Aug. 22, 2014 SIGN IN | REGISTER

Would Health Reform Work Without a Mandate?

The Republicans’ other favored option to manage costs is to allow people to buy insurance across state lines.

We have tried this approach before with credit cards. What happened, predictably, is that companies gravitated to the state with the most lax requirements, and the result was something I and millions of others experienced: Be a day late with your minimum payment and you are hit not just with a stiff penalty but huge interest rates on your balance, including not just the amount due with the bill but on a much larger amount from your charge history. The patent unfairness of these and other practices led to sweeping credit card reform in the 111th Congress.

This “race to the bottom” would just as predictably hit the insurance market, with companies going to the states with the easiest requirements and laxest regulations, and people discovering only after they have insurance that it doesn’t cover many things they were sure were required.

I was sorry that the exchanges included in the reform legislation, which Alice Rivlin has called the best chance to create a true private market in the health arena, did not include a national exchange, which would have been the best way to accomplish the Republicans’ expressed goal. It would be a good reform to pursue in the 112th Congress, and there are others.

It will serve no one’s interests to fight over dismantling reform, by killing it outright or crippling its implementation, instead of having a real conversation about achieving our goals of a strong and equitable health care system. And a voting public that reacted against Democrats because they turned their focus from jobs to health policy may well have the same response to Republicans.

Another set of events in recent days has made it clear that even if Republican leaders succeeded in their goal of erasing the health care reform act, there will be huge problems and turmoil ahead in the health arena — problems that have nothing to do with what they call Obamacare.

It turns out that Rep. Michele Bachmann (R-Minn.) was right when she said that if Obamacare passed, there would be death panels. But they are coming from Republican governors and state legislatures.

In Arizona and Indiana, these political figures are struggling with a sluggish economy, the loss of stimulus money, the slowdown in revenues, the need to balance their budgets and the inexorable growth in Medicaid costs. In Arizona, the rash decision to summarily cut off funding for organ transplants from dying patients has raised a ruckus. In Indiana, it was denying a 6-month-old a life-saving treatment that has worked in 96 percent of the cases tried, on the grounds that it was an “experimental” application.

Whether you admire the health care reform plan or not, there were compelling reasons to grapple with the entire complex system. We know costs will continue to grow sharply and that many more excruciating decisions — yes, rationing decisions — will be made by states, insurers, doctors, hospitals and others, with or without Obamacare. And without, the challenges and decisions might be even more difficult.

Norman Ornstein is a resident scholar at the American Enterprise Institute.

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