Back And Forth On Health Care

The WSJ takes up the question of whether Hillary's health care mandates can actually allow her to declare her health plan as creating universal coverage:

The argument concerns whether the government should require all Americans to get insurance. Mrs. Clinton and Mr. Edwards would require people to get insurance, either through work, a government program or new health marketplaces that all three candidates promise to set up. Mr. Obama would only require that children be insured.

Other elements of their plans are similar, including subsidies to help lower-income and even middle-income families pay premiums, and various proposals to cut the cost of health care. The candidates say they would pay for their plans by rolling back President Bush's tax cuts for upper-income earners and by savings in health spending through various measures.

...

Mrs. Clinton charges that Mr. Obama's plan would leave 15 million people without insurance. Outside experts agree that number is in the ballpark. If people aren't required by law to buy insurance, many won't. There are millions of children, for instance, who remain uninsured, even though they qualify for free or subsidized government programs.

In addition, all three candidates want to bar insurance companies from rejecting sick people or charging them more. But it is hard to require companies to insure expensive sick people if they aren't guaranteed that cheap healthy people will balance them out.

...

Mr. Obama has replied that her attacks are more about politics than substance; they didn't come, he noted, until she lost ground in the polls. But his advisers don't dispute her central charge. Rather, they claim Mrs. Clinton's plan would also leave millions without coverage.

Obama adviser Austan Goolsbee argues that if Mrs. Clinton's health plan is enacted, she will have to waive the mandate for millions of people. That is because, he says, there isn't enough money for subsidies to make health insurance affordable enough for people to buy it.

"You can't put in a mandate until health care is affordable," he says. He predicted that a Hillary Clinton administration would wind up exempting 20% of the uninsured, or about 10 million people. That is the percentage of uninsured adults who were exempted in Massachusetts, the only state to try an individual mandate.

That view may not be true. Ken Thorpe, a health-policy expert at Emory University who has advised all three major Democrats, said he ran cost estimates for the Clinton plan at the Clinton campaign's request, and found there should be enough money to make insurance affordable for all. He said he ran three scenarios with varying levels of subsidies -- from $100 billion a year to $120 billion a year. The campaign chose one in the middle: $110 billion.

If it turns out that isn't enough money to make health premiums affordable, Mrs. Clinton would have to spend more on subsidies, one of her health-care advisers said.

But, the adviser said, it is wrong to assume that 20% of Americans will be exempted. It is impossible to say for certain, because the campaign has not explained how large the subsidies will be or who will qualify for them.

Ms. Seelye of the NY Times also joins in with a bit of a Hillary-basher:

Clinton Attack on Obama Overlooks Some Realities

...But while Mrs. Clinton is right that Mr. Obama’s plan would leave out millions, she is being misleading in implying that her own plan covers everyone. Mandates rarely achieve 100 percent compliance. In addition, they are almost impossible to enforce.

Because of those difficulties, Mrs. Clinton’s own plan would probably leave out millions.

Mandates have not worked with auto insurance. While all drivers are required to have it, 15 percent of the nation’s drivers have none, according to the Insurance Research Council.

...

Austan Goolsbee, an economics professor at the University of Chicago and senior economic adviser to the Obama campaign, said the Clinton campaign should acknowledge that its plan would leave out at least as many as Mr. Obama’s — partly because Mrs. Clinton has not said how she would enforce her mandate.

“She has not suggested a penalty,” Mr. Goolsbee said. “If there’s not a major penalty for skipping out on insurance, people will skip out on it.”

Ms. Seelye describes the American Enterprise Institute as "non-partisan", which draws Paul Krugman's ire.  His near-substantive contribution is to tell us that "many, many health experts believe that Obama is wrong, and that mandates are both feasible and essential", but he doesn't trouble himself with the tedium of naming names, so there we are.

Noam Scheiber of TNR lauds Timothy Noah of Slate for his defense of the Obama plan.

Matt Yglesias has some sensible ruminations, wondering who will be helped her hurt by the Clinton and Obama plans and concludes with this:

My sense is that mandate advocates are trying to obscure the fact that most of the people who wouldn't have comprehensive insurance after the proposed Obama reforms are people who'd be screwed-over by a mandate.

