Tyler Cowen says "I'm still wondering what -- de facto -- will be done against those poor people who are required to buy health insurance but don't do so." Tyler comes at this from the perspective of a bad right-winger, an opponent of universal health insurance, but I wonder, too. To me, this problem seems like a significant disadvantage of the current vogue for mandate-and-subsidize over a more traditional set-up wherein the government pays for all or some of people's health expenses and collects taxes from people in order to do so. We already have a mechanism in place for enforcing payment of taxes.
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Enforcement
07 Oct 2007 10:15 am
Comments (23)
The answer is obvious. States have mandates for auto insurance, right? If you get pulled over or have an accident, and don't have auto insurance, you go to PMITA prison. Similarly, if you get sick, and don't have health insurance, they'll send you to PMITA prison. I mean, that's the law, right?
Well, they can all just be put in prison...
And since everyone knows that people in prison get free healthcare---problem solved!
SImple, deny them health care. If you don't have an insurance card or cash or a credit card with an adequate limit you don't get health care service.
This is in fact how the market, any market is supposed to work. If you have to give the product away it's no longer a market. It's a pretend market. In fact that is what the health care market is, a pretend market. Little wonder if doesn't work.
Your baby is turning blue and you go to the emergency room. What, no insurance. Take a hike buddy. Immediately costs would fall sharply because no more subsidization of the uninsured.. More people could afford insurance. The market would work.
Sure it's tough letting the blue baby expire but think of it as tough love. Of course we nice libs would hate this but for the life of me I don't know why our hard headed conservative friends don't embrace it. The fact that they don't is why the so called debate about the 'market' vs socialism is so silly. We don't have a market.
Many middle and even upper-middle class citizens with a history medical problems become, in effect, uninsurable under a system like this due to the exorbitant cost of private insurance for someone with a record of health problems.
No, all the good health plans have strong "community rating" systems such that you will not be charged extra for having a pre-existing condition. It will, in fact, be precisely against the law to charge you for having a pre-existing condition. That's why universal care is such a good thing.
And on enforcement, is it really so hard? It's effectively a tax. Most people pay taxes. Some people will look to find ways out of it. If they game the system for too long, they'll be ticketed.
It is nice to see Tyler Cohen so worked up about the difficulties of paying for household goods when you're poor, though. I'm sure this will continue, for hte rest of his career, to be the lens through which he views public policy debates.
Willie is right. I'm one of those uninsurable upper middle class types. And if you looked at me, you'd never guess I had any medical problems. But if you saw an X-ray of my neck, you'd be surprised that I can even walk. Those X-rays mean nobody will cover me for spinal cord injuries. So the mandate scares me. If I won't be covered for my most likely medical problems, why should I have to buy insurance? The strange thing about it, is that if they throw me in jail for not buying insurance and I have an accident, the jail will have to provide me the medical services that the insurance companies refuse to cover. In the end, the government will end up paying much more because they will pay for my treatment and my incarceration. And they will lose the tax revenues of an upper middle class taxpayer while I am incarcerated. To make matters worse, I could do my job just fine even if I couldn't walk. The mandate either has to go in both directions (I must be covered) or we need a single payer plan.
DivGuy brings up the good point that the current proposals seem to deal with the pre-existing condition issue. My concern is that the mandate will pass, but the part about pre-existing conditions will be dropped in the House-Senate conference.
Realistically, people without insurance will probably fall into the same two categories they do now.
Some portion (at the moment I believe it is about one in three) will be eligible for Medicaid, or the new system's equivalent, but won't have bothered to sign up.
The rest will be those who (at least according to government benchmarks) should be able to afford insurance but haven't bought any.
The first group is pretty easy to deal with. They get some version of the "you idiot, you, don't you know you have free coverage available?" lecture, and get signed up for coverage on the spot.
The second group is more problematic, and seem to be the real point of contention between those who favor universal coverage (in whatever form) and those who do not. I'm really not sure how best to deal with them, so I'm going to punt and see if anyone else has has an idea.
Judging from Tyler's question and Matt's response, it sounds as though some of the smartest people on both sides of the argument are stumped by this too.
Any thoughts? Witty and inventive ad hominems are always fun too.
foster-
Look up "community rating" in regard to the Edwards and Clinton health care plans. It would be illegal for a health insurance company to deny you care, or to charge you extra premiums, because of your spinal issues.
foster-
Oops, missed your post. Community rating is a completely standard part of every health care plan put forward by the Democrats. It is the backbone of universal care, without which universal care is impossible. It can't be separated from the packages.
In addition to people who have preexisting conditions, you have a pretty broad class of people (vaccine refuseniks, Christian Scientists, the Amish and so on) who basically don't much believe in mainstream healthcare for various reasons. Forcing them to buy insurance seems dubious. Of course, most of these people aren't going to be big consumers of healthcare anyway, but if you let them opt out you create something of a moral hazard where some other folks will want to opt out even though they actually would show up at the ER when the chips are down...
