As a centerpiece of her now-uphill battle for the Democratic presidential nomination, Hillary Clinton continues to attack Barack Obama because his healthcare plan does not call for an individual insurance mandate -- that is, a requirement that all Americans purchase a health insurance policy -- whereas her proposal, like the recently-scuttled Schwarzenegger-Nunez bill in California, includes such a mandate.
Whether the government should require everyone to purchase health insurance is a difficult issue about which reasonable people may differ. (Full disclosure: I am an unpaid member of a health care policy advisory committee for the Obama campaign, but I personally favor individual mandates as part of comprehensive health care system reform). But the sound argument to be made in favor of mandates is very different from the one reiterated daily by Clinton. As a result, her criticisms of Obama on this point are wrongheaded and disingenuous. Let me explain:
Clinton alleges that, simply because it includes a mandate, her plan would lead to universal health insurance while Obama's would not. This is not true. Obama would institute health insurance market reforms and subsidize health insurance policies for the poor, making insurance more affordable, but he wouldn't require adults to purchase insurance, at least at first. (He is open to mandates down the road if, after the reforms and subsidies reduce costs, a large number of healthy "free riders" still do not buy coverage). Clinton wants to require all Americans to purchase health insurance, but she refuses to describe how she would enforce such a requirement. Just as many drivers get behind the wheel of a car without coverage in spite of auto insurance mandates -- 25 percent of Californians, according to estimates -- many Americans simply would ignore a health insurance requirement. Massachusetts mandates that individuals buy health insurance and even threatens fines if they do not, but 20% of that state’s citizens still remain uninsured.
Mandates would reduce the number of uninsured Americans significantly only if accompanied by the strict enforcement of a severe penalty, such as garnishing the wages of anyone who fails to submit proof of insurance with their income tax return. Clinton has refused to propose a penalty and enforcement structure for the mandate that she trumpets so loudly, and she has dodged the question of whether she would exempt the poor from the requirement. This makes her call for mandates meaningless rhetoric, and the claim that her plan would cover everyone false.
What makes Clinton's criticism of Obama really off the mark, though, is that she is trying to market mandates as a benefit for the large number of currently or potentially uninsured Americans, when mandates actually are a concession to constituencies that otherwise might favor the status quo against attempts to make insurance more affordable. Auto insurance mandates are good for the people who might be hit by an uninsured motorist, but they are hardly welcomed by the uninsured who feel, rightly or wrongly, that they can't afford coverage. Similarly, health insurance mandates are good for people with insurance, employers who would be forced to pay into an insurance pool, and private insurers who would face greater regulation under a reform plan, because expensive subsidies that would be required to help the "sick" uninsured to purchase coverage would be at least partially offset by requiring the "healthy" uninsured to contribute their fair share to the system. But telling someone without insurance that the government will force him to buy it at whatever price the market charges is unlikely to convince him that his problem is solved.
To see why Clinton's argument is nonsensical, consider that the country could achieve nearly universal health insurance immediately simply by enacting an individual mandate coupled with a truly draconian penalty for non-compliance. But so what? This would be good for Blue Cross, Health Net, and Aetna, but the worried middle class wouldn’t sleep any better at night knowing the government was going to force it to buy unaffordable insurance than knowing that it might have to go without unaffordable insurance. Clinton understands this, of course, which is why she refuses to discuss penalties or enforcement.
Clinton could reasonably argue that, as president, she would need to accept an individual mandate in order to win Congressional backing for market reforms and subsidies that would truly help the uninsured. Instead, she chooses to claim that mandates are themselves the goal, because doing so allows her to falsely charge that Obama is less committed than she is to the real goal of making affordable health insurance available to all. Her choice of tactics can be rooted only in a cynical belief that her attacks can succeed because the issue is just too complicated for most voters to understand.
I have no doubt that our messed up insurance market is in dire need of improvement. I also accept that government might have the ability to improve things, but I'm always nervous when they get involved.
What are ways in which Obama wants to reform the market? Allowing individuals to buy without the tax penalty vis-a-vis employers? Encouraging insurance companies to enter into long term contracts? Allowing for people to opt out of coverage they don't need?
My gut is that mandates would cost too much to enforce compared to the increase in coverage that would result.
Occurrences of "McCain": 1
One wonders why you guys don't want to talk about the Republican candidate so much...
As the kids say, Wtvr.
I think that's putting it gently.
My gut reaction was "Comment declaring either plan to be socialism in 5....4....3....2..."
I need to do more research before I can make a decision on mandates myself. I do believe that there are significant problems in the Insurance market, (IE Adverse Selection, opt out problems), however, I'm unsure how to remedy those while preserving the maximum amount of market freedom and available competition.
As part of the non-existent cohort that finds either plan a move in the right direction, thanks for fleshing out one of the differences between them.
Wikipedia's definition matches my general intuition: "'free riders' are actors that consume more than their fair share of a resource, or shoulder less than a fair share of the costs of its production." In today's health care market, uninsured people pay significantly more for a given service than insured people and their insurance providers pay. It seems like this would have to change for an uninsured healthy person to be fairly called a free rider. If so, why would that change? If not, what makes the uninsured person a free rider?
Good to see our readers enjoy knowledge for its own sake....
When an unemployed couple in their 50's looks at the cost of getting insurance, there will be enough zero's at the end of the bill to make evasion a worthwhile consideration.