UPDATE: I should have added that these are people who arguably should be screwed over. The goal of national health care policy should be to support the needs of the poor and the sick, and the individual mandate is a clumsy way of doing that by making the prosperous and healthy cross-subsidize their insurance premiums.

That is quite an update!  My sense (shared by this commenter) is that the young, healthy working near-poor are the least likely to go looking for insurance, but screw 'em.

Finally, there is this table-pounder in support of Obama:

Krugman also insists that Clinton’s plan makes more economic sense. He says that forcing young, healthy workers to buy insurance they don’t think they need will subsidize insurance for others, making “universal coverage” affordable.

But that analysis is hopelessly simplistic. Who are those young, healthy workers likely to be? White-collar and other highly paid workers won’t refuse to buy insurance; its cost amounts to a small portion of their pay. Nor will older workers and workers with families, who need insurance more and know it. So the people most likely to “self-insure” are young, single blue-collar workers (including the poor and near-poor), for whom the cost of insurance is a substantial part of their earnings.

Forcing these people to buy insurance they don’t want will have two adverse effects. Politically, it will drive young, single, healthy workers away from the Democratic party. It will put the so-called “Reagan Democrats” back in the arms of the Republicans, precisely when Democrats need them to consolidate their status as a majority party. For someone supposedly astute at politics, that’s a downright stupid thing to do.

Economically, Clinton’s mandate will turn the health-care system into a regressive tax. Imposing extra costs on young, single, healthy, low-paid workers in order to finance others’ health care will put part of the burden on those who can least afford it.

Obviously, some of this debate is in a vacuum - until we know what subsidies and penalties are involved it is virtually impossible to guess who will be helped or hurt by the proposals.  And Hillary has no intention of discussing any possible penalties for non-compliance; Edwards did and was panned (except by Krugman!).

No worries - eventually Jonathan Cohn will solve this for the rest of us.

Comments

[Other Tom]

Whether or not insurance is mandated, there is one very simple reform that would improve the entire business of health insurance: Allow people to buy insurance from any seller, not just those who offer coverange within the buyer's state of residence.

If you live in New York, I am told that you cannot buy a policy that does not provide coverage for podiatry services. This requirement is not dictated by the consumers' demand for podiatry coverage, but rather by the legislature in response to lobbying by the podiatrists. Suppose everyone could shop for a policy covering only what he wanted to insure against, and not including, say, either podiatry or mental health services? Wouldn't that go a long way toward making "affordable" health care more generally available?

[Pofarmer]

Take it one step further. Don't tie people to one provider. Let folks shop for healthcare like they shop for everything else.

[MayBee]

Mandates have not worked with auto insurance. While all drivers are required to have it, 15 percent of the nation’s drivers have none, according to the Insurance Research Council.

Auto insurance even has an incentive that medical insurance would never have- it your car is not insured and you get in an accident, nobody is going to fix your car. If YOU are not insured and you get in an accident, you will receive medical care at someone's expense.

I know this is a bit off topic, but I wonder how accurate that statistic is. Have you seen the cost of insurance for an under-18 year old driver? It is exorbitant. I'm willing to bet a huge percentage of teen drivers are driving their parents' cars without the car being adequately insured.

[clarice]

MayBee--most people would benefit by putting their car insurance with the same people who insure their home, keeping a high deductible and not filing claims except for really big stuff. We did that and were astonished how low insurance for our son was when he took up driving.
Nevertheless, your point is a very good one.

Of course, the "Plan" would mean more numbskulls to put on the federal payroll (and union dues contributions to the Dems) without seriously improving health care--just the administrative costs.

[LindaK]

Auto insurance is not off topic. I have an under 22 year old driver who had an expensive fender bender and the cost of insurance (in NY State) is astronomical. However, unlike healthcare insurance, I was able to shop around, change the deductible and reduce the annaul cost significantly.

The affordability of healthcare insurance would improve if we could cross state lines to buy it. In NY State, healthcare insurance costs are among the highest in the US becahse the legislature has been pressured by various interest groups, principally the very powerful healthcare workers union 1199, to mandate that insurance cover everything. You cannot buy basic healthcare insurance. If you are a healthy young man of 25 you are forced to purchase insurance that covers fertility treatments, hormone replacement therapy and many other treatments that are inapplicable.

