Extra Mandate Blogging

I should say with further regard to the health care mandates issue that this is pretty much exclusively a disagreement about tactics. The people who drew up John Edwards' and Hillary Clinton's health care plans think they've devised a really clever method of moving the country to a much better health care system. I think they're overestimating their own cleverness. But either plan is something I'd be glad to see passed into law as an alternative to the status quo, and if either one of them becomes president I'll roundly condemn people trying to block the reform.

If it were up to me, I'd either try something more ambitious than what they're proposing (have taxes pay for people's health insurance), or else I'd try something more modest (have taxes pay for kids' health insurance) and focus my spending mojo elsewhere (health care's important, but so's climate change, preschool, infrastructure spending, housing programs, etc., etc., etc., and realistically no president is going to build Matt's Social Democratic Utopia by 2012), but since I'd like to see something more ambitious on the merits I'd support the Edwards or Clinton plans. Indeed, they're both very good plans all things considered, I just don't happen to think the mandate aspect -- which has become the focal point of attention since it's the place where they can disagree with Obama -- is a particularly appealing element to their proposals. Unfortunately, in the context of the primary campaign you hear less about the area of overlap between all three candidates, which contains tons of good stuff.

Comments

I agree 100%.

Also, I'd like to respectfully request that this blog go a little easier on the use of "Blogging" or "Watch" in the post title, as those words have been overworked to the point of exhaustion in recent weeks.

Posted by James Gary | November 30, 2007 8:52 AM

Two points.

First, I can't speak to the politics. It seems to me that Edwards and Clinton have a pretty good political stance in the primary - they make Obama sound like a conservative when he defends his plan. This may or may not be useful in the general election, and it may or may not be useful in getting the plan through Congress, but I think you're far too certain of the politics involved.

Second, you still haven't addressed the basic issue with mandates. As Cohn and Klein have argued, mandates are a necessary part of community rating - we can't have universal insurance unless we have nearly universal paying-in to the system. It's just like Social Security - it's only by having everyone pay in that we can pay out to everyone. Community rating is non-negotiable - so we need the mandate.

I am willing to risk the politics of the mandate in the general in order to create real universal social insurance.

Think of the mandate as the health care equivalent of the payroll tax. Social security works, and it wouldn't work without near universal buy-in. So with the mandate.

Posted by DivGuy | November 30, 2007 8:59 AM

"which has become the focal point of attention since it's the place where they can disagree with Obama"

Speaking for myself, I greatly enjoy disagreeing with Clinton and very much don't enjoy disagreeing with Obama.

I've avoided criticizing Obama over some of his Social Security weirdness specifically because I don't enjoy disagreeing with Obama.

It doesn't occur to Matthew that universal healthcare might really be a litmus test issue for many, many progressives. Matthew doesn't have to worry about healthcare coverage, so for him, it's just part of some campaign game.

Similarly, Matthew must think that today's Krugman column was inked just because Krugman seeks out places where he can disagree with Obama.

The universal healthcare issue doesn't matter to Matthew, so he thinks it must no matter to anyone else either. It's all just some game, right?

Posted by Petey | November 30, 2007 9:00 AM

Think of the mandate as the health care equivalent of the payroll tax.

But that's just it - it isn't a payroll tax, it's forcing people to buy insurance and then coming after them with collection agencies if they don't pay their premiums, when a tax would be simpler, more efficient, and sound less draconian.

Posted by Christmas | November 30, 2007 9:05 AM

Petey, here's a bit of Krugman's wisdom:

First, Mr. Obama claims that his plan does much more to control costs than his rivals’ plans. In fact, all three plans include impressive cost control measures.

Obama makes claim.

Krugman doesn't come close to refuting claim, but implies that he does.

Posted by hlah | November 30, 2007 9:07 AM

Read what Ezra just posted, Christmas. He makes the case far better than I possibly could.

Posted by Petey | November 30, 2007 9:08 AM

it's forcing people to buy insurance and then coming after them with collection agencies if they don't pay their premiums, when a tax would be simpler, more efficient, and sound less draconian.

I don't disagree here, but I'd make two points in response.

First, you're really overstating the "collection agency" thing. Here in MA, most everyone is signing up. Further, the sanctions are very weak, and only set in over a long period of time - I see no reason to think that Edwards or Clinton would immediately release the hounds. It's not necessary for the program, and it would be bad policy and politics. You are actively misrepresenting the program.

Now, that is the misrepresentation with which the right will hit this health care plan. The issue is being able and prepared to fight back. Since there is no universal health care without universal buy-in, we have to be prepared to fight for it.

Second, I really don't see why this is so scary. Lots of states require car insurance, for instance. When you send in your taxes, you send in your proof of insurance. So, you make sure you get insurance before you do your taxes. It's really not that complicated.

