By John Ballard
I don't want to pick a fight, but a simple point needs to be made.
Without a mandate health care will not be, by definition, universal.
Despite a veritable chorus of progressive voices to the contrary, The Wonk Room at Think Progress agrees.
The math is really quite simple. The individual mandate creates incentives for otherwise healthy Americans to purchase insurance and may be the the only way to achieve affordable universal coverage. Without a mandate, only the sick who need health care would be motivated to purchase it. The pool of insured would be weighted with sick individuals, forcing the costs of the premium to escalate. According to a study by MIT economist Jonathan Gruber, �a plan without mandates, broadly resembling the Obama plan, would cover 23 million of those currently uninsured, at a taxpayer cost of $102 billion per year. An otherwise identical plan with mandates would cover 45 million of the uninsured � essentially everyone � at a taxpayer cost of $124 billion.� As Paul Krugman concludes, a plan without mandates would cost $4,400 per newly insured person, the plan with mandates only $2,700.
Since every person has at least some risk of experiencing a medical crisis, encouraging Americans to assume a collective responsibility for medical cost is a reasonable proposition. Its also essential for reforming health insurance markets. After all, demanding insurers accept every applicant without regard for pre-existing condition and charge every beneficiary a community rate is impossible if healthy people game the system and wait until they fall ill to purchase coverage. After all why would anyone spend their healthier years paying insurance premiums if the neighbor across the street can obtain the same coverage for the same rate on a need-it-now basis?
Stated another way, here is the same issue argued by me at Liberal Politics at About.Com
Deborah said: If the Obama-Lieberman plan does not mandate that all Americans purchase health care coverage, then only the sickest uninsured people are likely to purchase coverage� which, of course, will raise premiums prices charged to consumers by the private insurers.
I asked: Help me understand how that is different from what is already happening. One of the famous defenses of the current delivery system is that sick people still get attention even without insurance. Providers routinely inflate charges to those who pay to cover those who don�t.She replied: Good point.
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At this point (and for the last couple of weeks) anything we say out here in the Village is moot. Compared with a host of other issues, this one is trivial. The bill as it stands is too emasculated to mean much. And until the final reconciliation comes out of the joint committee we still won't know the dimensions of the end result.
Before Barack Obama got the nomination I was a Hillary supporter, not because I didn't like Obama but because I didn't think he had a chance of getting elected.
Also, there was one health care policy difference between him and Clinton that I thought was important. He was NOT running on the promise of a mandate, but she WAS. That, and the matter of employer-subsidized health care, was about the only difference I could find between otherwise identical health care ideas. I thought at the time, and still do, that if we are to have universal health care, then everyone must be in the program.
Arguments against the mandate fall apart when fines imposed for not having health insurance are way below the premium costs. Clearly, there will be those who opt to pay the fine rather than the premiums. And besides, the industry already has products so bad that the premiums would be less than the fines. It's easy to forget now that the campaign is a year in the past that health care was a given, no matter who or which part won the election. (Thank goodness we aren't dealing with a GOP plan. The thought gives me shivers.) As the saying goes, one way or another we pay to play.
Health insurance is just like all the rest. If you want life, auto or any other kind, there are el cheapo products on the market. (But you better hope you never have a claim.) Does anyone really think those products are about to vanish? They are the business analogues to lottery tickets and email scams.
One final point. The much discussed FEHBP insurance that everyone talks about that is supposed to be so great is NOT all that great, nor it is optional (unless you want to have none at all). The Federal Employees Health Benefits Plan is a menu of choices, ranging from luxurious to what is derisively called a "postmans plan," from policies so cheap that they have high deductibles and limited coverage. The reason that federal employees have such a good deal is that the government, their employer, pays seventy-five percent of their premiums. Aside from the government's vast negotiating position having one of the largest employee groups in the world, all they pay is twenty-five percent of the premiums.
While I agree that a mandate is necessary a mandate with no option other than the private insurance companies is not acceptable.
ReplyDeleteI find it a rather disappointing spectacle seeing nominally well-intentioned people twist and contort themselves into odd shapes in any and every attempt to justify accepting the HCR bill the Republicans have deemed allowable for the Democrats to vote on. The sad pretense that somehow the legally enforced "purchase" of corporate insurance -- and now only that -- is an abundantly good thing is simply beyond belief. (Although one must admit, the constructed mandate is a terribly clever way to shovel even more tax payer money to health insurance companies through whatever, undoubtedly meager, subsidy program is squeezed out of this process.)
