With the three-day ObamaCare circus at the Supreme Court behind us, let's fast-forward to June. Suppose that five justices find their constitutional bearings and do what a majority of Americans want them to do: Scrap the individual mandate, the key provision without which the law will collapse. What then?
Will that mean that our current system can just lumber along as is? No. America's health care system is wasteful, inefficient and way too expensive: The U.S. retail price for an MRI, excluding professional fees, exceeds $4,000—about 20 times more than in Japan and France. This makes it extremely hard for Americans without coverage to spring for their own care, creating a system of medical haves and have-nots. It is not surprising, therefore, that a Kaiser Family Foundation tracking poll earlier this month found that six out of 10 Americans want lawmakers to keep searching for workable reforms even if the Supreme Court eventually kills the president's reform law.
But any reform has to be based on the correct diagnosis of the problem. The administration's main argument for ObamaCare's mandate—that unless every freeloader is forced to buy coverage, we won't be able to control spiraling health care costs—is a total red herring. The cost of uncompensated emergency care in America adds up to only about $40.7 billion annually, less than 3 percent of the country's total health care spending. Arguably, even if hospitals were not legally required to treat uninsured patients, they would provide that amount of care pro bono—just as they do in India, a far poorer country. Many private, for-profit hospitals I queried during a previous visit reported treating up to 10 percent of their patients for free. American law firms, by comparison, aim to offer 3 to 5 percent of their billable hours in pro bono services.
But the question remains: What kind of reforms do Americans want? The Obama administration completely misread the public mood when it based its decision to craft a 2,700-page, Rube Goldberg-style makeover of literally one-sixth of our economy on polls suggesting that Americans would be willing to pay higher taxes for universal coverage. Worse, a joint Reason-Rupe poll released last week found that the misnamed Affordable Care Act—a.k.a. ObamaCare—imposed trade-offs that Americans were simply unwilling to accept. The act's supporters insist that even though a majority of Americans view the overall law unfavorably, many of its specific provisions are quite popular. But the problem is that most polls pose questions in a vacuum, without actually confronting Americans with the consequences of their choices. The Reason-Rupe poll was among the few to do so systematically, and it found that although Americans do want equity and coverage for all, they want control, choice and quality for themselves even more.
Like other polls, it found that Americans don't want the government forcing them to buy coverage, although they were more amenable to employers being forced to provide coverage to employees, even if that means job losses and pay cuts. Indeed, 56 percent of respondents said they were fine with an employer mandate, compared to the 39 percent who said they were not.
Americans like the idea of giving everyone the same access to health care, regardless of medical status—except if it means sacrificing affordability or quality. Fifty-two percent approved of the community rating provision in the law, which would ban insurance companies from charging higher premiums based on medical history, compared to 39 percent who opposed it. But this support drops precipitously if the provision's side effects include longer wait times for doctors (41 percent) or higher premiums (38 percent) or higher taxes (37 percent) or lower-quality care (15 percent).
But what was truly revealing was how eager Americans are to control their own health care dollars. Forty-eight percent said they'd prefer it if their employers gave them the money to purchase their own coverage, compared to 41 percent who would not. Even more remarkably, 65 percent of Americans want Medicare payouts in the form of a credit for use toward a private health plan, compared to 24 percent who don't. This is good news for Rep. Paul Ryan's "premium support" proposal for Medicare reform.
All of this makes perfect sense in light of another finding. When asked to rate how much they trust various entities in "addressing their health care needs," 61 percent said they have a "great deal of trust" in themselves—but only 15 percent said that of their employers, and 5 percent of the government.
What's more, Americans want to make their own coverage decisions. Almost 70 percent said they want the same ability to shop around for "a less expensive or better [health] insurance policy" as they have for their auto insurance.
So what are the implications of all this for health care reform? Americans are not dogmatically opposed to government intervention in health care markets. But their intuitions are more in line with advocates of consumer-based medicine who believe that the best way to control spiraling costs—the key to improving access—is to give patients more control over their medical dollars and inject a modicum of price sensitivity into our health care system.
If the Supreme Court relegates ObamaCare to the dustbin of history, Congress ought to bear that in mind when it crafts a revised bill. The last thing the country needs is another failed reform effort.
Reason Foundation Senior Analyst Shikha Dalmia is a columnist at The Daily, where this column originally appeared.