Of course, given the tentacle-like way the IRS oozes into everyone's life, you'll probably have to supply a policy number on your tax return or else...
There's a distinction between uninsured healthy people and uninsured healthy people that have been injured.
It's more or less a plain fact that if you're injured in a significant way (IE enough to require a visit to the emergency room) and you go, you're going to get treated, regardless of whether you have insurance and or can pay. Granted, you might get shuttled to a county hospital or get put last in line, but you'll get treated. There are usually subsidies to pay for this, but they fall far short.
Hospitals in areas with significant numbers of uninsured people are often forced to either move, or charge significantly higher rates to their paying customers to make up for this shortfall, and because those paying customers rely on insurance to pay, everyones rates go up.
This also ties into the fact that in order to have a profitable business model, Insurance companies must take in more in payments than they are paying out in benefits. If we assume for the sake of simplicity that we're dealing with a limited community and a single provider, every healthy person that chooses to opt out of health insurance forces the company to have to raise their premiums to reach the break even point.
The situation is compounded because these problems interact with one another, pricing people out of the healthcare market and forcing them to seek "free" care.
If I can't pay, kick my ass out the door and leave me to deal with it. The government ain't the boss; it's the servant. Remember We the People .......
I apologize for intentionally misplacing this comment, but Klein's apology is so strikingly GOOD that I can't leave it unmentioned. He was accused of making an error. He looked into it, accepted responsibility, and publicly apologized. We shouldn't expect anything more from anyone. A blog like this is a community; it should be a community that is able to forgive human error. In particular, it should be able to forgive human error when the person responsible takes responsibility and apologizes as forthrightly as Klein.
We all make mistakes. Klein accepted responibility for his like a mature adult. I'm sure that I'll make far worse mistakes in the future. When I do, I hope that I will respond the way that Klein did here.
Also, is the goal to provide first dollar coverage? Or catastrophic coverage?
I would also be interested in proposals to keep the inevitable flood of mandates down. The taxpayers do not need to be paying for aroma therapy, etc. And are the candidates willing to lock in a maximum percentage of GNP for health care? Or at least the mandatory portion?
You may believe personal responsibility requires that, but be aware you're in a minority.
People may disagree over policy, but most look poorly on a hospital that lets people die because of their inability to pay, and it's been federal law for more than 20 years.
And FWB, market forces don't work so well in the health care system. The great demand for continuing to live, and the extreme asymetry in the need for the service, mean that relying on market forces alone means a lota people are gonna die.
Course, they were weak, so maybe your coming at this from a thinning the heard/evolution perspective?
You really think "We The People" are going to support a rule like that? I guarantee you, the first time a hospital kicks out someone halfway sympathetic who can't pay but wants care anyway, there will be a huge public outcry. Not to mention, many if not most doctors would be horrified at the thought of leaving a sick person to suffer just because they can't pay.
You say if it's wrong to force people to buy insurance for themselves, it should be wrong to force people to buy insurance for others via subsidies.
I don't think the argument is that its wrong to force people to buy insurance for themselves, but that's counterproductive. The poor have limited resources, and may sensibly want to buy housing or food instead of health insurnance. More importantly, it would be counterproductive because the enforcement costs would probably exceed any benefit.
As for whether its wrong to force people to subsidize health care for others, I would argue that's just the nature of what the government does. When a wealthy person pays for national defense, he pays far more for the same amount of "protection" as does a poor person. Moreover, we do subsidize the care for uninsured people now, just in the form of higher premiums for our own care.
The question whether a person should be forced to subsidize another person's health car should not be analyzed by reference to unanswerable questions of "right" or "wrong," (whatever that even means) but instead by whether it creates net benefits to society. I think, certainly in the long term if not earlier, it will. 1) You will have a more productive workforce; and 2) if it comes with some sort of mandatory co-pay or something, then less health care per person would be consumed, which might be the biggest reason we have such unreasonably high medical costs.
There's a simple way to test this. Ask "how well has this worked in Massachusetts?"
There were certainly a fraction of people for whom insurance was affordable and just weren't bothering. But there were also lots of people had chronic conditions that made insurance more expensive than just paying out-of-pocket.
I was on of 50 people in this country who slogged through the entire 3000 (or so) pages of Hillary-care way back when. As far as I could tell, it was too fussy in concept and it would never have a chance of passing. There is no way a president can get such a complex concept through Congress so why is everyone so concerned about it?
It still seems to me universal medicare is the best system to start with, but if the two Dems want to play footsie with the HMO's, what is there to do?
Stay healty, I guess.
Which is one of the reasons Obama's approach seems more realistic on it's face.
The fundamental problem with Clinton's first approach seemed not to be in it's details (although I admit I've not studied it), but in it's execution. It was written and pressed on congress as "the president's wishes."
My impression (initial one at least) of Obama's plan is that he is more likely to view policy making as an inclusive process. The idea that he's put forward something typically seen as a sop to the healthcare industry as a part of his initial plan seems to be somewhat supportive of this.
First of all, this is an evidence-free assertion. I am curious to know what evidence Korobkin has to support it.
