Yes, providing health care to (almost) every American as a right is indeed a historic change. Like most other achievements that require seventy years, however, this one can’t hide a vague mustiness reminiscent of something in the fridge you should have finished long ago.
Far from the “government takeover of an entire industry,” as apoplectic Republicans characterize it, or the transformation of the industry that Democrats once promised, the bill, though monumental in size and cost, consists primarily of expanding existing taxpayer-subsidized coverage and insurance regulation (no dropping coverage for children with pre-existing conditions, for instance). These provisions, though major in scale and effect, are hardly novel in conception. Precious little is done to address the costs or composition of the most expensive (but far-from-best) health care system on earth. The bill is noteworthy mainly in that it could have been enacted in (choose one) the ‘60s, ‘70s or ‘90s.
But as long as Republicans move further right the more they lose, in the absence of a responsible opposition Democrats will feel no pressure to develop a vision relevant to the current century. President Obama hadn’t even signed the health care bill before the long-planned conservative legal counterattack began, proving that if you go far enough to one side of the political spectrum, you come back out the other.
The Republican lawsuits are about a whole lot more than health care – in fact, it’s a fraud on the public to contend that that’s the motivation. Instead, the central goal of the conservative legal agenda long has been the reversal of New Deal-era rulings that gave the constitutional green light to the modern state as we know it, based on the view that if something wasn’t recognized as the government’s role in 1787, when the Constitution was written, then it’s illegitimate. Despite the pooh-poohing of most (liberal) legal scholars, the challenge to the health care bill indeed may be conservatism’s “moment come round at last,” to borrow William Butler Yeats’ phrase. The current Supreme Court certainly has shown it’s not shy about such things.
There are countervailing constitutional and historical arguments, including that the Civil War and the constitutional amendments adopted in its wake fundamentally changed the Founders’ original design. To the extent the advocates of the “original intent” and “original meaning” of the Constitution (the so-called Originalists) refer to this today, however, it is largely to argue wistfully that everything’s been downhill since Lincoln’s election.
But the core of the challenge to the insurance mandate is that the expressly-limited power given the federal government to regulate “interstate commerce” doesn’t extend to anything other than transactions crossing state lines. This is contrary to a 1942 Supreme Court ruling that even seemingly local economic activity – such as a farmer’s decision to grow wheat for his own consumption – affects “interstate commerce” because, basically, in this day and age, unlike in 1787, there is no longer any meaningful distinction in fact between the local and national economies. In the health care challenge, conservatives argue that anyone wealthy enough to self-insure (and, let’s be clear, we’re only talking about the super-wealthy here) is outside the national insurance market and thus should be beyond Congress’ power to regulate commerce.
Of course, the federal government could create a program run entirely by the government, providing health insurance for all, and require all Americans to pay taxes to support it (because, otherwise, Social Security and Medicare would be unconstitutional, too, which – at least for today – is a bridge too far even for conservatives). The conservative argument thus essentially boils down to this: The government cannot require all Americans to use the money they would have paid in taxes for government-run insurance to purchase the same coverage from private insurers, instead.
Needless to say, this is not Your Father’s Conservatism. It’s not even the conservatism of the Bush Administration, which gave us “Medicare Advantage” and “Part D”. Under Medicare Advantage, the government plan must compete with private insurers – you know, kinda like the “public option” the conservatives torpedoed earlier in this health care debate. Medicare Part D created a government drug benefit for seniors – through private insurers. Now, conservatives find themselves arguing that the Constitution allows the government “to provide for the general welfare” by creating mandatory socialist programs that “tax and spend” your money (yep, there’s a clause for that) – but it can’t just privatize the whole effort and let you keep the money to spend by yourself on corporate alternatives. Republicans thus have moved so much further right than Ronald Reagan or George W. Bush that they’ve come out some political wormhole as Dennis Kucinich.
Perhaps that is to be expected when Democrats have been coming out wormholes of their own for the past decade or two looking more like Republicans. Take the insurance mandate itself, born not just of a principled belief in universal coverage but also of a less idealistic determination to bring insurers into the fold this time rather than letting them defeat health care reform as happened with the Clinton effort in 1993-94. Thus the Obama White House, oddly agnostic on virtually every aspect of reform other than that they wanted it, decided early on to befriend the industry by building health care around a government-mandated universal market for its product. To be sure, conservatives stoking the fury of pitchfork populism over policies that favor the rich and big business is breathtakingly hypocritical. But you’ve got to understand the resentment: Democrats stole their business model.
Perhaps all the overwrought millennialism on both sides is appropriate, after all, for the political scene today recalls Yeats’ image of the apocalypse: “The best lack all conviction, while the worst/ Are full of passionate intensity.”