Healthcare Mandate Blogging

I'm in total agreement with Kevin Drum's criticisms of John Edwards' now-more-detailed individual mandate plan. And I should say that I don't think this is a problem with Edwards as such. Other advocates of an individual mandate have mostly evaded the flaws of Edwards' plan by just avoiding discussion of how this is supposed to work in practice. I think that in a whole variety of ways, it's just a fundamentally flawed approach. See Matt Stoller for more on this.

The best alternative would, of course, be a proper system in which we achieve universality by having the government either sign everyone up for a health care plan (universal!) or else sign up everyone for a health care plan who doesn't have one. Unfortunately, of course, the only person in the race with a plan like that is Dennis Kucinich. And if people tell me something like that is politically infeasible in the short run, I'm happy to believe them.

Where my thinking departs from the current Democratic consensus is that I don't think it follows from the desirability of a universal system and the impracticality of doing it right in the short run, that we ought to therefore put an absolute priority on creating something -- anything -- that counts as universal no matter how flawed the design. To me, the incrementalism-in-a-good-way aspect of both the Edwards and Clinton plans is the introduction of strong public sector competition with crappy, crappy private health insurance. Over the long run, I think that gets us where we want to be. The mandate itself is neither here nor there. But if the candidates insist on universality-by-mandate as the core principle, then there's a real risk of the best aspects of these bills getting gutted by congress leaving only a shell of individual mandates and subsidies to insurance firms.

Comments

I demand some sort of posting concerning marijuana.

But, on the issue at hand, I disagree with Matt. Incremental reform is superior to some sort of revolutionary action.

Posted by anon112 | November 30, 2007 3:39 AM

Not necessarily, and I speak from immediate experience. MA's plan ("Commonwealth Care") seems to be the model for everybody these days, but I can tell you that the health care people are swamped. It's only been going a week, so I imagine that they'll sort themselves out to meet the current demand, but what happens when everyone else is legally obliged to opt in? We had a functioning low-income health care system in MA; whether we can keep it remains to be seen.

Posted by foolishmortal | November 30, 2007 3:50 AM

"But if the candidates insist on universality-by-mandate as the core principle, then there's a real risk of the best aspects of these bills getting gutted by congress leaving only a shell of individual mandates and subsidies to insurance firms."

Huh? I literally don't follow the reasoning here.

If mandates are impermissible to Congress for some reason, they'll respond by enacting mandates?

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Of course, there are incredibly compelling policy and political reasons for not backing away from universality.

Ezra and Jon Cohn have dealt with the details at length for many months now, and I've never seen anything even approaching a sensible refutation.

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So Matthew and Kevin come out in opposition to universal healthcare.

Good to know where folks stand when the chips are down.

And no wonder it's the exact same crowd now opposing universality who were opposing laying out any healthcare plan whatsover six months ago. They weren't in favor of universal healthcare then, and they didn't want folks to know that.

One of the reasons I like primaries is that they really let you know where people stand.

Posted by Petey | November 30, 2007 3:53 AM

Checking back in Matthew's archives, I find this gem he wrote in early 1935:

While a Social Security system that covers all workers would be desirable, I think it's a bit impractical to do it in the short run. Many will oppose the mandatory nature of Social Security taxes, and we ought to therefore put an absolute priority on creating a voluntary Social Security system. Creating a universal Social Security system is neither here nor there.

Posted by Petey | November 30, 2007 4:02 AM

Petey: "Matthew [is] coming out in opposition to universal healthcare."

Matthew: "The best alternative would, of course, be a proper system in which we achieve universality by having the government sign everyone up for a health care plan (universal!)"

???

Posted by julian | November 30, 2007 4:09 AM

"???"

John Edwards announced yesterday the automatic enrollment details of his universal healthcare plan, the precise thing Matthew says he wants in principle.

Families without insurance will be enrolled in Medicare, Medicaid, SCHIP or another targeted plan or be assigned a plan within new Health Care Markets.

But Matthew prefers the details of a voluntary non-universal healthcare system. He's quite clear about that here. He says that someday in the future, he'd like to see us move towards universal healthcare. But Matthew thinks now is not the time.