ReplyDeleteThis is the free market? Buy this shit you cannot afford or pay a fine? Or go to jail? (Which may actually wind up being the only option poor uninsured Americans are given: health care courtesy of the US penal system, after being fined into penury.
Jacob Hacker has pointed out that, at some point in their lives, 58.7% of the US population will live "at least one year" below the poverty line. This trend is only worsening. And on top of that unpleasant fact, the Obama administration insist that forcing uninsured Americans to spend money they do not have is the solution to the health care problem. It is not. Those who are defending the corporate-controlled mash-up, do so for one reason alone: a "win" for the Democrats, and Obama in particular.
The real agenda: "This reform has to pass on our watch," the presidentsaid. "We are on the precipice of an achievement that has eluded Congresses and presidents for decades."
That is now what this is all about.
These arguments are compelling. And I cannot refute them. We all share, as was pointed out, good intentions. My reaction is visceral, not rational, so it's best I not go deeper. That said, I must get the following off my chest.
ReplyDeleteUltimately I trust the system. The Executive branch has attempted to do what the Preamble calls promoting the common Welfare for most of our lives. The Legislative branch has reluctantly gone along with the idea incrementally but always grudgingly because promoting the common good has a Robin Hood like quality. And those best positioned to help others know that assistance calls for their doing with less.
As a parent I know that helping is not always helping. In the case of substance abuse there is a fine line between helping and enabling. Sometimes paying a utility bill is better than sending money. Life is full of challenges, not only for those who need help, but also for those expected to render that help.
I just heard on the radio that three hundred million Americans now receive "food stamps." (In the digital age the stamps are gone but the term endures.) About ten percent of the population is now eligible. Poverty in America is a growth industry. I think that trend is part of the big picture calling for universal health care.
Our collective urge to help others becomes diluted as our numbers grow. Helping the family is a higher priority than helping the community. The welfare of the country is important only as long as it doesn't tread on the state. For non-citizens, help stops at the border or the water's edge. Et cetera.
Meantime, the Judicial system has yet to weigh in. I doubt anyone will go to jail for not buying insurance any more than we cannot be put into prison for the non-payment of taxes. (We are subject to imprisonment for tax fraud, but debtor's prison is unconstitutional.) And as in the case of prohibiting alcohol (Or marijuana use? Or undocumented immigrants? Or DADT? The list is long...) if it fails to work, judicial remedies will eventually force changes. Whole generations passed between The Civil Rights Act of 1875 and The Civil Rights Act of 1964. And between Plessy and Brown.
If this effort fails, the next will be equally contentious. There is no reason to imagine that special interests now opposed will weaken with the passing of time. Incremental progress is better than none. And buried in the language of this legislation are seeds of change that eventually must pass Legislative and Judicial muster.
Unintended consequences will result. There is no reason to think otherwise. But universal participation, as in the case of Social Security, will necessarily be part of the bedrock. It is a bitter pill, but sooner or later, universal care will require universal participation.
I don't mean to be contentious, but this post is entirely beside the point. Yes, if we're going to construct a system of universal health care, the mandate is necessary. The question is, are we going to adopt some cost controls (single payer, Hacker style public option, regulation of the private market on the Swiss or Dutch model) to make this universal care affordable for everyone, or not? Are we going to be mandated to purchase ever more expensive private market insurance and health care, or are we going to be mandated to buy something affordable? That's what the question is, and our fearless leaders have taken another pass (60 years and counting) on making the system affordable.
ReplyDeleteOne final point. The much discussed FEHBP insurance that everyone talks about that is supposed to be so great is NOT all that great, nor it is optional (unless you want to have none at all). The Federal Employees Health Benefits Plan is a menu of choices, ranging from luxurious to what is derisively called a "postmans plan," from policies so cheap that they have high deductibles and limited coverage. The reason that federal employees have such a good deal is that the government, their employer, pays seventy-five percent of their premiums. Aside from the government's vast negotiating position having one of the largest employee groups in the world, all they pay is twenty-five percent of the premiums.
