recognition of constitutional limitations. It certainly is an encroachment on individual liberty, but it is no more so than a command that restaurants or hotels are obliged to serve all customers regardless of race, that gravely ill individuals cannot use a substance their doctors described as the only effective palliative for excruciating pain, or that a farmer cannot grow enough wheat to support his own family.  The right to be free from federal regulation is not absolute, and yields to the imperative that Congress be free to forge national solutions to national problems, no matter how local–or seemingly passive–their individual origins. See Heart of Atlanta Motel, Inc. v. United States, 379 U.S. 241, 258-59 (1964).

Some Thoughts

Any thoughts on the opinion?  Here are a couple of my bullet points:

  • Federalism v. Due Process.  This is the second time we’re getting a suggestion from a federal appellate court that the federalism challenge to Obamacare is really not about federalism at all, but is about due process.  Could Obamacare revive Lochner-era economic due process challenges?  Stay tuned.
  • Which Way are we Leaping?  Judge Silberman does a good job with his contention that, at least when it comes to federalism and the Commerce Clause, the plaintiffs’ arguments RE the unconstitutionality of compelling people to enter commerce are just as unique as the idea of an individual mandate itself.  In other words, Silberman is saying that, while the plaintiffs arguments may have a familiar ring to them when it comes to Due Process, when it comes to federalism the Obamacare plaintiffs are asking courts to make just as much of a leap as Congress is with the individual mandate.  This adds a new dimension to the arguments.
  • Lots of Ammo for the SCOTUS.  The Supreme Court is going to have a lot to draw on by the time this one gets before them.  It will be interesting to watch — not only which way they decide to rule, but how they decide to go about it.
  • Anti-Injunction Act Gaining Momentum?  Will we see a 5-4 decision to uphold Obamacare, with the 5 Justices voting to uphold splitting on whether to uphold on the merits or to uphold based on the courts’ lack of subject matter jurisdiction over the plaintiffs challenge?

Is the MCAP Act the Republican Version of Obamacare (Federalist-ly Speaking)?

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Hat tip to Daniel Burton at Publius Online for this interesting story about potential federalism hypocrisy from the right side of the U.S. Senate.

In preparing its response to President Obama’s famous “pass this” jobs bill, Senate Republicans — specifically Senators Inhofe, Vitter, Burr, Cornyn, and Alexander — are resurrecting a prior house bill (previously known as the Help Efficient Access Timely Healthcare, or “HEALTH”) as the Medical Care Access Protection Act of 2011 (“MCAP”).

MCAP is nationwide tort reform, which would create a federal law of medical negligence that would not only govern medical tort suits in federal courts, but would govern medical tort suits in state courts and medical tort claims in private non-judicial proceedings, such as mediation and arbitration.

What MCAP Does

Specifically, MCAP would:

  • Impose a nationwide statute of limitations of 3 years on any tort claim based on the the provision of “healthcare goods or services” by any “healthcare provider” or “healthcare institution” (collectively encompassing everyone from nurses to hospitals).
  • Impose, for the above-referenced class of cases, a cap on noneconomic damages (defined as noncompensatory damages, i.e., punitive damages) of $250,000 per claim per defendant (capped at $500,000 total).
  • Impose, for the above-referenced class of cases, a mandatory minimum sanction for state (or federal) Rule 11 violations (Rule 11 is the rule that, as a practical matter, prohibits frivolous lawsuits).   Ordinarily, the decision to sanction, and severity of the sanction, is left to the discretion of the trial court.
  • Require, in the above-referenced class of cases, the assessment of pure comparative fault and not allow damages to be assessed against any party for an amount inconsistent with its proportion of fault (i.e., no absolute or modified [51%] contributory negligence bar).
  • Allow a court to alter or veto any contingent fee arrangement the court deems unfair, and to redirect monies that would, under a contingent fee arrangement, go to attorneys, to a plaintiff if the court concludes that doing so would be in the “interests of justice.”

MCAP does qualify its impact on state law somewhat.  For example, MCAP allows for states to set their own maximum cap for noneconomic damages — whether that amount is greater or lesser than the $250,000/$500,000 cap that MCAP would otherwise imposed.  In other words, MCAP only sets a limit on noneconomic damages where state law has not already set a limit.  Furthermore, MCAP does not prohibit states from enacting laws providing greater protections to healthcare providers.