Fine. Like I said, it's good to know where folks stand.

And as stated, it makes sense now why Matthew was opposed to the Democratic candidates laying out their healthcare plans. After all, almost all Democrats (and a good chunk of Republicans) are in favor of universal healthcare. If you're in favor on a non-universal, voluntary system instead, no wonder you'd like to keep the topic out of the campaign.

Posted by Petey | November 30, 2007 4:28 AM

No need to be snarky, Petey. This chips are up, healthcare-wise, and I see no reason to believe that Matt isn't just trying to figure the best way to do something about it in good faith. Expanding the IRS' duties to include policing people's insurance doesn't seem to be prima facie the best idea in the world to me, but what the hell do I know about it? We should figure out a decent health care policy, and that's going to involve contemplating bad ideas. Saying that bad ideas are bad shouldn't disqualify one from further debate. If it makes you feel better, we could call IRS-policed health care "insufficiently awesome".

Posted by foolishmortal | November 30, 2007 4:35 AM

"Expanding the IRS' duties to include policing people's insurance doesn't seem to be prima facie the best idea in the world to me, but what the hell do I know about it?"

What you might want to know about it is that the exact same enforcement mechanism that is used for student loans.

That's worked out horribly, on both policy and political terms, hasn't it?

"I see no reason to believe that Matt isn't just trying to figure the best way to do something about it in good faith."

Sure. To be honest, I think George Bush is just trying to do something in good faith in Iraq. Of course, personally, I think that his strategy of endless occupation in Iraq makes Bush a dangerous idiot. And likewise, Matthew's good faith idea of coming out for a non-universal healthcare system makes him about the same.

Posted by Petey | November 30, 2007 4:56 AM

There are three things that a healthcare plan needs to offer.

1) Gobs of public funding for people who can't afford health care
2) Community rating, so that insurance companies can't screen out sick people
3) public option

The problem is that there are only two ways to accomplish both (1) and (2). One is a program like single-payer, and the other is mandates. Without forcing everyone into insurance, the money isn't going to work out for community rating. Social security wouldn't work if people could decide not to contribute to the trust fund. This is similar - universal insurance needs to be universal.

The evidence from Massachusetts is that even a very weak mandate will be successful. With a month or two before any possible sanctions, and with very minimal sanctions, there was already 80% compliance from the previously uninsured. With a plan like Edwards', which has much stronger sign-up mechanisms, the numbers would be even better.

Mandates work, mandates are necessary to any health care plan, absent single-payer.

What's a little weird to me is that Ezra Klein has made this point repeatedly and clearly, but Matthew doesn't even acknowledge him in this blog post. I can't tell if this is an NYT-like refusal to name who you're arguing with, or a crippling oversight of an important policy point.

Posted by DivGuy | November 30, 2007 6:41 AM

So what happens when someone fails to get the mandated healthcare?

Would you put them on the goverment plan and bill them for it? Then, if they still didn't pay, court proceedings . . . garnished wages and so forth?

Posted by southpaw | November 30, 2007 6:57 AM

But if the candidates insist on universality-by-mandate as the core principle, then there's a real risk of the best aspects of these bills getting gutted by congress leaving only a shell of individual mandates and subsidies to insurance firms.

But there's also the risk, if we don't seize the moment, that universality itself won't be accomplished. I think the political stars are lining up for UHC: 1) lots of frustration over healthcare + 2) a Democratic president + 3) increased economic anxiety + 4) increased recognition among elites that said anxiety is undermining support for globalization + 5) deeper Democratic majorities in Congress + 6) private sector dissatisfaction with the health insurance status quo -- and I believe that 2009 will be our best chance in a long while -- and possibly for a number of years -- to get every American covered by decent health insurance. I'm afraid if we squander the opportunity we'll regret it. Insured Obama supporter Matt Yglesias has no such fears. I'm shocked.

