Death Spiral

Jonathan Cohn has a very informative article on the Obama health care plan and the mandate debate. He sums up the case for mandates thusly:

Still, the most important rationale for a mandate may be a more practical one: It's necessary to keep other reforms from unraveling. If you make insurers sell to everybody, even people with pre-existing conditions, but let people choose whether or not to buy it, people in good health will be more likely to wait until they're sick before buying coverage, figuring there's no point in forking over premiums while their chances of needing care are so low. This will cause a chain reaction. As healthy people opt out, insurance programs will be left dealing with a population of sicker and sicker people. Since insurance relies on contributions from healthy people to offset costs from sick, it will become more expensive--which will cause even more healthy people to opt out. The cycle will repeat over and over again, with the cost of insurance going up and enrollment going down. Wonks call this the "adverse selection death spiral." And it's hardly theoretical. By the late 20th Century, most of the nation's Blue Cross plans had stopped offering insurance to all comers, regardless of pre-existing condition, because their competitors--who didn't make the same generous offer--had stolen away all the healthy patients.

Now in my view promoting a death spiral among private sector insurance companies could be a good thing if the intention was to kill 'em off and move people into an alternative public mechanism, but unfortunately I'm pretty sure this isn't what Obama's driving at. And there's the rub. I like Obama and I don't really like the mandate fad. And Obama doesn't like it either. But all indications are that his team doesn't come to this conclusion from the same direction I do, and his proposals are as bad as Clinton's in terms of a misguided focus on taming private insurance firms rather than destroying them.

John Edwards, who's publicly hinted around about his plan as designed to put us on a slippery slope to the bountiful world of socialized medicine, is a clear winner here in my view.

Comments

Scorecard:

Health Insurance: Edwards' plan is clearly better than the others.

Global Warming: They're all pretty good, AFAICT.

Iraq/Middle East: Edwards and Obama are clearly better than Clinton.

Those are the three crucial issues, and Edwards is best on them.

Posted by low-tech cyclist | December 8, 2007 10:29 AM

Edwards' policy makes sense if you want to start down the road to single payer; Clinton's policy makes sense if you want to achieve universal coverage through private insurance; Obama's policy makes sense if you're fucking nuts.

Obama's health care plan as elucidated by his alleged defense of it is now no more economically literate than Republican plans to increase revenue by cutting taxes. There's no justification for anyone to support it, and anyone who does is a flat -earther crank of the first order.

As of now I can say with confidence that I will not vote for Obama in any election, primary or general. The man is trying to prove he's an idiot, and I'll take him at his word. This country can't survive four more years of an idiot in charge.

Posted by R Johnston | December 8, 2007 10:31 AM

Re: Edwards' policy makes sense if you want to start down the road to single payer;

I don't think we'd ever get to pure single payor (and not sure we'd need to), though with Edwards plan we get most of the way there. I suspect we'd end up with a situation like the education system: most people would be using the public plan, but a significant portion of the upper classes would still have private insurance much as these same people generally use private schools despite the fact that public schools are free.

Posted by JonF | December 8, 2007 10:46 AM

Edwards clearly has the best policies, and would be the best candidate for Dem hopes across the board.

You like Obama, MY? His right-wing talking points on SS? His embrace of homophobes? His tentative half-measure policies? His attacks on Krugman?

Posted by Gore/Edwards 08 | December 8, 2007 10:59 AM

Matt, I was wondering if you had seen this commentary from Stephen Rosen at Middle East Strategy at Harvard:

In my view, the Iran program halted in 2003 because of the massive and initially successful American use of military power in Iraq. The United States offered no “carrots” to Iran, but only wielded an enormous stick. This increased the Iranians’ desire to minimize the risks to themselves, and so they halted programs that could unambiguously be identified as a nuclear weapons program. They were guarding themselves against the exposure of a weapons program by US or Israeli clandestine intelligence collection, and were not trying to signal the United States that they were looking to negotiate. They did not publicly announce this halt because if they did so, they would be perceived as weak within Iran, and within the region. By continuing the enrichment program, they kept the weapon option open.

Sorry for the off-topic, but I thought it would be interesting to hear your take on it. You know, for schnitzengiggles.

Posted by JA | December 8, 2007 11:32 AM

I could definitely see a spot for Edwards in an Obama administration, especially since he's not a sitting senator whose seat would have to be fought for. But he's basically a one-issue pony at this point.

Posted by KathyF | December 8, 2007 11:34 AM

Is anyone going to mention the one candidate who's plan is the simplest, most efficient and not something that looks like it was designed by a bi-partisan panel at the Brookings Institution?

Posted by DRR | December 8, 2007 11:41 AM

I'm surprised by how often these discussions stay on the plane of ivory tower economic theory and avoid the messy realities of politics. At the level of economic rationality and pure, apolitical policy wonkery, mandates make overwhelming sense. But substantial numbers of Americans have a stubborn and instinctive aversion to the government making them do something they were not made to do before - even when it's good for them; even when it's probably something they would do on their own anyway. Their initial reaction is irrationally hostile, and that hostility will be easily exploited by the established beneficiaries of the current system to block reform of any kind. If you want mandates, here's how you get to them: You first enact a set of reforms from which there is no turning back, but in which the problems of free-riders and spiraling costs become glaringly obvious in fairly short order. Before long, the public will forget their earlier "don't tread on me" impulses and cry out for mandates, so that healthy and would-be healthy young freeloaders are forced to pay their fair share, and providers will at that point eagerly join in the calls. Who knows? At that point even the virtues of single payer might begin to become obvious to most of the public.