[clarice]

LindaK, Maybe in the short run. Those mandated provisions are political--get someone who wants to cover marrow transplants for cancer treatment even though they were expensive, painful and inefficacious or whatever else is your pet project--get sympatheitc coverage and a good lobbying effot and bingo your state legislature will add it to the list.
What makes you think once there is federally mandated insurance coverage we won't get the same "mission creep". Remember, there are parts of the country where civil servants and even jailed felons are entitled to transgender operations.
(OTOH, there's a rosy lining--in Argentina everyone is entitled to one plastic surgery a year for life.)

[sbw]

Simple considerations:

-- People need to be personally invested in the cost of their health care to have an incentive to control costs.

-- Government is not personally invested in the cost of health care (see the unfunded mandates from New York's legislature).

-- Competition works to keep health care costs in check, so encourage competition.

Laugh at any candidate that ignores these considerations. Be prepared to laugh hard and often. These considerations are so little part of the political discussion because snake oil salespersons are still trying to sell that there is such a thing as a free lunch.

[clarice]

Absolutely so, SBW--(I have to watch myself--people will say we're in love.)
When she's paying out of her own pocket, my mom watches the bills like a hawk. When the state pays --as it did to have all her wrists and ankles xrayed for something that involved one wrist, she never said a word though she knew it was fraudulent.
In Southern FLorida with no co-pays, many seniors make regular trips to the doctor just to visit. It's become a major social activity.

[Paul Zrimsek]

As an evil, selfish opponent of socialized medicine, I'm riveted by the spectacle of liberal Democrats forcing each other, at long last, to confront the problems with the idea. I assume their shared conviction that people like me oppose socialized medicine because we're evil and selfish will survive nonetheless, but I'm not enjoying the show any the less for that.

[LindaK]

I'm for the Argentinian model. But seriously, if there is mandated insurance, advocates for every disease, ailment and age-related disorder will insist on coverage and we'll be left with unaffordable Rolls Royce. If we were able to shop around for healthcare insurance as we can for auto, home and personal liability insurance, we can choose between the Civic and the Rolls. In fact, there are more healthcare choices in states that mandate less coverage. If you go to ehealth, for example, in states like NY, there are only a couple of choices.

[PeterUK]

We have health insurance here - National Insurance -compulsory - turned out to be a tax.
Since it isn't a hypothecated tax,politicians use it as a ponzi scheme.Because it is a tax it is extracted by menaces,because it is run by politicians health care is rationed.

Over to you Hillary.

[stomper]

i don't see the value of insurance companies once everyone is mandated to have insurance. after it is mandated, why not turn it into a tax, turn it over to the hospitals and doctors cutting out the middleman of insurance carriers, and receive subsidized healthcare?

then... we could buy insurance to cover the remaining portion of the doctor's bill that wasn't subsidized...

or we could just keep it the way it is and have the same thing.

[Other Tom]

Stomper:

(A) Because the hospitals and doctors, unlike the insurance companies, have no incentive whatsoever to limit services only to those who genuinely require them. As long as the money is there they will take anyone who shows up, and when it runs low they will ration their care. It has happened all over the world wherever it has been tried.

(B) Because the amount of money available is dependent on the tax, and is not determined by actuarial calculations of what is needed to cover legitimate services.

[Ralph L]

My very high deductible insurance used to be very cheap (<$40/month), but when I got over 40, it skyrocketed. I've had three companies quit writing individual policies in NC, due to profitability, and I've yet to reach the deductible.

[jacksmith]

The #1 cause of injury, disability, and DEATH in America is, Health Care. More people die now from contact with the American Medical Health Care system than from any other cause of death. More than from Cancer, Heart disease, or Stroke. More than any other country in the world. Many times more than any other people in the world. This fact is a catastrophic indictment of the entire US Health Care System.

Driven by greed. And a rush to profit. Thousands of Americans are killed, and injured daily in America. By compromised health care. Cutting corners. Over, and under treatments. And poisonings with all manor of toxic, poisonous pharmaceuticals. Especially the children. America only makes up 2-4% of the world population. But Americans buy, and consume 50% of all pharmaceuticals world wide.

But the tide has turned. I can see it. Hear it. And feel it. The message is getting out. And taking hold about the fact that we have a very serious, and major health care crisis going on in America. Hurting everyone. Especially our precious little children. Rich, and poor alike. And most all Americans seem to understand now that "HR 676 Not For Profit Single Payer Universal National Health Care For All (Medicare For All)" is the way to go. Like all the other developed countries have done. I have seen numbers as high as 90% of Americans want government managed health care Now. Medicare for all. Like other developed countries have. And like older Americans have now.