More importantly, though, I find Korobkin's post missing an important point. He asserts that a mandate would not help uninsured persons. That seems to me to be incorrect. Korobkin focuses his post on people who cannot afford insurance. But this seems to me to be misplaced. The mandate would cause people who can afford insurance but choose not to purchase it to join the insurance pool. This presumably would lower the cost of insurance for everyone, thereby making it more affordable for those who cannot currently afford it.
I see. And how does this work when you get into a car crash, are knocked unconscious and out of your clothes, and are taken naked to the emergency room?
"Does this guy have insurnace?"
"I dunno."
"Well, kick his ass out the door, then."
I love the free market as much as the next Volokher, but there are fundamental places here where we can't just leave things to the market.
The question becomes "how do we separate those things that the market can handle well from the things that the market cannot?"
There's a difference between shopping around for pricing on your dialysis and shopping around when you've broken your leg and are bleeding on the floor.
A fundamental question....just because one doesn't have insurance doesn't mean they aren't getting medical care, does it? Is the problem really that big of a problem?
It seems that the unisured are either getting care and paying for it (no problem, their choice to self-insure). Or they are getting care and are unable to pay for it (in which case the country is already "insuring" them or providing a subsidized insurance policy.)
True, the last category of people don't have access to the same level of service that I get from my generous employer-provided benefits....They don't have access to the same level of lots of things (like food, shelter, etc) that people with more money or better jobs have access to.
Maybe some tinkering with bankruptcy laws to deal with the problem of people losing their homes when a catastrophic medical condition strikes might be enough without ruining it for the rest of us?
Or is this really about being sure that everyone gets exactly the same thing? Even if it means waiting months for emergency surgery, or all the other reasons that Canadians come down here when they can afford it.
Maybe I live in a bubble. Costs are a problem for the economy, but our basic system has never let me down, even when I was an unisured student.
What is the penalty for failure to have insurance? Is it similar to the penalty for being in this country in violation of our laws?
We could always turn medical bills over to the IRS for collection. Other countries use versions of this.
But any system that allows insurance providers to deny care based upon their own need for profit is simply not needed and should not be supported by progressives, or by businesses who have to compete worldwide with companies that do not have to provide health coverage for their workers.
A. Zarkov,
Despite being a fervant advocate of universal coverage, I'll start the bipartisan ball rolling and stipulate no free aromatherapy for illegal aliens. How 'bout that?
Don't hold me to this, but I seem to vaguely recall from one of the debates that Clinton, Obama and even Edwards placed severe limitations on the coverage contemplated for illegals. I think only Kucinich was actually advocating full benefits irrespective of immigration status. But again, I could be wrong.
That's a problem. We should mandate people purchase housing. Food mandates are important too - diet is a big component of health, so there should be some vegetable purchase mandate.
Another big component of health is genetic. We'll be able to decrease health costs in the long term by making sure the healthiest people reproduce the most. Anyone with a family history of longevity or certain genetic markers indicating disease resistance should be mandated to reproduce far above replacement rates (to make up for the less fit who should be strongly discouraged if not forbidden from childbearing).
[Of course we won't go that far say the mandate supporters, and thanks for the straw man. We only want control over 15% of the economy, and only for the public good, and we'd never dream of increasing government control past that point unless we thought it would reshape the country to our liking.]
Then there is the problem of cost shifting. The government in its attempts to keep its own costs down, caps payments. But those capped costs are often below the costs of the suppliers, so they have to be cross-subsidized. But most of these programs seem to be greatly increasing the capped costs, while reducing the ability to cross-subsidize. Already, it appears that primary care providers are in a big bind, some not making as much as many of the lawyers (and law profs) here, while living under much higher stress levels, due to the volumes necessary to break even.
I guess my problem here is that it sure seems to me that Hillary! and Obama! are thinking with their hearts here, and saying to heck with any adverse consequences that might occur as a result. I am open to suggestions on how the market can be improved, but all I have seen so far would seem to make the markets worse.
Wikipedia's definition matches my general intuition: "'free riders' are actors that consume more than their fair share of a resource, or shoulder less than a fair share of the costs of its production." In today's health care market, uninsured people pay significantly more for a given service than insured people and their insurance providers pay. It seems like this would have to change for an uninsured healthy person to be fairly called a free rider. If so, why would that change? If not, what makes the uninsured person a free rider?"
I think the answer is that the benefits of both emergency care, which cannot legally be refused on the basis of inability to pay, and the expected bailout from the system for regular care would be available to the (presently) healthy who don't pay premiums into the system. The whole point of a universal insurance pool is to have there be more in premiums than in realized claims, and if only the net claimants buy the insurance, that's a systemic solvency problem. So it's the latter clause of the above definition of free rider.
Query whether the whole free rider issue could be avoided by instituting a Canada-style single payer system, and making health care a welfare benefit rather than an insurance purchase mandate or subsidy (or both). Then it would be funded by taxation rather than private payins to the pool. That seems to be a political nonstarter in the U.S., but the beneficiaries of cheaper and (mostly, to the average citizen) better health care there might have something good to say about it. As with all systems, Canada has drawbacks, notably the high tax burden (though our current system ain't cheap in this respect either, and it's failing a lot of people) and difficulty obtaining certain services promptly, such as organ transplants.