Despite those qualifications, MCAP, if it were passed, would be a major — indeed, almost unprecedented (?) — legislative encroachment on the autonomy of state courts, even though it would not alter much of the substantive law governing medical tort claims.  The current consensus seems that the bill has zero chance of being passed in its current form, but let’s not allow that to prevent us from dissecting it. :)

Constitutional Basis

I know the question you’re dying to ask:  Is this kind of encroachment constitutional?

Here’s the purported constitutional basis for MCAP:

Congress finds that the health care and insurance industries are industries affecting interstate commerce and the health care liability litigation systems existing throughout the United States are activities that affect interstate commerce by contributing to the high costs of health care and premiums for health care liability insurance purchased by health care system providers.

Sound familiar?  It should.  Read this from Patient Protection and Affordable Care Act (a/k/a Obamacare):

(1) IN GENERAL — The individual responsibility requirement provided for in this section (in this section referred to as “the requirement”) is commercial and economic in nature, and substantially affects interstate commerce, as a result of the effects described in paragraph (2).

(2) EFFECTS OF THE NATIONAL ECONOMIC AND INTERSTATE COMMERCE — The effects described in this paragraph are the following:

(A) The requirement regulates activity that is commercial and economic in nature: economic and financial decisions about how and when health care is paid for, and when health insurance is purchased.

(B) Health insurance and health care services are a significant part of the national economy. . . .

(C) The requirement, together with the other provisions of this Act, will add millions of new consumers to the health insurance market, increasing the supply of, and demand for, health care services. . . .
. . .

(E) Half of all personal bankruptcies are caused in part by medical expenses. . . . .

(F) Under the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act (42 U.S.C. 201 et seq.), and this Act, the Federal Government has a significant role in regulating health insurance which is in interstate commerce.

A Federalism of Convenience?

Both MCAP and Obamacare involve health care.  The Democrats justified Obamacare by reference to the so-called “substantial effects” doctrine of the Commerce Clause, and the Republicans do the same for MCAP.  Is this just pure hypocrisy from the Republicans, or is there a legitimate basis for distinguishing (at least as a matter of constitutional enacting authority) Obamacare and MCAP?

As a matter of constitutional law, I don’t think there is a basis for distinction.  Both bills claim on the Commerce Clause as enacting authority, involve the same industry, and rely on the Wickard v. Filburn substantial effects line of cases.

So, yes, there’s clearly some hypocrisy here.  But I don’t think that Republican support for MCAP is pure hypocrisy (please note the emphasis), either, and let me tell you why.  I suspect that if you were to press Republicans on the differences between the two bills they would say something like, “MCAP doesn’t require you to do (or buy) anything, while Obamacare does.”

An admission like this helps us drill down to what the furor over Obamacare’s insurance mandate is really about.  In the judicial challenges to Obamacare, Republicans are trying to use federalism to do the constitutional heavy lifting that, in a prior time, would have been done by the Due Process Clauses of the Fifth and Fourteenth Amendments.  As much as Republicans claim the judicial challenges to Obamacare are about ensuring that enforceable limits to Congress’ Commerce Clause authority remain (and make no mistake about it, they can make a good case for their position), what these challenges are really about is constitutionally enforcing a nationwide sense — a very smart federal judge referred to it as an intuition — that government should not be telling us what to buy and what not to buy when it comes to matters of our personal health.

In other words, if it wasn’t clear already, MCAP just makes it more clear that Republicans’ problem with Obamacare isn’t that it upsets the federal division of powers, it’s that it runs afoul of their idea of basic economic liberty.  I referenced this briefly in a prior post dealing with Republican Presidential candidate Michelle Bachmann’s stance on state health insurance mandates, and received some interesting comments, especially from Ben Lusty, that I would recommend to readers interested in the relationship between economic liberty and health decisions.

So, do I think MCAP is just a matter of Republican hypocrisy on federalism?  Well, to a point, yes, and Republicans should be called on it.  Cries of hypocrisy are the price of embracing federalism primarily as a convenient stand-in for substantive policy provisions.  But I also think that for many Republicans (whether these lawmakers are among them, I’m not sure) it’s not conscious hypocrisy.  To many of today’s Republican federalist-types, what they really mean by federalism is substantive — as opposed to subject-based — limits on the legislative power of the national government.  And when you look at MCAP from that perspective, Obamacare is quite easily distinguishable, and I suppose MCAP isn’t hypocritical at all.