BRAVO!!! America. YOU GET IT! YOU REALLY GET IT! See sickocure.org.

It's NOW TIME to bring out the BIG GUNS!! The BIG GUNS!! are you. The American people. And anyone else that wants to help. From now until HR 676 is passed into law. I want every person to reach out and touch their fellow Americans every day if you can. I want you to take a phone book. And call at least one of your fellow Americans every day. And ask them to pickup the sword of HR 676 Single Payer Not For Profit Universal Health Care For All (Medicare For All).

Call more than one each day if you can. And ask them to do the same as you are doing if they can. And also to put maximum pressure on their politicians to get HR 676 done. And to make sure their politicians support HR 676. Accept no substitute. HR 676 is a no-brainer. It's the best way to go on health care. It's the only moral, and ethical way to go. That is why every other developed country has done it. Most did it years ago.

I know that many of you have been doing a fabulous job of spreading the word by talking it up with family, friends, and co-workers. And putting pressure on the politicians to get HR 676 done ASAP. The phone calls to your fellow Americans will increase the pressure. And grow the movement at an astonishing, and exponential rate. And I know many of you have been wanting to do something more to help. The phone calls to your fellow Americans is something you can do every day to help.

Trust me. It will be something to see. But you have to keep the focus, and pressure on getting HR 676 passed pronto. They will try to distract you. With all manor of other crises, and catastrophes. And other plans. Don't be distracted. HR 676 Single Payer Not For Profit Universal Health Care is the #1 concern of the American people. Thousands of Americans are dieing daily now. And you or your loved ones could be next.

There is no good reason HR 676 cannot be passed into law well before the coming elections. Do not tolerate delays. If it is not passed before the coming elections. All America will know which politicians are on the side of the American people. And which are not when they vote. Well before the elections.

Everyone can do this. Most of you are well informed about HR 676. This truly is one of those no-brainers. Be considerate of your fellow Americans when you call. But be comfortable about calling. These are your fellow Americans. Some will be receptive. And some will not be. Some maybe rude, and mean. Just thank them, and move on to the next. Most will be with you. And if you get a call from one of your fellow Americans about HR 676. Let them know you are already on board. And thank them for calling. Build them up. And keep them strong. They are fighting for all of us.

I will try to make a second post with just a few of the reasons everyone with 2 working brain cells agrees HR 676 is the best way to go. But you can also look them up for your-self. And read some of the positive informed post on many of the message boards too.

Lastly, I am sick and tired of hearing how the candidates, and politicians health care plans are going to protect, and preserve the private for profit health insurance companies that have been killing, and ripping off the American people. And now the politicians want to mandate (require) that every American has to support the private for profit insurance company's that have been killing, and ripping you off. Or you will be fined, and PENALIZED. Thats right. PENALIZED. Ridiculous! The politicians really think you are all detached idiots. CASH COWS! To lead to the slaughter. Don't put up with that.

So get on it America. Get those phones going. Chat it up! Save some lives. You want all of America talking about HR 676 becoming law, Now! Before more die needlessly. Make it happen. And to my fellow cyber warriors. You have been doing great! I see it! Keep it up. 1 of 2 post...

Below are a few reasons why "HR 676 Single Payer Not For Profit Universal Health Care For All (Medicare For All) is a no-brainer. And some reasons why private for profit health insurance is a stupid idea, and injuring, and killing you and your loved ones.

Medicare cost 2-3% to administer. Private insurance cost 30% to administer.

Under HR 676 everyone would be covered from birth to death. No co-pays. No-deductible. No out of pocket cost. Plus Dental. And Vision. For less cost than we pay now under private health insurance.

With private insurance. You have 47 million Americans with no insurance.

And 89 million Americans that had no insurance part of the time from 2006-2007.

And over a 100 million that are under insured.

18-30 thousand Americans that die each year from lack of health care.

Health Care bills as the #1 cause of personal bankruptcy. And loss of homes.

Under HR 676 health care is moral, and ethical.

Private for profit insurance is immoral. And unethical.

Profit is the primary motive of the private insurance companies.