The problem is a combination of level of care combined with creeping mandates. If the solution is universal care, then the level of universal care has to be defined up front. If not, health care is going to consume the entire budget, and then much of GDP. The reason is that no matter the problems with markets right now, they are likely to only get worse, much worse, with the abolishment of price as a limiting factor or signaling mechanism. If cost is not felt by the user of the good or service, then demand is guaranteed to go through the roof.
That is why, way up the thread, I asked for the level of care that was going to be guaranteed, and how that was going to be locked in. Catastrophic care is far more responsive to economic forces than is first dollar coverage, low deductibles, low co-pays, etc. We really need to know what is being promised here.
I have not heard that. But Schwarzenegger has advocated covering illegal aliens. He submitted a CA plan for medical insurance while declaring a financial emergency for California! Are we to believe that Obama and Hillary are less generous? Moreover it’s one thing to say that as a matter of principle that illegal aliens should not get coverage, but another to actually enforce such a policy in an effective manner. Look at our current immigration policies mostly talk, and no action. Even minimal action is met with stern opposition from the ACLU and immigrant rights groups. I have no confidence that illegal aliens won’t get coverage at a tremendous cost to the US taxpayer.
Secondly, you need to define what you mean by failing a lot of people. I would also ask why they have a moral right to demand that those who work hard and live often much more healthy and maybe even virtuous lives should pay for their bad decisions and poor life styles. Yes, I know that many of the uninsured are that way for no fault of their own. But I would guess that many more have plenty of fault, ranging from having kids out of wedlock at a young age, through drug addictions, lack of exercise, bad eating habits, etc. Why is it a moral imperative for those who work hard and do things right to pay for those who don't?
I would expect that most of those here would do better under our present system of medical care than under the Canadian system (and, yes, that is because of the audience here). You are, in essence, asking those of us who are doing better to sacrifice for the common good.
Economically, how come health care for-profit is preferable to "socialized" government-run health care?
I realize both systems have problems, but the current status quo does not seem to work, where the "socialized" approach seems to work modestly in other countries (judging simply by life expectancy and quality of life).
Examples:
Here, with for-profit care, a sickness will cause many families to declare bankruptcy (100,000 a year just from cancer), thus making them victims twice over. Creditors lose out, the economy suffers, etc.
Here, the average family pays around $12,000 a year in health care costs (no cite, but feel free to google it). The congress has just enacted a $600 per family stimulus package; wouldn't a $12,000 stimulus (even if it comes with higher taxes) be a hell of a lot more stimulating?
Here, corporations are being crushed by increased health care costs for their workers, making them uncompetitive internationally. GM reportedly spends more on health coverage than it does on steel. Wouldn't freeing up that health care burden allow them to become more profitable, resulting in higher wages, more jobs, expansion, etc.?
There certainly may be valid counter-arguments, but I have not heard them.
Two points: Massachusetts is a 'commonwealth', not a 'state'; and it's denizens are 'subjects', not 'citizens'.
Incidentally, if you increase the ability of people to pay their medical bills, guess what? The bills will get bigger. There's no other practical effect except that insurance companies make a pile. This really does have all the hallmarks of the Democratic party's being bought by the insurance industry.
I don't know if this remains true, but I once heard a commentator talking about the various presidential candidates' health plans. He claimed that, since McCain, Rudy, and Fred Thompson had all overcome bouts with cancer, none of them would qualify for their own proposed plans!
They would all be classified as having pre-existing conditions and denied coverage. If that's really true, then clearly the status quo is not a serious option.
Where in the Constitution does it say the gummint is responsible for health care or health insurance?
It was the government sticking their noses into health insurance/mandated health care that caused prices to soar in the first place. What used to be covered by charity is now somehow a government responsibility.
I have a better idea than health care/health insurance, etc., mandated by the Feds. Enforce the actual Constitution, not the ones the far-left (and far-right) seem to
wishthink exists. And watch federal taxes go down and our lives improve.Wouldn't it make more sense long-term to provide preventive care via offering a health insurance plan available to anyone regardless of immigration status rather than forcing the uninsured to tie up the ER?
Oh, and anyone promoting government run health care should be sure to mention that it will result in the deterioration in quality care, a loss of privacy, being forced into treatments you don't want, long waiting periods for care, physician shortages and having a big government run bureaucracy decide whether you're worth saving or not. But at least everyone will be covered...right?
Agreed which is why the most worrisome mandates that Clinton and Obama’s plans each include isn’t the individual or employer mandate, it’s that BOTH plans would require that any private insurance plan sold anywhere in the United States have as many or MORE mandates than are covered in the rather generous plans offered to federal employees. In other words the problem we have right now in which instead of buying health insurance which covers things like major medical, we’re instead forced to buy prepaid health care (which is why it’s so blasted expensive) would be made worse rather than better under their proposed “reform” and even more people would be priced out of the private insurance market.
So what happens is this – Obama and Clinton’s plans both impose new mandates on the private market which make it even more cost-prohibitive for people to buy health insurance BUT they’ll give you a subsidy if you go into a government-run plan. Their idea of “market forces” is to essentially regulate people (even more so) out of the private market with new mandates but subsidize them at taxpayer’s expense if they go on the dole.
It should be pointed out though that McCain has come out in favor of John Shaddegg’s proposal which would let consumers pick from any plan sold anywhere in the United States rather than just the ones which meet their home State’s mandated benefits requirements. For those who favor free markets and federalism, this is a pretty clear contrast to Obamacare and Hillarycare 2.0.