I have to say, you seem much more frightened of the right-wing noise machine than is necessary. It's not that powerful. It can't just misrepresent everything in sight and convince all of American. UHC is really popular. They'll be fighting a serious uphill battle in public opinion. I don't see why we should start the fight by quaking in our boots.

Posted by DivGuy | November 30, 2007 9:12 AM

a tax would be simpler, more efficient, and sound less draconian.

Sorry, let me cross the "sound" part of that out. A tax would be less draconian than a collection agency, as anyone who's ever been hounded by a collection agency will tell you. And you're going to find a much larger percentage of people who've been hounded by collection agencies among the uninsured than among the population at large. As soon as you say, "my health plan is being enforced by debt collectors," you've lost a not-insignificant chunk of support.

Posted by Christmas | November 30, 2007 9:14 AM

The thing I mean I don't disagree with is taxes - yes, single-payer is best. I don't see how we can get single-payer with the number of Democratic senators in hock to big insurance. The only way is to sneak it in, which means Mandates + Public Option.

If you think this plan will fail, and is not worth fighting for, that's fair, but I think you're wrong and you're opening yourself up to Petey's claim that you're not fighting for giving health care to sick people.

Posted by DivGuy | November 30, 2007 9:15 AM

Again, read what Ezra just posted, Christmas.

Posted by Petey | November 30, 2007 9:18 AM

"Again, read what Ezra just posted, Christmas."

Now with effort-saving supplied link!

Posted by Petey | November 30, 2007 9:21 AM

I've read it, Petey, and Ezra doesn't really add anything new to what he's said before (i.e., that he's overlearned the lessons of 1994). He also doesn't specifically address any point I've made here.

Posted by Christmas | November 30, 2007 9:27 AM

Klein:

The individual mandate will still face hurdles as we argue over enforcement, but it basically trades away certain amount of economic efficiency . . .

Economic efficiency being, of course, heretofore the main selling point of doing this at all

. . . .in order to evade the political implications of nationalizing health spending. Figuring out how to enforce it -- which will really only take a modified version of Obama's language, that it's not as if people don't want health care -- is an easier sell than trillions in "new" taxes.

This is crap. People against whom enforcement would be directed, by definition, would be people who can afford and do not want health care.

And the idea that these plans will automatically enroll individuals in health care should, for liberals, be an exciting prospect, one they're enthusiastic about advocating for. How you enforce this on the tiny remnant who refuse to pay their premiums is a really weird place to focus, and applies as much to Obama with his mandate-4-kidz as it does to Edwards and Clinton.

It's not a weird place to focus. The people against whom enforcement would be directed are the ones this proposal negatively impacts. If, say, you're a 20-something in good health who's thinking of starting his own business and would forego health insurance to make the numbers work, these plans are telling you

"NO! We will ruin your credit if you don't pay for health insurance."

Now, it may be that it's right for those people to bear that burden so that poorer people can have health care, but we should impose it upon them with open eyes.

Posted by southpaw | November 30, 2007 9:59 AM

That last blockquote segment in my post above is me, obviously, and not Klein. Should've been italics . . .

Posted by southpaw | November 30, 2007 10:01 AM

I have two problems with mandates. I've been poking at this at Ezra Klein's place, so this is a distillation.

#1: Poor people have experience with fees for services being a way of denying them the service in practice while it's allegedly available to all. When you don't have the money for your current obligations, each additional charge up front is one more thing you're not going to be getting or using. Further, poor people are used to fees changing without notice or obvious sense, and to this being a way of cutting them off from services they used to use. Fees rise, as a general thing, and money up front is what poor people don't have.

#2: Collection agencies are a serious blight on the lives of a lot of people they target. Collectors routinely lie about what they can do and what targets must do, and the very best an individual hit with such lies can hope for is an acknowledgement of the truth as it applies to that individual that time around if the target can get the truth from some other source and stick to it in the face of sustained hostile lies about it all. It's worse with poor people and those in need like the disabled, because agencies know that such people have fewer channels of recourse, and when there's talk of collection agencies, a lot of poor people will go the other way.

If health care is to be universal, then it needs to cost least for those who have least to pay, and the fact of poverty needs to not look like the gateway to endless trouble for those who'd like to use the new system but know (or have reason to expect) they won't be able to manage a lot of big fees in hands of hostile collectors. That is, mandates put the burden exactly where it shouldn't be. It seems to me that mandates are mostly a sop to those who don't really want to cover everyone, out of the lingering puritanical belief that some people haven't really earned their right to coverage. Poor people get that a lot: "Oh, sure, in theory this is for all...but in practice, not for you." An actual universal system should have no looming collection threat for those most in need. The costs should rise with ability to pay, and the bottom rung should be "you're covered, and society as a whole will handle the expense of keeping you healthy". That's what universal coverage is all about.

Mandates make sense if the goal is universal insurance. But honestly I'm not very interested in that. I'm interested in universal health care.