ReplyDeleteWell then our legislators will have no problem passing an amendment that they have to go to the same plan as the rest of the US.
The problem with the insurance mandate is that it doesn't actually consolidate risk within a single insurance provider.
ReplyDeleteIf insurance company A has 1000 sick people and 10,000 healthy people, and insurance company B has 10,000 sick people and 1000 healthy people, which one will survive?
I think there was some provision within the legislation that would seek to siphon profits from companies with few medical loses and pay into companies with many medical loses, but what is the point of all that? It's a needlessly complex system ripe for exploitation and fraud, when a single payer plan is what we're all trending towards anyway.
Forcing everyone into the pool will accelerate us into a single payer system. But, at the end of the day, it's a question of whether we get a single payer corporation or a single payer government entity.
A bill stripped of regulations and reforms and without a public option safety valve, will quickly degenerate into the worst kind of single payer imaginable.
"Ultimately I trust the system."
ReplyDeleteWell, Hootsbuddy, this is whence our differences must arise. Because I do not.
We have watched the system systematically eviscerate public life and the very idea of the public good for 40 years. The Powell memo is highly instructive here. We know the statistics: median wage in American has fallen since the early seventies, among a vast spectrum of other metrics: manufacturing capacity, income equality, etc. These declines have ultimately led to our present predicament, as an also rising consumerist culture insisted on upping consumption as the sole social criterion of "success." The sublimated message, absorbed over decades, ensured a debt-bound population, one whose own capacities to engage in that activity have been diminished by the same system.
The system has overseen the impoverishment of American society for forty years, through an overt attack on critical thinking and public dialogue, the role of a bestial gubmint or any other non-market institution. Witness the crazies at townhall meetings. They are there to pollute the public spaces engaged in democratic dialogue, and they are there for a reason. The system has put them there. The system that put the gun-strapped nutjobs into schools for a public discussion on health care is the same system we watched dismantled health care reform legislation before our very eyes.
This is not a system that is to be trusted.
I felt the need to share with you the story of Jason Bromby, a 28-year-old British diplomat who has gone missing in China. This is very scary. Read more about it:
ReplyDeletewww.maolovesyou.com
Spread the word, something needs to be done.
Hoots,
ReplyDeleteSorry to keep harping, but another product of the system. From a recent study by the American Association of State Colleges and Universities (AACSU):
"the U.S. is one of only two nations on Earth in which people aged 25 to 34 have lower educational attainment than their parents."
and
"There is a diminished interest in science among undergraduates in the U.S., and the U.S. is losing ground to other nations in the proportion of young people earning a college degree."
Damn you, Tiger Woods!
There is only 3 ways a mandate is acceptable 1)with a strong public option, 2)with a buy-in to Medicare for all ages and 3)with not for profit private insures regulated as utilities. Anything else I say Nooooo!
ReplyDeleteI'm flattered by all these comments. I'll leave it to others to follow the various ideas, all of which are excellent.
ReplyDeleteThe forty-year comment caught my attention because twenty-five of those years were the "Reagan revolution" (and yes, I consider Clinton part of that sad story) preceded by the Nixon era (Nixon-Ford and poor Carter, stuck with picking up the pieces) which were two of the most retrograde Executive periods of our lifetime. Those forty years are among the darkest of American history. I can see how that would turn anyone against the system.
There was a Civil Rights Act of 1874 but it was not enforced and was declared unconstitutional by the Supreme Court a few years later. The Plessy decision (separate but Equal) was in 1897 and fifty-seven years went by before Brown reversed it in 1954 (separate is inherently UNequal). And another decade passed before the Brown decision got federal teeth with the Civil Rights Act of 1964.
The Eighteenth Amendment (Prohibition) was ratified in 1917 but it only took the country sixteen years to repeal it with the Twenty-third (1933). In any case the national learning curve is embarrassingly slow. Churchill said it best when he said "You can always count on Americans to do the right thing - after they've tried everything else."
Some of us in the streets in the Sixties take a long view of history. (Looking backward can be reassuring if looking forward is frightening.) Should it survive I see the battered mess dragging its way through Congress as a step forward on a very long trek that may eventually benefit my grandchildren.
Thanks for all the comments.