And anyway, why does the fact that some people will be forced to buy health insurance mean "the best aspects of these bills" won't be enacted? It seems to me desirable "aspects" of healthcare legislation could be left out whether or not the rest of the legislation makes individual coverage mandatory. I don't see how the two are related. I'm hopeful the eventual legislation that gets signed by a Democratic president provides for genuinely meaningful subsidies that ensure no American's premiums cost an excessive portion of his/her budget. I'm hopeful coverage denials based on preexisting conditions are soon a thing of the past. I'm hopeful we can slash the number of bankruptcies brought about by medical crises. I'm hopeful no American will ever again have to ignore addressing a health problem in favor of an eventual visit to the emergency room once it's reached crisis stage. I'm hopeful job lock will be eliminated, along with every other harmful aspect of the status quo. Now, it's certainly possible the eventual reforms won't live up to my hopes. But again, this possibility remains whether or not coverage is mandatory for individuals. Why are the two issues related? I'm really not following Matt's logic here. If anything, the degree to which healthcare reform reflects desirable concessions by the insurance industry will likely be proportional to the number of new customers the government can guarantee them. It might not be pretty. And it might not be cheap. But it will probably yield a better bill than any legislative effort that strives for meaningful reform (which will obviously impact the insurance industry) without the sweetener of 45 million new customers.

Finally, I actually agree with Matt about the possible virtues of incrementalism. I think if we get a universal health care system enacted, we can improve upon it incrementally. Indeed, I think that's how it's going to have be, as I see no prospect that the United States is going to adopt a kick-ass French style UHC system in 2009 or 2010. It'll no doubt take several more rounds of reform and another decade or so to reach that sort of lofty healthcare Valhalla. But Krugman and I would just as soon not have to wait ten years to get to universality.

Posted by Jasper | November 30, 2007 7:30 AM

Petey, you're embarrassing yourself.

Posted by DRR | November 30, 2007 7:39 AM

"So what happens when someone fails to get the mandated healthcare?"

They don't have the option to "fail" to get healthcare. Enrollment is automatic.

Here are the details.

Posted by Petey | November 30, 2007 7:39 AM

"Petey, you're embarrassing yourself."

No doubt. It's fucking embarrassing to be in favor of universal healthcare.

On the other hand, it's admirable for trust fund baby Matthew Yglesias to be opposed to universal healthcare since he's covered for all of life's little rainy days. What's 20 or 30 million uninsured among friends? They can always get treated at the emergency room, right?

I feel incredibly embarrassed.

Posted by Petey | November 30, 2007 7:47 AM

The Krug-Man hath weighed in. An excerpt:

...Mr. Obama accuses his rivals of not explaining how they would enforce mandates, and suggests that the mandate would require some kind of nasty, punitive enforcement: “Their essential argument,” he says, “is the only way to get everybody covered is if the government forces you to buy health insurance. If you don’t buy it, then you’ll be penalized in some way.”

Well, John Edwards has just called Mr. Obama’s bluff, by proposing that individuals be required to show proof of insurance when filing income taxes or receiving health care. If they don’t have insurance, they won’t be penalized — they’ll be automatically enrolled in an insurance plan.

That’s actually a terrific idea — not only would it prevent people from gaming the system, it would have the side benefit of enrolling people who qualify for S-chip and other government programs, but don’t know it.

Mr. Obama, then, is wrong on policy. Worse yet, the words he uses to defend his position make him sound like Rudy Giuliani inveighing against “socialized medicine”: he doesn’t want the government to “force” people to have insurance, to “penalize” people who don’t participate.

I recently castigated Mr. Obama for adopting right-wing talking points about a Social Security “crisis.” Now he’s echoing right-wing talking points on health care.

What seems to have happened is that Mr. Obama’s caution, his reluctance to stake out a clearly partisan position, led him to propose a relatively weak, incomplete health care plan. Although he declared, in his speech announcing the plan, that “my plan begins by covering every American,” it didn’t — and he shied away from doing what was necessary to make his claim true.

Now, in the effort to defend his plan’s weakness, he’s attacking his Democratic opponents from the right — and in so doing giving aid and comfort to the enemies of reform.

http://www.nytimes.com/2007/11/30/opinion/30krugman.html?_r=1&n=Top/Opinion/Editorials%20and%20Op-Ed/Op-Ed/Columnists&oref=slogin

Almost sort of fightin'in words, no?