 

Judge Conner of the Third Circuit District Court Weighs in on Obamacare, in a Judicially Modest Way

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Another Obamacare decision was released today, this one at the district court level in the Third Circuit:  Goudy-Bachman v. U.S. Dept. Health & Human Servs.  This latest decision, striking down the individual mandate as an unconstitutional exercise of Congress’ Commerce Clause authority, was authored by Judge Christopher C. Conner, a George W. Bush appointee,  and is, in my view, high-quality legal analysis that improves on the initial district court decisions (and some of the appellate level opinions) addressing the constitutionality of Obamacare.  This is not surprising, as Judge Conner had all the previous decisions to draw from and consider when drafting his opinion.

[adsenseyu2] As you might expect, much of Judge Conner’s analysis is duplicated in prior opinions and need not be rehashed here.  But there are a couple of interesting aspects to his opinion that I wanted to highlight.  Feel free to post your thoughts as comments using the form below.

1.  Careful Emphasis on Judicial Role

Throughout his opinion, Judge Conner was careful to note that it was his job, as the spokesman for an inferior federal court, to assess how far the United States Supreme Court had taken the Commerce Clause and take it no further than was clearly justified.  Somewhat paradoxically, he began by noting that past Supreme Court precedent was not particularly helpful:

Given the unique factual circumstances of this case, both the Bachmans and the government can effectively distinguish Commerce Clause jurisprudence that appears unsupportive of their respective positions. Therefore, the Supreme Court decisions in Wickard, Lopez, Morrison, and Raich provide only limited guidance for the court’s analysis. Quite simply, this is a case of first impression.

Having determined that Obamacare presented unique legal questions not squarely addressed by prior Supreme Court precedent, Judge Conner turned to the decisions of the various Courts of Appeals that have split on the constitutionality of Obamacare’s individual mandate and to his own analysis of the relevant constitutional questions.

Ultimately, Judge Conner determined that nothing in Supreme Court precedent or the text of the relevant constitutional provision itself went so far as to mandate (pun intended) upholding Obamacare’s individual mandate as a constitutional exercise of Congress’ Commerce Clause authority.  Essentially, he said:  ”Until the Supreme Court says this is constitutional, I’m not going to step out on a ledge and say so.”  Here are some quotes from his opinion:

As set forth below, this Court’s ratio decidendi is straightforward: Heretofore, the Supreme Court has never sanctioned, under the auspices of the Commerce Clause, the enactment of a broad scale economic mandate in anticipation of a probable but uncertain future transaction. The Supreme Court’s Commerce Clause jurisprudence does not lend itself to such an expansive interpretation. Until the Supreme Court interprets the commerce power to permit these anticipatory mandates, I am bound by stare decisis to conclude that Section 5000A is unconstitutional.

Thus, both decisions spotlight the individual mandate’s voyage into unchartered territory of constitutional law. Whether the extension of power is logical or appropriate, the fact of the matter is that Commerce Clause jurisprudence is bereft of authority clearly permitting the extension.

This court’s interpretation of existing precedent, including Lopez and Morrison, leads the court to the conclusion that the Supreme Court would not construe the Commerce power to have such expansive reach. The extension of the Commerce Clause in the manner the government suggests is unsupported by precedent and therefore beyond the scope of this court’s proper function to grant.  An expansive interpretation of the commerce power that will permit Congress to equate the individual financial decision to forego health insurance with commercial activity having a substantial effect on interstate commerce, must come from the Supreme Court.

It would be uncharitable (and inaccurate) to say that Judge Connor simply punted and said, “I’ll leave it for the Supreme Court to address the issue.”  He ultimately reached his own conclusions about how he thought the Supreme Court was likely to rule given his reading of precedent.  But there’s no doubt he crafted his opinion very carefully and that, in addition to how he may have felt as to the merits of the challenge himself, he felt uncomfortable as a lower-tier federal judge (though obviously a very able one) in unilaterally extending the commerce clause based on his own reading of the text and marginally-applicable precedent.  This is an effort in judicial modesty that does the federal judiciary proud, in my opinion!  And lawyers should pay attention — this strikes me as something that can be a very persuasive approach to argument that can win you a lot of cases.

2.  Response to Anti-Obamacare Hyperbole

The second aspect of Judge Conner’s opinion that’s quite notable is his approach to what he obviously considered to be hyperbole in the plaintiffs’ arguments (though he more charitably identified it as overstatement accompanying “zealous advocacy” in a footnote).  Judge Conner himself rejected the contention, which we hear so often, that upholding Obamacare would necessarily lead to either (1) laws mandating broccoli consumption, or (2) acceptance of the constitutionality of laws mandating broccoli consumption.

