Who could have predicted that the conservative bloc of the Supreme Court doesn’t like the individual mandate? Not me, I never expected any different. Of course, whether they want to overturn it is still up in the air. In my opinion it is not a question of whether they want to do it, it is not a question of whether they think the law supports it (they don’t, regardless of what the experts say), it’s a matter of if they have the guts to do it. Of course, I remind you that this is one of those short-term smart/long-term dumb kind of things that characterizes nearly everything they’ve done post-Bush. For example, stirring up xenophobia is brilliant during tough economic times, as people naturally look for scapegoats when money is tight, but the long-term implications are just awful for the GOP. Similarly, if a mandate-subsidize model gets struck down by SCOTUS, the only position left for healthcare reform folks is single-payer. Absent the mandate, the ACA’s effectiveness will be sharply curtailed. A significant Court decision against the bill could be a real body blow in terms of public opinion of the Act and Obama personally, likely discrediting the Romney/Gruber/Obama healthcare approach within the Democratic Party.

But contrary to what some pundits say, it won’t take another two decades for the issue to come up again, due to the decreasing number of people on employer-based plans. Part of the reason we don’t have universal care is because in spite of not having a true system, most people do actually have insurance. It’s a hacked together, piecemeal thing, not to mention wildly inefficient but most people can’t gauge the mediocrity as they have nothing to compare it to. But this is the kicker: if your typical person has something that they value highly, like life-saving insurance, even if it is actually worthless they will never give it up. On the other hand, if they have nothing, then almost anything starts to look darn appealing. So here it is: as costs continue to mount, as they have since the mid-1990s, more workplaces will drop these plans. This will remove the primary obstacle to aggressive healthcare reform, which is that people who are insured don’t want to lose what they have. Clinton’s plan was (falsely) believed to do this thanks to a falsehood campaign, and it was doomed after this became widely believed. But if people have nothing, the main obstacle will not exist. And with mandate-subsidize out of the question, the only remaining approach with any sort of organized support will be single-payer (which will undoubtedly and accurately be sold as Medicare-for-All). I suppose the key determinant here could wind up being how Vermont’s pending single-payer reforms work out.

Conservatives came up with the mandate-subsidize approach specifically to head off something like single-payer. And it could very well still do so! Nothing has been overturned yet. But if they do take the short-term win here, as might well be too irresistible for them to pass up, they’ll be shooting themselves in the foot on the longer-term strategic issue. I don’t want the ACA to fail because it would cause considerably more suffering if it did. I like single-payer just fine, but mandate-subsidize can work perfectly well as some states and plenty of countries have shown. I don’t need a “left” solution just because. But the point is, there has to be a solution. The Mitch McConnell “do nothing” approach simply will not work in the long term: people don’t want to pay enormous amounts of money out of pocket for insurance, and they will not, one way or another. The private insurance system we have is not only unstable, it is failing. At the moment, enough people still get coverage from their work that there is a significant impediment to a truly universal system. For now. But by, say, 2020, the environment will be very different. One wonders, if the mandate goes down, that Republicans then won’t see this current episode as an enormous strategic disaster, in which they could have wound up with a nice market-based system instead of a huge single-payer one.