If the Court overturns the mandate this June, there are other options to persuade millions of Americans to buy insurance. Starr suggests that people be allowed to avoid a penalty if they do not buy insurance, but they would no longer be protected by the clause forbidding denial of insurance because of preexisting conditions. Alternatively, premiums could be raised substantially for those who don’t sign up right away. There are other potentially effective proposals as well. And if the political makeup of Congress changes, there could be much to build on. A strong public option could be added at any time. So could a provision allowing those who are fifty-five to sixty-four to buy into Medicare. In short, the future of health care in America will depend critically on who wins both the White House and Congress in November, and thereafter.
It would help Obama’s cause in this election if some of the other attractive components of the ACA were already in place. But most are not scheduled to take effect until 2014. This concession by the White House and Democrats, in my view, was a major political error. If Americans had already begun to understand better some of the benefits, the ACA could have become a serious campaign advantage for Obama and the Democrats. As it is, especially if the mandate is disallowed, support for the ACA will require aggressive boosting by the president himself, and his colleagues in Congress and state houses. He avoided that through much of 2009, finally coming in to rescue the plan late that year. He cannot be so aloof anymore. He has much to be proud of, yet he must still show Americans why they will be better off.