Posted by El Cid | November 30, 2007 8:20 AM

I understand that Petey believes he is Robespierre reincarnated.

Posted by ostap | November 30, 2007 8:23 AM

"I understand that Petey believes he is Robespierre reincarnated."

Nope. I'm in favor of elections and opposed to the guillotine.

Posted by Petey | November 30, 2007 8:27 AM

Petey,

Your own link:

For the few people who refuse to pay, the government will help collect back premiums with interest and collection costs by using tools like the ones it uses for student loans and taxes, including collection agencies and wage garnishment.

Kind of intrusive, no?

Posted by southpaw | November 30, 2007 8:36 AM

Fine, but once guillotines are outlawed, only outlaws will have guillotines.

Posted by El Cid | November 30, 2007 8:37 AM

"Kind of intrusive, no?"

Same mechanism as with college loans.

Social Security taxes are pretty intrusive too, no?

Posted by Petey | November 30, 2007 8:47 AM

Like Petey, I'm a little confused by Matthew's points here. Didn't every one of us supporting a universal health care plan (that wasn't single payer) understand that at some point, we'd be hearing about an enforcement mechanism for mandates? Why the fear and loathing now? Way to cede the battle before it's joined, guys. I share Petey's frustration.

Seems to me that in large part, Matthew's problem is the "now-more-detailed" part of "John Edwards' now-more-detailed individual mandate plan." Look, the devil may be in the details, but so too the saving grace: like DivGuy astutely noted above, having a mandate is the only way universal health care achieves the benefits we want it to achieve. And having a mandate means enforcing a mandate - but I guess acknowledging that means sounding the alarm or something.

It's irresponsible to buy into what will no doubt be a Republican frame - IRS cops are coming for you! - instead of emphasizing the benefits, both political and administrative, of a plan with a mandate. Enforcing the mandate doens't have to be any scarier than enforcing student loan payments. Indeed, paying for one's health care will be a hell of a lot easier than paying for one's student loans - if you can't pay for even the cheapest plan (which you will be automatically enrolled in), you'll be subsidized.

This is what universal health care circa 2007 looks like. As progressives, are we in or out? I know what side I'm on.

Posted by Will | November 30, 2007 8:48 AM

Wow, Krugman really is shrill today, isn't he?

Posted by Petey | November 30, 2007 8:49 AM

Sorry, I've been an Edwards fan for a while, but this only demonstrates what a half-assed scheme mandates are. Clintoncare failed politically in large part because Republicans made everyone afraid of what it would do to them; the specter of collection agencies and wage garnishment - which looms heavily over college debt, too, Petey, by the way - will make it very, very easy to demonize mandate-based plans. This is bad policy and bad politics.

Posted by Christmas | November 30, 2007 8:49 AM

Hillary Clinton's original health care plan also represented a huge division within the business community: since it was conceived largely by the Jackson Hole group including the 5 largest insurers and HMO's, it led to support by those particular companies (which stood to be the Managed Competitors of pretty much all US health care) but also to opposition by the vast majority of slightly less large insurance corporations. It was those corporations, not "the right", that ran the Harry & Louise ads, right?

Posted by El Cid | November 30, 2007 9:36 AM

All this talk of mandates and no one is talking about two salient facts: (1) this isn't universal health care, this is universal health INSURANCE and (2) insurance companies are, last time I checked, for-profit business. To the extent you mandate health insurance, there will HAVE to be a trade-off between amount of that insurance. Social Security doesn't provide much of a retirement benefit. I suspect the universal health insurance won't either. Which will mean that insurance companies will offer . . . SUPPLEMENTAL insurance....

Posted by Keith | November 30, 2007 1:01 PM

Just vote for Dennis Kucinich and you won't have to worry about all that.

Posted by Phil | November 30, 2007 3:56 PM

OK, so we can force people to sign up for health care, and add to the numbers of the ever messy industry, or maybe we can focus on those that are getting hit badly from these corporations! There are a lot of elderly people that are living on fixed incomes and they cant afford to pay their increasing medicare premiums. These are people that need medical attention more than they ever have before in their life. But the major insurance companies just sit back and collect their money while this continues to happen. This is why AARP has set up http://www.thisissoridiculous.com so that we can all sign a petition to make our voice heard. While your there you can also read updated news, watch videos, and even e-mail your congressman to let him know how you feel. I’m working to help AARP promote better Medicare because this is an important issue that isn't getting enough attention.

