Virginia Attorney General Ken Cuccinelli, who sued the government over health reform just moments after President Obama signed reform legislation, has filed a response to the federal government’s motion to dismiss that state’s independent lawsuit. Over at the main site, Ian Millhiser mocks Cuccinelli for producing “an often-incoherent brief” that “argues that a 236 year-old colonial boycott of British products somehow renders the new health care law unconstitutional.” But judging by the 25-minute conference call Cuccinelli hosted last night about the suit and the detailed press release his office released, the AG is taking this thing very, very seriously:

Of all the controversial items on Cuccinelli’s agenda, he has said his most important initiative is this lawsuit. It also happens to be the issue that tends to get him the most hearty support from the public–though certainly not a few detractors as well.

Maybe all those reasons explain why he has seemed so particularly eager to discuss his position on this case. Along with this evening’s call, his office also put out a a press release that walked through the case’s legal issues in an unusual depth for such documents. In a grid, the release shows each of the federal governments six arguments for dismissal, along with Cuccinelli’s response for each.

The call continued for close to 25 minutes. Cuccinelli discussed why his suit is ripe now, even though the mandate doesn’t go into effect until 2014, why he believes the constitution’s “necessary and proper” clause does not give Congress constitutional authority for the law, why the fine citizens will face if they do not buy insurance should be considered a penalty and not a tax and why that would matter legally. He also explained why his suit should be heard separately from a 20 state suit against the law filed in Florida but why the cases will likely be heard together at the U.S. Supreme Court.

“Virginia has a sovereign interest which has been infringed and we therefore have standing in this case,” he said.

What’s strange is how sincerely concerned Cuccinelli seems about a piece of legislation that doesn’t kick in until the very end of his four-year term in 2014. Cuccinelli charges that the state of Virginia is injured by reform “[b]ecause the federal health care law purports to invalidate a Virginia law (the Health Care Freedom Act).” But the injury is self-imposed. Virginia purposely passed a law that contradicted the federal bill, knowing full well that the supremacy clause would invalidate the measure. Rather than deal with other more pressing problems, the state government manufactured standing and is now determined to spend taxpayer dollars and time arguing a highly improbable case.

The most exciting part of today’s health care town hall occurred when a transgendered senior asked the President a question about managing chronic health conditions (watch that HERE), but the most effective portion came in the introduction. Echoing the arguments of some Senate Democrats, Obama framed the GOP’s efforts to repeal the health care law as an attempt to take away immediate health benefits:

OBAMA: There are some folks are against health reform in Congress. They still think that none of this should have happened. They don’t think you should be getting these rebates. Don’t think we should be closing this doughnut hole. In fact, you have an entire party out there that’s running on a platform of repeal. They want to roll back all of these reform efforts. They say they have their own plan, but over the last 14 months of debate, they never seriously advanced it. And when you look at it, you can see why.

They would roll back the rebate to help you pay for your medicine, if you fall in the doughnut hole. They’d roll back the free preventive care for Medicare recipients. And away from seniors, they would roll back all of the insurance provisions that make sure that insurance companies are not cheating folks who are paying their premiums. Their plan would let insurance companies continue to deny folks coverage when they get sick. They would do little to make insurance more affordable. They gut the existing consumer protections. They’d put insurance companies back in charge. And some have even filed legislation that would end Medicare as we know it, giving every senior a voucher for health care instead. I refuse to let that happen. We’re not going back. We are going to move forward. That’s why I was elected.

Watch it:

Obama’s remarks highlight the political difficulty of repealing sweeping reforms and create more rift within the Republican party. While the GOP leadership is calling for a partial repeal or a repeal and replace, more conservative activists are pushing for a complete reversal of the law.

The problem for both factions, however, is this: since the majority of the legislation does not kick in until 2014, the GOP’s talking points about ‘bankrupting Medicare’ or the destroying businesses, are a commentary about future projections and events. What the public will experience now are tangible and immediate benefits of reform. The doughnut hole checks. Coverage for uninsured individuals with pre-existing conditions. Small business tax credits and extended dependent coverage for young adults. Regardless of their concerns about the feasibility of the law, the GOP’s strategy of repeal will take away popular benefits, a reality the President rightly recognized and will likely reinforce in the weeks and months ahead.

Today, Health Affairs released its new issue, dedicated to exploring how policymakers can effectively implement the new health care reform law. The issue asses “why reform finally passed” and makes suggestions for how regulators can design the new health insurance exchanges, implement the insurance market reforms, expand the Medicaid program, and transform the delivery system. I’ll have more on the issue as I read through it, but this study from the RAND corporation struck me as significant.

The researchers took an analytical approach to determining if reformers got the best deal possible (given the political limitations) and concluded that the bill “provides health insurance coverage to the largest number of Americans while keeping federal costs as low as reasonably possible.” The only alternatives that would have covered more Americans at a lower cost to the federal government were all politically untenable “– substantially higher penalties for those who don’t comply with mandates, lower government subsidies and less-generous Medicaid expansion,” the researchers found.

The study used this graph to illustrate the trade-offs between the number of people who are newly insured on the horizontal axis and the annual cost to the government on the vertical axis. The red square in the middle represents the new law. The blue line represents a boundary that contains all of the combination of policy parameters and the four territories are defined by the researchers’ estimate of the number of newly insured people—the horizontal line—and the annual cost to the government—the vertical line:

- Policies in 1: would produce results that are better than the new law (more insured people at a lower cost). The individual-mandate penalty would have to be much higher. To increase the number of newly insured people by 10 percent, the penalty would have to increase 47%.

- Policies in 2: would produce unequivocally worse results (fewer insured at a higher cost)

- Policies in 3A and 3B: would produce more newly insured people, but at a higher government cost than under the new law.

- Policies in 4A and 4B: would produce fewer newly insured people at a lower government cost.

Look:

“The key drivers of where a policy scenario falls,” the author note, “are the size and design of the individual mandate penalty and the eligibility threshold for Medicaid” (other policy options like level of subsidies, rate bands, and the employer mandate are also significant, but not determinative). Higher penalties for failing to comply with the requirement to purchase coverage specifically targets the uninsured and would produce a higher insured rate, while the Medicaid expansion also targets lower income Americans without coverage. But as the Medicaid threshold increases, more people are encouraged to “switch from employer-sponsored insurance to Medicaid—a phenomenon known as crowd-out.” “High rates of crowd-out are undesirable because they increase the cost of coverage expansion to the government without making a comparable reduction in the number of uninsured people,” the report argues. “Therefore, thresholds at 100 percent and 133 percent of the federal poverty level are preferred to higher thresholds.”

All this makes some sense, but it’s not entirely clear — as the researchers themselves admit — that more efficient policies would result in better or more affordable coverage for patients. For instance, while reducing the generosity of the subsidy, lowering the Medicaid expansion threshold or increasing the mandate penalty would reduce government spending, it would make health care less affordable for the consumer or force him to purchase coverage he can’t afford with less government aid.

So did Democrats find the sweet spot for reform or could they have secured a more “efficient plan?” Territory 1 suggests that they could have done a bit more, but that wouldn’t’ have necessarily endeared them any closer to their constituents.