How is that different compared to a huge health management organization? Other than the fact that the government is not presumably looking to deny coverage to make a profit...
Then wealthy people who do not want to wait for their health care ration, will go to the cash only doctors.
I don't think it's a moral imperative, but it may be something we as a society nonetheless politically decide to do because it makes society better off as a whole. Also, I question your premises: For example, I'm not sure that it is "morally" better for the filthy rich but hard drinking Mickey Mantles of the world to be able to afford liver transplants doled out on the basis of ability to pay, than for a poor person who lives "right" but has a non-lifestyle related chronic illness to be refused care because he has not proved his superior virtue through accumulation of wealth.
"I would expect that most of those here would do better under our present system of medical care than under the Canadian system (and, yes, that is because of the audience here). You are, in essence, asking those of us who are doing better to sacrifice for the common good."
I am not asking anyone to do anything. I would point out though, that the status quo asks us to sacrifice for parts of the common good--the indigent (Medicaid) and the elderly (Medicare)--in a way that is rife with inefficiency. Given that reality, if an improvement in the system could produce better average results at lower average cost (counting both private and social costs), isn't that a more desirable system than the status quo? On average, people in France, Great Britain, Germany, Japan and Canada live longer, have lower infant mortality and lower incidence of most disease (lifestyle related or no), than those living in the U.S. All of these are rich industrialized democracies with some form of socialized medicine. You can't credibly tell me that all of these countries are suffering unduly from the systemic burdens of drug addicted teenage mothers, or Cadillac driving welfare queens for that matter or that all are relying on the U.S. as a safety valve.
Forgive me if this post is redundant to one of the ones above, but in the top half of comments there seemed to be confusion about Korobkin's reference to Obama's plan having a problem with free riders. I'm guessing the reference was to the below problem:
Obama's plan is susceptible to free riders because it promises to give low coverage to all without forcing people to buy in. So you can "free ride" by waiting until you get sick to buy coverage, and possibly even dropping it after your bills are payed. So you can free ride by paying less (even if you are not healthy) than healthy people who sign up for Obama's plan for the long term (rather than just when they get sick), and still consume more health care than healthy people who sign up over the long term.
I think that's accurate, but is that a bad thing? A government-run system does not mean private insurance will not live on and profit. It only means people who want to upgrade will simply have to pay more.
I think of it along the lines of law enforcement:
The police are a government-subsidized program, but there is nothing stopping someone from hiring a body guard or a private detective to supplement that system. Why would health care be any different?
I think Dr's, employers and individuals would all jump on board. The States could contract with existing insurance companies to bid on the catastrophic coverage business, and they could continue selling policies to individuals, and companies could continue offering insurance as a benefit up to the 2500/5000 limit.
The difference between hiring a body guard and health care is that the average joe walking around does not require a body guard. However, everyone needs health care.
But isn't that an argument for universal coverage?
All I'm saying is that socialized medicine will not eliminate the demand for private/luxury health care.
Seems to me that we’ve heard that one before.
schemesharksscammersindustry.They'll pay for heart attacks, arthritis, diabetes, etc., but pay for obesity prevention? Never!
"I actually think that it's unconstitutional, what the insurance companies are doing."
Ben Smith of politico.com posted the quote under the heading "a broad reading" (http://politico.com/blogs/bensmith ).
Ultimately the devil is in the details. Suppose the subsidies the Clinton plan offered were so great they reduced the cost of health insurance to $1 for everyone but the indigent. Surely then it would be justified to penalize those people who didn't comply. Now obviously her plan doesn't do this but the point is whether or not this is imposing a hardship rests on complex details of the plans that people aren't really paying any attention to and it seems to me that one can have a serious debate about whether these subsidies are enough that the penalties will be reasonable but to single out the penalties on their own is to paint a misleading picture.
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Anyway I think you also gloss over the real benefits of an individual mandate. The benefits acrue to everyone through decreased transmission of communicable diseases and greater preventative care. In particular government subsidy of health care means that allowing people to not purchase health insurance allows them to push the cost of their failure to pursue preventative care onto the government in the future.
Frankly though if you aren't going to bother with an individual mandage what's even the argument for 'universal' health care?
They'll pay for heart attacks, arthritis, diabetes, etc., but pay for obesity prevention? Never!"
It's even worse than that! Why, they'll pay for pregnancy, but they won't even pay for condoms!! It's absolutely outrageous.
Chem geek makes a good point about obesity prevention. Why, if you can't get free coverage for weight loss, people will have no conceivable incentive to lose weight.
I remain doubtful that any system designed contrary to the laws of economics is likely to provide better results at a lower cost. Rather, I would suggest that your belief in such is wishful thinking. And I would further suggest that both Obama's and Hillary's proposed systems attempt to hide the fact that they try to slide around the laws of economics through smoke and mirrors, and that is exceedingly unlikely to work.
One thing that is scary to me is that the proposed mandates for coverage would seem to contravene high deductible policies as I did when I wasn't covered by a group plan. One beauty of such plans is that you have an incentive to only go to the doctor when you really need to. And that puts some level of cap on demand. But first dollar coverage, low deductibles, or low co-pays have the opposite affect, disconnecting supply from demand. Demand is artificially inflated, since those obtaining medical care are not the ones directly paying for it. And the lower the cost to those using a good or service, the higher the demand.