They make profit by charging needy, vulnerable, sick Americans as much as they can charge them.

Then they make more profit by denying them care when they most need it. And are most vulnerable and unable to fight back. When they are sick. Or trying to recover from major illness.

Yep! I know you are getting angry. I'm sorry. But I have to continue.

Under HR 676: we will save 300 billion dollars in administrative cost each year.

With private insurance: we spent more per capita on health care than any other country in the world. Over twice as much as most other developed country's. Yet we have 47 million with no health care.

We rank at the bottom in quality of health care #37.

Americans have a shorter life expectancy than people from all other developed countries. We rank # 42 in life expectancy. Down from #1.

For the first time in American history. The life expectancy of American children is less than that of their parents. American children are dieing at a record rate. And are in terrible health generally.

People from other country's enjoy a much higher level of general health than the best privately insured Americans.

Americans are also shrinking. We used to be the tallest people in the world. Now we are down to # 10.

People from other country's never have to worry about going bankrupt, or loosing their homes over medical bills if they get sick.

Maybe you should go take a break for a while before I go on. I know this must be upsetting. But this is just a small part of the sad truth about private health insurance that HR 676 can fix.

Under HR 676: Health care will be based on need. Not on profit. And high standards, and quality will be enforced, and patients protected by the Government through a dedicated civil service. With the power, and resources to rain in abuses of patient care. Like they do with Medicare now.

With private insurance: Medical care is base on ability to pay. And profit. Tens of thousands of patient are killed, and millions are injure, crippled, and mutilated each year under private for profit health care, and insurance.

By insurance companies denying needed care to increase their profits.

By hospitals cutting corners. And using the cheapest least experienced personnel, equipment, and standards they can get away with.

By doctors that over treat, and under treat. Who injure, mutilate, and kill patients with unnecessary test, procedures, surgery, and invasive diagnostic test for profit. Who poison, kill, and injure millions of Americans with all manor of unnecessary pharmaceuticals for profit. Men, Women, Children, and babies.

Americans makeup 2-4 % of the world population. But Americans buy, and consume 50% of all pharmaceuticals world wide. This is a monstrous evil. And immorality.

And lastly, by politicians that take blood money from all these despicable groups and turn blind eye's to this slaughter of the American people. And the slaughter of their own loved ones. And them-self.

Well I could go on. And on. But I think this is enough to get you started making your daily phone calls to your fellow Americans to support HR 676. And to help them understand how important it is that each of them join the fight. And bring the MAXIMUM pressure to bear on all individuals, parties, and especially your politicians, and Representatives. To get HR 676 passed into law immediately.

This is an emergency. America is in a crisis. More Americans have died from this health care crisis than have died in all the wars in US history. Do your best. Millions of Americans lives are counting on each of you. Including your own life. Remember, you are Americans. You know how to fight for your country when you have too. The whole world is in your blood. I'm with you.

All the best... 2 of 2

[kim]

How sick, that man should profit by his labor.
==========================

[Paul Zrimsek]

HR 676 is a no-brainer.

So I see.

[Walter]

... high standards, and quality will be enforced, and patients protected by the Government through a dedicated civil service. With the power, and resources to rain in abuses of patient care.

You know, I'm no fan of the current system.

But there are more than a few people who are concerned about this very prospect.

Verily, I say unto you: Worship at the altar of the dedicated civil service and the abuses will rain down upon you!

[glasater]

I totally agree with Clarice @2:45 PM and totally disagree with jacksmith @3:15 AM.

[cathyf]

Hey, Walter, I think you picked up on JOM's Best Freudian Slip Of the Week. And since I scrolled on by, I had missed it!

[clarice]

I am thrilled!
I just got a postcard response from Florence King. She says the Clinton article I loved so is in The Florence King Reader. (Since I can't find my copy I went to Amazon and you can get good used copies for under one dollar. Go-Enjoy). She says of the essay "It was written originally for the L.A. Times where it drew a huge pile of hate mail. Apparently I said something to offend everybody.I think you're right that he has a compulsion to sabotage her campaign."

Now to dins a safe place to put this.

[hit and run]

That's hot!

[clarice]

Isn't it--and "dins" should of course be FIND

[MayBee]

clarice- Our Lady of Results

[clarice]

Ms King is reportedly in ill health so I treasure the fact that she took the time to respond.C