Last week, opponents of the new health care reform law cheered what they saw as two victories -- a federal district court said a Virginia lawsuit against the reform could proceed, and Missouri voters overwhelmingly supported an anti-reform ballot initiative. Both targeted a key part of the reform law -- the requirement that everyone have or purchase health care insurance.
As Sen. Minority Leader Mitch McConnell, R-Ken., put it, "The voters of Missouri sent a clear message that the federal government has no business forcing people to buy health insurance against their will. And I applaud them for it."
So let's say reform's critics win and the "individual mandate" is killed. What then?
It's far from clear that conservatives should cheer this outcome. Because it's not just "Obamacare" that would be likely to fall, but the entire private market for health insurance as well.
Though you wouldn't know it from listening to the talking heads on either side of the debate, federal health care reform was actually designed to strengthen the private health insurance market. It did so through the following deal: Health insurers would no longer be allowed to deny people for pre-existing conditions. In exchange, everyone would be required to have health care coverage.
Each part of this deal depends on the other.
If insurers can deny people for being sick, they have a strong incentive to offer policies only to the healthy. This vastly increases the number of people who are dependent on public programs or who simply have no way to pay for care. These costs get passed along to everyone else in the form of higher premiums and co-payments.
If insurers can no longer deny people for having an illness but there is no requirement to have coverage, people can simply wait until they fall ill before they buy insurance. This leads to increasingly sicker pools of people according to what is technically (and spookily) named an "adverse selection death spiral." This is what's happened in every state that tried to require insurers to provide policies to everyone who applies without requiring everyone to have coverage.
If you knock out either of the legs in health care reform, the private insurance market falls.
We cannot just go back to where we were before health reform, though, because even Republicans agree that health insurers shouldn't be able to deny coverage to people because of pre-existing conditions. And none of the Republican ideas during health care reform -- including the proposal that people should be able to buy insurance across state lines -- would have addressed these issues.
If this round of reform fails, therefore, we'll have to do something entirely different. But don't hold your breath waiting for a system that relies even more heavily on the private market for health insurance.
In fact, the most likely thing that we will do is move toward a system like Medicare that is financed by the government.
It turns out that Medicare is extremely popular among seniors of all political persuasions, even tea partying ones. After all, the thing the town hall screamers were the most upset about was the idea that the program would be changed to institute "death panels." This was a vicious smear that could not have been further from the truth. But it shows just how little appetite there is for changing the Medicare program in any way, even among members of the conservative right.
So people of all political stripes love to love Medicare, and they love to hate insurance companies. It stands to reason, therefore, that if we have to start over, we'll build on what is popular rather than heading even further in an unpopular direction.
Conservative Republicans are free to continue their quest to undermine health care reform. But they should be careful what they wish for, because through their actions they may be the very people who finally lead this country to ... a single-payer health care system.