I hope that none of our future leaders actually expect their efforts to reduce health care costs. If they do, they show a lack of historical awareness and understanding of economics.
If they were to deregulate the provision of medical services -- no FDA, no government insurance contract design, no professional licensing, no outlawry of the construction of medical service institutions; costs might drop. Otherwise, not a chance.
That's a bad definition. Consider a person who manages to evade paying local taxes. That person never calls the police or fire department and has no children in school. Acording to you that person has done no wrong and isn't a free rider.
Re: In fact, the elimination of insurance, medicare, medicaid, and all other governmental programs would force the medical community to react to market forces.
Yep-- by turning away millions of people and letting them die on streets. That's not hypebole since your suggestion is in full force in a number of countries around the world. Visit Haiti (for a nation too terribly far away) for a lesson in the results.
Re: Government mandated insurance is just more welfare for corporate america.
I suppose you would also have us repeal public nudity laws since those are corporate welfare to the garment industry.
Re: Going to a Canadian system would likely ultimately remove that option from both countries.
Yes, but then public demand would force both systems to behave themselves better.
Re: the deterioration in quality care, a loss of privacy, being forced into treatments you don't want, long waiting periods for care, physician shortages and having a big government run bureaucracy decide whether you're worth saving or not.
We have all of these things right now, except instead of a government bureaucrat it's an insurance bureaucrat.
The concept is still very market-based. Basically, if your employer doesn't pay much towards your share of health care, you can pick up a bunch of normal-looking health plans from the state system. Your income and how much paid by the employer are the 2 major factors.
Your monthly premium is about the same amount as you'd pay for a 75% employer subsidy (the standard amount for a working professional). So your waiter buddies and 7 year college students don't have to worry so much about preventative care. If you lose your job, it's much more reasonable to hop on the state plan vs picking up the awfully expensive COBRA coverage for the family.
The state also has extended the Medicaid safety net wider for elderly, disabled, etc. In my opinion, it is a better implementation than a single payer system or the other European systems that exist today, as it allows the natural competition between doctor/hospital and actuaries at the insurance companies to keep the cost of services at a normative level.
At the same time, the penalty system is keeping more participants with skin in the game - which also has the useful side effect of being able to determine which citizens will suffer from chronic conditions (due to having more people participate and become part of the data set) - this is not insignificant. If you have less than 1500 employees, insurance companies have a very hard time seeing how healthy your employees will be from year to year, which will impact your employer premium with the insurance company.
I think the Mass system is a great effort and will help provide some useful examples for the future that doesn't drag quality down, kill the poor, or punish the wealthy / taxpayers.
Why, I was with you until that last sentence...
I believe people pay in rough proportion to the amount of protection they receive because wealthy people have much more to lose than a poor person. They have to pay much more for every other kind of protection: on their mansion, on their yacht, on their jewelry, on their airplane, on their Lamborghinis and Rolls-Royces, on their life. The wealthy man needs bodyguards and armored cars, the poor man does not. The wealthy man always has the option to relocate anywhere in the world he chooses, yet somehow here they remain.
The government's been forcing me to buy health insurance for others since the mid-1960s (Medicare), so it must be ok. I'm still hoping it will be my turn to receive some some day.
These are the people who need help most. My neighbors were caught in the dotcom bust. The best they could get was retail without benefits. Which leads me to
People are relatively healthy from 20 until 40 when they start to fall apart. This is the bathtub curve familiar from reliability science. If someone opts out from 20 to 40, he will have saved a lot of money for other purposes, but he will be sucking funds from those contributors who are under 40 when he finally signs up.
The obvious answer seems to be so that he can pretend to be proposing neither socialized health care nor mandated health care.
Obama's healthcare seems slimier to me the more I think about it. What possible reason could there be to subsidize a system and then give people the "option" of buying into it. Citizens who play fair are punished for dutifully buying health care.
And what about those who feel they cannot afford it? What possible reaction could we have, once they get sick, except to shrug and say "sure" when they ask into the open program? Allowing anyone to buy in after the fact of sickness is an invitation to free ride, not merely a loophole. There is no way, with a straight face, a politician could tell the sick that they ought to volunteer to remain outside of Obama care, and just die (or suffer) from some wasting illness.
I can see why Obama might like his plan: it grants potential access to health care to the poor, without necessarily imposing the cost of mandates on them.
But to the extent that it does this, it is merely socialized health care. It is disingenuous of Obama to pretend otherwise. Or perhaps Obama is merely being disigenuous when he says he won't demand a mandate. Either way he is deceiving people about something.
I wouldn't object to that. Why do people have a right to deviate from the median quality of life?
One thing that I wonder about is what's the real price of medical anything? After every visit to the doctor, my insurance plan mails me a nice little sheet of paper that has the following numbers on it:
A) How much the doctor said it costed.
B) How much my co-pay was.
C) How much the insurance company will pay for the whatever.
D) How much the insurance company paid the doctor, equal to C.
D) Amount the doctor's still owed, equal to A - B - C
E) How much I still owe the doctor, equal to zero.
So is the price A, or is it B + C, or is it B plus my premiums (adjusted for the time value of money)? And what happens to amount D?
Actually, maybe that dissapearance of amount D, which an uninsured person would have to pay, is what the "free-rider" bit's about.