Posted by Warren | November 30, 2007 7:04 PM

The private health insurance industry cannot offer affordable policies that are even minimally comprehensive. Should one of these mandates be enacted to purchase these deeply flawed products, it will be highly unpopular with the public forced to part with their hard earned dollars in order to be underinsured and financially unprotected from bankruptcy due to medical bills.

In the Massachusetts mandate plan it is only the subsidized insurance policies that uninsured people are signing up for. Of those who must pay full price only 4% of the previously uninsured have signed up to buy insurance under the mandate. There is a $147 million shortfall already in the fund for subsidized insurance. The premiums for the policies negotiated by the "Connector" state insurance brokerage agency will be going up by 10-12% next year, so they will be even less affordable, even in the short run. Private insurance simply isn't affordable.

If any of the candidate's mandate plans are enacted the hatred people now feel for the private insurance companies will immediately be transferred to the administration that is trying to force them to purchase policies from these companies. It's not clear to me why the Democratic Party, of which I was an active and contributing member for 38 years, wants to get out in front of these hated corporations and bear the resentment the public rightly feels for them. Health care providers won't love you, either, because the private insurers are now paying equal to or less than the government, with far more costly hassle involved. Be careful what you ask for, you might get it.

Only a publicly funded single payer plan will work. All this passion and analysis would be better spent figuring out a way to make it "politically feasible", rather than burying the party's political future abandoning the voters to the tender mercies of the private insurance industry.

If Democrats are contemplating the best way to political suicide it might be quicker and less painful to simply privatize Social Security, rather than health care.

Paul Krugman should have stuck with his advocacy for single payer, then he was being coherent.

Posted by Jay | December 1, 2007 7:49 AM

Petey, John Edwards opposed universal health care four years ago, and favored the incrementalist approach, as I assume you did when you were arguing on his behalf back then.

I'm glad that both of you are in favor of it now. We always welcome new converts. It's the self-righteous hectoring that's embarrassing, both for Edwards and yourself.

Posted by Chris | December 2, 2007 12:59 AM

Using the term "universal health care" interchangeably with "universal mandates to buy health insurance" is really disingenuous, a perversion of the term. Turning around and then framing the opposition to coercive mandates to pay private health insurance companies as being against "universal health care" is a total mischaracterization of the debate.

People who oppose health insurance mandates disagree with being forced to pay premiums for degraded, often worthless private health insurance coverage, along with the giveaway of our taxpayer dollars for subsidies for the poor to buy degraded coverage.

We don't favor subsidizing Big Tobacco, either. The private health insurance industry has public approval ratings just above those of Big Tobacco, because they have been nearly as destructive to the public good. Paying 31 cents out of every dollar toward systemwide administrative costs to delay and deny needed heath care is not everyone's ideas of worthwhile government spending. This neoliberal privatization of what can only be efficiently handled by government is an insidious slam against the middle class.

Many people who oppose mandates are doing so from the left, so trying to obfuscate the issue by calling our objections "right wing talking points" is simply deceptive and deliberate mischaracterization of the debate. Smearing the left isn't appreciated, and will further divide the Democratic base.

Not a smart move.

By promoting mandates Democrats will earn the support of extremely wealthy insurance companies, however. Is that the real agenda?

Aetna supports the mandates, since the privatization of Medicare and other government health programs is the new cash cow for these private health insurers. They look forward to even greater profiteering if the public is forced to buy their products. Perhaps they have more political heft than the democratic left?

Then after public opinion swings against the Democratic Party for their sellout of the voters to the private insurance industry, Aetna and the others can easily switch the political party name on their campaign contribution checks over to the Republicans again, who won't bother them with trifles like consumer protection regulations, community rating, and guaranteed issue.

Careful who you are getting in bed with.

Posted by Jay | December 2, 2007 10:04 PM