Divguy is absolutely right, this is effectively a tax, play-or-pay. If you don't buy it you pay the tax, that's how it works in Mass. It's not that hard.
Take the insurance out of health care. Instead of talking about health insurance we should be talking about health care. In fact, the problem with health care today is the insurance companies.
Snark:
We could require that everyone, on their income tax return, report their medical insurance payments.
We could even provide that, along with taxes, everyone pay their insurance premiums directly to the Treasury, which then would forward these funds to the respective insurers.
:End_of_Snark
Wow that Tyler guy is one brilliant conservative!! He can read at a grade level that allows him to comprehend BusinessWeek!! And!!! And--quote statistics. Probably home-schooled.
As mentioned above all the proposed manditory insurance health care plans actually thought of this a long time ago. In fact, they all are based on the need the insurance companies have in the present system, to cherry-pick only well people to buy their policies.
As to the analogy to un-insured motorists, it's a pity Mr Tyler didn't think about that a bit. The state requires YOUR insurance co. to include something called "un-insured motorist" protection. (Gets deep here for right-wingers, eh?)
So do y'all think there could be a sort of "un-insured sick-person" insurance for the Emergency Room? And maybe a social-worker would come around and sign that person up for pay-roll-deduction (like they do now for Medicaid)?
This has the potential to be a real nightmare.
Imagine this scenario- the Dems pass a plan that involves a premium for people in the $20-40k income range. This involves some real belt-tightening at a time when real cost of living rise is measured in the double digits.
Then the insurance companies screw people over while feeding at the public funding trough- just as we're learning this morning that the insurance companies have done with the Medicare Part D coverage.
Republicans exploit these problems to regain control politically and, instead of fixing the problem, make it worse. Finally most people throw up their hands and say "Well, that sure didn't work."
Back during the fuel crisis of about '73 I asked my Dad why we shouldn't just set up a rationing system. He said, "Well, we tried that in WW II and it didn't work very well". Maybe it did, or maybe it didn't, but that was the impression left in the mind of John Q Public.
Matt needs a catchy slogan for his preferred single-payer policy. How about the "iron bedpan"?
Mandatory premiums is just a type of poll tax. I don't understand why Democrats are endorsing the most regressive form of taxation to pay for health care. Hell, even a national sales tax would be less regresive.
http://en.wikipedia.org/wiki/Poll_tax
You know, mandates don't have to be enforced with jail time. It could be something as simple as sending out a form saying "as of X date, you are required to have health insurance. On this form, please list your current insurer, or you can sign up for public health insurance by checking this box here." Then if you don't get a response within X months, you temporarily enroll them in the public program, so that if someone shows up in the ER with a sick kid or something, you treat them right away knowing they're provisionally covered.
Why not make purchasing health insurance a requirement for getting a W-2 form?
Re: Many middle and even upper-middle class citizens with a history medical problems become, in effect, uninsurable under a system like this due to the exorbitant cost of private insurance for someone with a record of health problems.
If I am not mistaken all such mandate proposals require community rating so that people with health problems cannot be priced out of the market or denied outright.
Re: If you don't have an insurance card or cash or a credit card with an adequate limit you don't get health care service.
At least in emergency sitiations that's not doable. what if the person's wallet has been stolen? and what about children? We have EMTLA (which requires emergency care) for a very good reason after all.
Re: My concern is that the mandate will pass, but the part about pre-existing conditions will be dropped in the House-Senate conference.
But even if that happened, the government would end up having to subsidize the difference between the cap on what a person would be rqeuired to pay and the amount actually charged (I don't see the subsidy portuon of this plan dropped). And for that reason, because dropping community rating would end up costing the government more, I suspect it will not be dropped.
The enforcement isn't the problem. The federal government could simply impose a tax penalty on those who don't obtain the insurance. On each person's tax return, he or she could be required to list a 10 digit number that corresponds to his or her insurance policy, that is given to the policyholder by the insurance company. The insurance companies provide their lists to the government, and the IRS can simply match the list to tax returns. Taxpayers who don't enter the number would be issued a penalty equivalent to the approximate cost of a policy. People who didn't buy insurance and who refrained from accepting the penalty would be committing tax fraud.
Of course, these plans are still odious for their regressive nature. The Republicans could make serious inroads among the young working poor, who would be very negatively impacted by a mandatory plan.
Not just the young working poor, but many among the young and working. Many people in their early 20s take the risk of having no insurance, or maybe just a cheap catastrophic coverage policy. Who's to say they're wrong? Why should we force them to do something that they have rationally decided not to do?
Comments closed October 21, 2007.
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Heads in the Sand
It's not just poor people who would have trouble paying under a forced heath-care system. Many middle and even upper-middle class citizens with a history medical problems become, in effect, uninsurable under a system like this due to the exorbitant cost of private insurance for someone with a record of health problems.
If I remember correctly, this was an issue in Mass, under Romney's "universal" health care plan.
Posted by willie | October 7, 2007 10:53 AM