Guess what?
They already do.
Draw from this whatever conclusions you wish, but poor illegal aliens, just like poor Legal Residents and Poor US citizens, will be treated if they show up to a hospital in some state that requires care.
- Those lard asses who sit next to me on the airplane and seem to require two seats
- Those same behemoths who seem to "acquire diabetes through no fault of their own"
- Those who slack on gymn memberships while whining that others should cover their health care
- Those who demand priapic drugs to compensate for their anerobic lifestyles and diabetes-induced circulatory problems
- Smokers. Of any kind. Of any plant.
- Anyone who took a vacation of any kind while I was putting three kids through private school. THier kids are functional illiterates who my kids will have to support
- Anyone who paid someone else to mow their yard while they watched sports from the Lazy Boy
- Anyone who hikes into the woods, alone, and expects rescue
- Double anyone who hikes into the wod with their kids and expects rescue.
- Anyone who has an STD except by legitimate verified rape.
If and when you propose a society in which someone gets after the above with some sort of experienced professionals with armed with cattle prods all day and every day, then you can come after me for a "subsidy". Until then, it is not a medical subsidy, it is a life-style subsidy.
Don't like that brave new world. Well, then that means you have not confronted the dishonesty of your call for subsidies that protect the innocent. Your call for fairness is merely a dishonest cover for buying votes.
I'm rather dubious of this claim. Going to an undergrad institution that had a very large percentage of "pre-med" students, only the best had a significant chance of getting into med school. There's a few places where people who were otherwise can get in, but not many. The rest of them were fighting for tenths of a point between 3.8 and 4.0.
(- Anyone who paid someone else to mow their yard while they watched sports from the Lazy Boy )
Considering that MA was at around 10% uninsured before the insurance mandate, and has gone down from there, you might want to check your facts.
Yes it is rambling - but every one of them is arguably choosing poor health over better health. If there costs are covered by society, every one of them is choosing to rely on someone else paying for their life-style choices. THsi means every one of them is free-riding.
I do not think society should require each of them to reform. I want to be able to eat a stick of butter stright from the fridge every day if I wish (although I don't wish).
I just think that those who take the rare case and use it to talk about fate and unfairness are making a dishonest argument. Most of the people who die early die early for one of two reasons: bad decisions or bad genes.And we won't do much for them anyway if they have bad genes. (Jim Fixx outlived his father and grandfather, but still died in his 40's).
If you want to argue that society should cover the unusual cost of the run-away steam roller, so be it. But if I have to pay for your health care, I should be able to snatch that cigarett from your mouth and grind it into the ground, and take away your Krispy Kremes as well. From there it is a short step to regulating sexual behavior and french dinners with reduced cream sauces.
The more the government stays out of peoples lives the better they are.
How long before they mandate physical fitnes( if you don't you are wrong and wasteing tax money in fitur healt costs) or strict government approved diets. Thats the kind of tyrany I cannot abide.
Yes, but then public demand would force both systems to behave themselves better.
Aleks get my "optimist of the year" award
Sir, you go too far.
Less ludicrous than universal legal representation but only slightly.
All the programs that infect people with the idea that they are subsidized, or even worse, free. are destined for the ash heap of things over-valued or under-used.
Our biggest problem is that we are committed to trying to provide only a single tier of service. Imagine if we decided that all car owners had to have the very safest cars. Every new safety feature would be a threat to the economy and the average person would spend a lot more on cars than they do now.
“They already do.
Draw from this whatever conclusions you wish, but poor illegal aliens, just like poor Legal Residents and Poor US citizens, will be treated if they show up to a hospital in some state that requires care.”
I already said that anyone with an emergency or an infectious disease should receive treatment.
Do you assert that anyone, including illegal aliens, can simply show up at the ER or the hospital and get procedures like bypass surgery, transplants, cataract surgery, hip replacements etc? If such is the case then we already have universal coverage and we don’t need new programs.
As Milton Friedman said you can have either open borders or a welfare state, but not both.
Now, I know that this only a proposed solution, but here is what ABC reported her as saying:
I'm surprised that the people who read this blog missed that. While that does not mean that she will push for wage garnishment, she has certainly led people to believe that it's a possibility. As a matter of course, I refuse to support anyone who propose economic tyranny, which is exactly what that is.
I can't stand it when people use auto insurance analogies as proof that health insurance mandates will be a good idea. They pass right over the issue of whether a person can opt out of buying health insurance like they can with auto insurance. They also pass right over the fact that people can, in many, if not most, states, choose to decline uninsured motorist coverage.
As Dew has noted, your facts are wrong. Here's some interesting commentary on the effects of RomneyCare: http://www.cato.org/pub_display.php?pub_id=9127.
Is Mr. Tanner wrong in his conclusions? If not, why would anyone in their right mind use the MA model as a model for what should be done on a national level?
What I want to know is what either of the socialists plan to do about the over-regulation. Mandates on the insurance companies themselves at the state level are large contributors towards the rising prices. As states continue to mandate that insurance companies cover more procedures and illnesses, the companies raise prices to cover the increased expenses that come with paying for those procedures and illness. Do Clinton and Obama plan on forcing insurance companies to cover everything under the sun, thereby causing prices to skyrocket, or do they plan on deregulating the insurance industry and allowing insurance companies to provide customers with the option of picking and choosing what procedures they want coverage for and what procedures they don't want coverage for (e.g. allowing me to decline coverage for cancer, HIV/AIDS, paralysis, obesity-related illnesses, and other conditions that are catastrophic or chronic in nature)? I imagine that they aren't in favor of that since they want to socialize the costs of health insurance (to include socializing the costs of care for people who make atrociously bad lifestyle choices) but it's worth asking since we have an adviser for one of the candidates here.