Judge Conner specifically noted that he himself had no doubt that the market for healthcare was unique and that it was entirely possible to craft a constitutional standard that could distinguish between a health insurance mandate and a broccoli consumption mandate — he just refused to be the one to do it:

It is clear to the court that the health care services market is unique. In other markets, including other insurance markets, when an individual suffers a loss or is in need of a commodity or service (such as food, transportation, or housing) there is no obligation that society compensate for that loss or provide the commodity or service without advance payment. In the health care services market, however, against the backdrop of state and federal laws such as Emergency Medical Treatment and Active Labor Act, individuals can and do receive medical treatment regardless of their ability to pay.

Uniqueness as a limiting principle presents the court with a wholly novel question in Commerce Clause jurisprudence. The text of the Constitution itself does not admit such a limiting principle. Moreover, the court has been unable to find any precedent, and the parties have been unable to direct the court to any precedent, that permits the expansion of the Commerce Clause authority to regulate individuals prior to their engagement in commercial activity on the basis of the unique nature of the market being regulated. This court is bound by the principles of stare decisis and must reasonably interpret, not create, law.  This court’s interpretation of existing precedent, including Lopez and Morrison, leads the court to the conclusion that the Supreme Court would not construe the Commerce power to have such expansive reach. The extension of the Commerce Clause in the manner the government suggests is unsupported by precedent and therefore beyond the scope of this court’s proper function to grant.  An expansive interpretation of the commerce power that will permit Congress to equate the individual financial decision to forego health insurance with commercial activity having a substantial effect on interstate commerce, must come from the Supreme Court.

The Framers carefully constructed our national government with a system of checks and balances. This court’s role in that system is to assess the matters presented before it on the basis of the constitutional text and Supreme Court guidance, consonant with the principles of stare decisis. The minimum coverage provision of the Patient Protection and Affordable Care Act exceeds Congress’s authority under the Commerce Clause of the United States Constitution. The court does not reach this conclusion because the alternative would be disastrous to this nation’s future, such as the Bachman’s prediction of America evolving into a socialist state. These suggestions of cataclysmic results stemming from Article III authorization of an individual mandate are both unproductive and unpersuasive.  Should the Supreme Court determine that the Commerce Clause extends to anticipatory mandates, or, that the health care market is unique for purposes of Commerce Clause analysis, the Supreme Court will delineate clear limits to that power. Until that occurs, the minimum coverage provision of the Patent Protection and Affordable Care Act cannot withstand constitutional scrutiny.

Some Thoughts in Conclusion

Ultimately, I suspect Judge Conner’s decision will polarize people a bit, even though it shouldn’t.  There will be some that will view him as equivocating, trying to avoid meeting the issue head on by saying, “The mandate’s not all evil, but I don’t have authority to uphold it at this point.”  Others, like myself, will really like his approach, even if they don’t necessarily agree with all his analysis.

This is a very carefully considered decision that deserves a close read.  Once you’ve reviewed it, I’d love to hear your thoughts.

Bachmann — Federal Constitution Prohibits State Insurance Mandates

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At today’s Palmetto Freedom Forum debate, sponsored by the good Constitutional Reverend Senator Jim DeMint, Republican Presidential candidate Michele Bachmann ratcheted up the constitutional political rhetoric with a claim that, not only does the federal Constitution preclude Congress from enacting a health insurance mandate, it precludes state governments from mandating health coverage as well:

I believe it is also unconstitutional for states to mandate as a … condition of citizenship, that an individual would have to purchase a product or service even at the state government’s behest.

When pressed about the constitutional authority for her statement, Bachmann said only that she believed it was “inherent in the Constitution.”

As Mitt Romney has discovered, Republican voters aren’t just upset about Obamacare because it was done by the wrong entity — though they employ this argument freely — they hate the idea of a mandate, period.  Yet, up till today, all of the major Republican contenders have been content to fight the state-level battle on old-fashioned policy grounds , without invoking all the constitutional rhetoric.

There are good reasons for this, as the two potential grounds for Bachmann’s position are fraught with some uncomfortable logical and ideological consequences.

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Option 1:  The Dormant Commerce Clause

First, by claiming that a state health insurance mandate was “inherently” prohibited by the federal Constitution, Bachmann could be arguing that state laws mandating health insurance coverage violate the Constitution’s so-called Dormant Commerce Clause.  The Dormant Commerce Clause is a wholly-judicial creation designed to be a mirror image of the affirmative authority granted to Congress over interstate commerce (per Wikipedia):

The Commerce Clause expressly grants Congress the power to regulate commerce “among the several states.” The idea behind the Dormant Commerce Clause is that this grant of power implies a negative converse — a restriction prohibiting a state from passing legislation that improperly burdens or discriminates against interstate commerce. The restriction is self-executing and applies even in the absence of a conflicting federal statute.