Posted by Bruce Baugh | November 30, 2007 10:32 AM

My biggest problem with Ezra Klein's analysis of health care is his interpretation of the politics. Specifically, he seems to think there's one, and only one, reason the '94 Clinton plan failed (it would have Changed Your Health Plan), and so any compromise is justified in order to create a hodgepodge, patchwork plan that leaves most people with the same, employer-based insurance they've currently got. But the threat of "changing your health plan" wasn't the only attack - or even the worst attack - aimed at the Clinton plan. It was also accused of being frighteningly complex and impossible to figure out. If a major Democratic candidate tried today to sell Medicare-for-all by saying, "look, it's really easy - we just sign everyone up, and then everyone has health care that can never be taken away," would that work better than the '94 plan, or the plans we're seeing now? I'm betting yes, but it's hard to say because nobody will try it.

Posted by Christmas | November 30, 2007 10:44 AM

Bruce Baugh's 10:32 comment is spot on.

Posted by Christmas | November 30, 2007 10:49 AM

An actual universal system should have no looming collection threat for those most in need.

It was my understanding that the Edwards and Clinton plans subsidized the health care costs of the poorest people, so I'm not sure why they would be under threat. Are the subsidies less than 100% of the mandatory costs?

Posted by southpaw | November 30, 2007 10:55 AM

It was my understanding that the Edwards and Clinton plans subsidized the health care costs of the poorest people, so I'm not sure why they would be under threat.

Who counts as "the poorest people"? Because I'm betting my definition is more expansive than John Edwards's, and his definition is more expansive than Clintion's, and both of theirs' is more inclusive than anything that emerges from a conference committee. Programs like Medicaid have always been easy targets for cuts by redefining away who counts as "poor." The difference here is that instead of just not getting health care, the poor will get hounded further into debt by private debt collectors.

Posted by Christmas | November 30, 2007 11:01 AM

Divguy is actually entirely right. As, Paul Krugman notes this morning. Obama's plan just doesn't work, community rating without buy in doesn't work.

Christmas, Edwards subsidizes up to 100,000 in income in a gradually phased out way. If you're deinition of poor goes beyond that, you and I will have to agree to differ.

Politically, Edwards would be better off emphasizing the automatic enrollment, which further has the advantage of signing up people for programs like s-chip and other aid that they already qualify for but don't know about.

Posted by AJ | November 30, 2007 11:55 AM

The mandate is essential to keep costs low for everyone. Paul Krugman in the NYT (11/30) makes the case for having mandates. His argument is irrefutable. In particular, the mandate is essential to prevent freeloading by people like Yglesias.

Posted by gauss | November 30, 2007 1:43 PM

If a major Democratic candidate tried today to sell Medicare-for-all by saying, "look, it's really easy - we just sign everyone up, and then everyone has health care that can never be taken away," would that work better than the '94 plan...

No, it would not, for the very simply reason that it would be untrue to say Medicare-for-all equals health care that can never be taken away, to the extent that many millions of people would have the private sector health insurance plans that they like and want to keep taken away if they were forced to join Medicare. My guess is no legislation could ever possibly emerge from the United States Congress that denies wealthy folks the right to opt out, but not everybody's wealthy.

While I personally would like to see us head toward some version of Medicare for all -- preferably a system resembling that of France -- and I think there's a strong chance America's healthcare delivery system will eventually get there -- I'm under no illusions that this is what a majority of Americans want right now. They don't. Millions of Americans agree that our troubled healthcare delivery system needs reform. But plenty of these same many millions will force you to pry their own health insurance arrangements from their cold, dead hands.

Posted by Jasper | November 30, 2007 2:31 PM

Re: But honestly I'm not very interested in that. I'm interested in universal health care.

Unfortunately in the real world of 2007 America the only way to get universal healthcare is to get universal insurance. Deal with it.

Also, I don't get where this talk of debt collection agencies is coming from. If someone doesn't sign up for insurance they would not owe a debt (assuming they also don't get medical treatment they can't pay for, in which case their situtaion is no different from the current situation). You wouldn't need a debt collector to enforce this: you could simply withhold the relevant portion of a person's tax refund, and if they persist in being recalcitrant, revoke their drivers license as we do with parents who don't pay child support. Also, as far as the poor are concerned, Medicaid would continue to serve them, those with too much income for Medicaid would be subsidized under the public plan (which might well be an expanded Medicaid charging premiums prorated to income).

Re: But the threat of "changing your health plan" wasn't the only attack - or even the worst attack

But it is a major deterrent. IMO, the idea of a gradually introduced single payor makes sense: let people see how the system works and join it voluntarily. Forcing 300 million Americans to make a major change in their life for something totally unknown and unfamiliar is like trying to herd 300 million cats. Good luck.

Posted by Jonf | December 1, 2007 10:18 AM