So what Obama is promising to do (and its virtually identical to the Clinton proposal in this regard) is to allow people to basically opt into a plan comparable to the plan offered to federal employees. Note that government health benefits are some of the most generous in the nation and usually include prepaid health care (as opposed to actual health insurance) at low deductibles and copays because the cost of which is being born by the taxpayer. Keep in mind that the new participants won’t actually be working for the government and many in fact will be having their premiums subsidized even further (thereby creating a new class of dependents). But here’s the part that ought to scare the s*** out of anyone who already has coverage either on their own or through their employer:
What Obama’s proposed here (and again this is virtually identical to the proposal offered by Clinton) is to “allow” people to continue to buy private insurance BUT now the insurance plan will be required to be “at least as generous as the new public plan” which means that in ADDITION to the already existing mandates which the States have imposed (and which Obama explicitly promises to allow to continue so long as they’re “as generous” as his plan), there will be a NEW set of mandates which will make private insurance even more expensive than before (plus the cost of regulatory compliance for his new “watchdog”).
So basically what Obama (and Clinton) has proposed is to (a) make it more expensive for people to get insurance on their own or through their employers by requiring private insurance plans to carry the same or comparable mandated benefits as are covered under health plans for federal employees and (b) to subsidize people who enroll into a new government-run plan paid for by the taxpayer. The logical outcome would be to displace people who have existing coverage and moving more people onto the dole.
If I understand mandated health care correctly, it'll still be an insurance bureaucrat, just one the government's compelling you to do business with. Somehow, I don't think the latter fact will improve the situation much.
Economically, how come health care for-profit is preferable to "socialized" government-run health care?
I realize both systems have problems, but the current status quo does not seem to work, where the "socialized" approach seems to work modestly in other countries (judging simply by life expectancy and quality of life).
Our status quo could probably be called capitalist on paper, but it's a pretty messed up version of that.
The law strongly encourages people to have insurance through their employer. This sets up two levels of insulation between the consumer and the bill.
It's like going out to eat with your friends, and you decide up front that you will all split the bill evenly. Maybe the filet mignon wasn't worth pay $10 extra, but when split it'll only be $1 extra. Sounds good, except for the fact that everyone else is getting filet mignon, too.
As I've said before in this thread, there are certain parts of the health care system that can't and shouldn't be made free market. However, that doesn't mean we should throw the free market entirely out the window.
Take a look at LASIK, for example. It's gotten a hell of a lot better and a hell of a lot cheaper over the past 10 years. Note that the insurance companies are generally totally uninvolved in it. That's not a coincidence. Taking the insurance industry out behind the barn and shooting it in the head isn't a bad way to start reform.
How can we capture the benefits of the free market while still allowing for emergency service and care for the poor? That's the question to be looking at.
Wouldn't it make more sense long-term to provide preventive care via offering a health insurance plan available to anyone regardless of immigration status rather than forcing the uninsured to tie up the ER?
"More preventive care will actually lower costs" is a common rallying cry, but it's not really true.
There are indeed a few preventative steps that lower long-term costs. And most of these are already encouraged.
But if one could magically lower medical costs by throwing money at "prevention" then it would've been done already. Look at all the states with budget crises. If all this money is sitting on the table to be saved if they just shoveled more onto the "prevention" pile, we'd see one of them doing it already.
I'll admit that the insurance companies don't always have incentive to promote prevention when it would save money; if it stops someone from getting sick ten years down the road, well, the patient will likely be on someone else's insurance plan at the time. That's why I'd really like to see insurance become more personal rather than employer-based. (I don't lose my house insurance if I lose my job.)
I suppose the government would have more force to encourage people to stop bad behavior than an insurance company would. That's not a re-assuring thought, though.
Either of these schemes will inevitably lead to single payer 'HillaryCare'. That is no accident. If the government rigs the system to give the young and healthy (the vast majority of the uninsured... economics at work) a simple way to get catastrophic insurance cheap... the entire private system will collapse in heap. Open secret- our current ponzi scheme like system is built on tricking the young and healthy into subsidizing everyone else with insurance they dont need.
Now, as someone said, neither Dem is actually interested in universal insurance coverage. They are interested in universal healthcare, run as a command economy. These plans are simply trojan horses to destroy the private industry. Granted our insurance industry is messed up and disfunctional, but NOTHING like the tragedy that will become when the people that brought you the IRS and the DMV run your health.
Agreed, we ought to get rid of the distortion in the tax code that favors employer-based insurance. Ideally I think we should give people who buy their own insurance the same tax benefits that employers get and put a cap on how much of the employer-based insurance is deductible to discourage the gold-plated policies with little or no deductibles and copays.
In addition Obama’s proposal would not only continue to favor employer-based insurance he would MANDATE it under a “pay or play” provision which would end up being just another tax on employment. Ironically enough while he would exempt some smaller businesses from this new mandate, those would most l