For you judicial types out there, the Dormant Commerce Clause is the constitutional equivalent of field preemption.  While states are ordinarily viewed to possess the authority to legislate in the absence of inconsistent federal legislation, the Dormant Commerce Clause prohibits states from legislating in certain ways even when Congress has not passed any inconsistent statutes.  Why?  I suppose it’s because the Supreme Court assumes, at least when it comes to interstate commerce, that the constitutional grant of authority to Congress is conflicting authority that says, in effect, to the states:  ”Not only can Congress legislate to correct interstate commercial messes created by inconsistent state regulations, the states lack the authority to create some of those messes to begin with.”  This is not the case with most other Article 1, Section 8 powers.

So, why haven’t Republicans embraced the Dormant Commerce Clause as a tool in the fight against state-level government-run healthcare?  I can see three good reasons:

1.  I think it’s pretty clear that the doctrine, as formulated by the Supreme Court, wouldn’t prohibit states from enacting health insurance mandates.  It’s just a losing argument.  But that hasn’t always stopped determined advocates — in both parties — from making politically palatable losing arguments part of their stump speech.

2.  The Dormant Commerce Clause is a judicial creation that appears nowhere in the Constitution.  And it’s just really sad for die-hard originalist, anti-Supreme Court types to rely on a judicially-created constitutional doctrine to make their case.  This is post 1787, after all.

3.  Reliance on the Dormant Commerce Clause creates a troubling logical corollary for those convinced of Obamacare’s unconstitutionality.  If the Constitution precludes the states from passing a health insurance mandate on the ground that the authority to do those types of things is reserved to Congress . . . then Obamacare is constitutional.  Game over.  Checkmate.

So, let’s give Bachmann the benefit of the doubt and assume she wasn’t talking about the Dormant Commerce Clause.

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Option 2:  The Due Process Clause

It’s more likely Bachmann’s statement was based a different ground.  The constitutional guarantee of due process of law, applicable to the states through the Fourteenth Amendment, could provide the basis for her contention that states are unable to enact a health insurance mandate.  The Due Process Clauses of the Fifth and Fourteenth Amendments prohibit governments from depriving people of “life, liberty, or property,” without “due process of law.”

Although most straightforwardly applicable to procedural guarantees in courts of law, there is a long tradition, both in this country and England, America’s primary constitutional wellspring, of viewing the constitutional guarantee of due process as more than just an assurance of proper procedural safeguards, but also as a substantive protection of fundamental rights.  The substantive component of the guarantee of due process is called, not surprisingly, substantive due process.  Substantive due process is the basis for United States Supreme Court striking down statutes criminalizing abortion and homosexuality.

The primary benefit of the substantive due process approach to the fight against government healthcare is readily apparent — by putting a health insurance mandate outside of the legislative domain entirely, conservatives avoid the most significant problem associated with the federalism/dormant commerce approaches:  The possibility that all the constitutional battle over Obamacare gets them is 50 separate government-run healthcare schemes, instead of a single one.  But in avoiding this problem, the substantive due process approach creates some other issues.

First, it forces conservatives to make some awkward distinctions.  For example, if state health insurance mandates are prohibited by the Constitution, what about automobile insurance mandates (and please spare me the arguments about how driving a car is “optional”)?  Second, and more importantly, the substantive due process approach would require conservatives to embrace the same judicial doctrine used to justify the current constitutional right to an abortion.  Just as conservatives have argued for years that, “The Constitution says nothing about a right to an abortion,” liberals are sure to respond to Bachmann, “Where is the constitutional right to be free from economic mandates?”

In fact, this is precisely how the Roosevelt Administration responded when conservatives argued, 75 years ago, that individuals and businesses had a constitutional right to be free from troublesome social welfare legislation like maximum hour and child labor laws.  It was conservatives’ insistence in pursuing the constitutional solution to state social welfare legislation that led to the Supreme Court abandoning economic substantive due process in a string of decisions that arguably culminated with that Tea Party favorite:  Wickard v. Filburn.  Sensing a troubling pattern here?  Conservatives should (and most do).  If nothing else, history counsels trying something new this time.

So, which is it, Candidate Bachmann — dormant commerce or substantive due process — that prohibits Romneycare and other state solutions?

I predict the Bachmann team begins an orderly retraction of this statement starting in 3, 2, 1 . . . .