Could I also point out the extreme political awkwardness of going into the general election with a plan that is now associated in the public mind with the Commonwealth of Massachusetts?

Posted by Dan Kervick | December 8, 2007 11:50 AM

Another plus for Edwards is his Marshall corps proposal, which would help a foreign-policy shift toward more diplomacy/trade/aid, apart from humanitarian war.

I see no reason in theory why Obama couln't coopt Edwards and adopt a similar proposal, but the fact is he hasn't.

Posted by roublen | December 8, 2007 11:50 AM

DRR:

No.

Posted by Xenos | December 8, 2007 11:52 AM

Matt,

You are or were in the Netherlands, I thought. They have a mandate system: everyone is required to have health insurance. The system works. Gets more expensive every year, like everywhere else, but up to now the system works.

Posted by Quentin | December 8, 2007 12:03 PM

Is there a summary somwhere, detailing the differences between the Health Care plans? Is the mandate the only difference?

Posted by Edgar | December 8, 2007 12:09 PM

"You like Obama, MY? His right-wing talking points on SS? His embrace of homophobes? His tentative half-measure policies? His attacks on Krugman?"

If you think what his campaign put out was an "attack" on Krugman, you're the biggest wilting violet I've ever seen. And he did not "embrace homophobes", he had one singer perform at a few campaign stops, and stated repeatedly that he disagreed with his views at the time.

Posted by mad6798j | December 8, 2007 12:12 PM

"Before long, the public will forget their earlier "don't tread on me" impulses and cry out for mandates"

Dan Kervick is "make things worse to make things better" Leninist? Who'da thunk it?

Posted by bob mcmanus | December 8, 2007 12:38 PM

Dan Kervick is "make things worse to make things better" Leninist? Who'da thunk it?

No Bob. Not at all. I want to make things significantly better first, but in such a way that it will soon be starkly clear to everyone just what we have to do to make things much better. If you take the first several positive and irreversible steps, people will ultimately opt for the remaining steps long before the "adverse reaction death spiral" catastrophe kicks in.

Suppose there is a general need for a new highway in a backward region. A sizable majority recognizes this need. The government announces: "We're going to build this new public highway that everyone knows we need, and we're going to pay for it by requiring everybody to use the highway, and to buy a permit to use it."

You're going to get a bunch of hysterics yelling, "You can't make me use a road!" You can't make me pay for a highway I might never use!" That's un-American! What is this, some totalitarian gulag?! I'll resist! Live free or die!"

Even a bunch of people who supported the highway initially are overcome by their irrational ant-government paranoia. And the wealthy fat cats who own the big established business on the old dusty, pothole strewn roads, which take a high volume of drivers past their businesses and into their shops, but who don't really care a bit about the specious liberty to be a stubborn fool yell along with the hysterics, "Yes indeed - it's un-American! Down with the socialist collectivists!" Siezing this emotional opportunity, they run adds against the new plan, the majority dwindles, and the highway proposal is defeated for another generation.

So what does the wise government do instead? They start out with a voluntary plan. They say, "Okay we're going to build a new road, and pay for it with an annual fee that buys the user a permit to use the road. Only those who use the road have to pay for the permit, although we'll let the poor use the road for free, so some the permit fees will have to take those costs into account.

So what happens? An overwhelming majority goes for this new plan. The highway is built and is a success, and there is no way people are going to go back to the old roads. It then suddenly dawns on everyone that their permits would be a lot cheaper if everyone had to buy one. Before long they notice that some of the people who have no permits use the highway from time to time anyway, and this irritating free-loading makes them even more inclined to collect from those who opted out. Then they notice that a few people who bought permits in the past are frustrated with the high costs, and don't renew them, thus driving up the permit costs even more.

So what happens? A "death spiral" where fewer and fewer drive on the highway for more and more money, until the whole system breaks down? Of course not. Very early on, people figure out what is going on, common sense kicks in, and they say "make the deadbeats pay!" They require everyone to buy a permit, whether they use the highway or not.

Most of those who are then forced to buy the permit decide they like the highway, and can't remember what all their earlier fuss was about. Just about everyone now laughs about those old gulag commercials. Except for a small, grumbling minority of fanatical libertarians, everyone lives happier ever after.

Posted by Dan Kervick | December 8, 2007 2:07 PM

You are or were in the Netherlands, I thought. They have a mandate system: everyone is required to have health insurance. The system works. Gets more expensive every year, like everywhere else, but up to now the system works.

They also have legalized, government regulated prostitution and effective sex worker unions, a system that cuts out unnecessary middle men and police corruption, is more lucrative for the worker, less expensive for the customer, and safer for both worker and customer. It' an extremely rational setup. We should have it here.

You might, however, have noticed that Americans are not the Dutch.

Posted by Dan Kervick | December 8, 2007 2:15 PM

John Edwards, who's publicly hinted around about his plan as designed to put us on a slippery slope to the bountiful world of socialized medicine, is a clear winner here in my view.

Edwards's and Clinton's plans -- which are nearly identical from what I can tell (the main difference being the latter -- shockingly but perhaps prudently -- doesn't price things out quite so clearly), should both have this effect. I feel that this is one of their main virtues. In my view the insurance industry won't survive in its current form if it's required to take all applicants and it's no longer allowed to engage in price discrimination. Under these circumstances it begins to pretty much look like a public utility. It also probably begins to undergo financial stress. I'm not sure if this is what Edwards is "hinting" at, but I think it's likely the "pressure to open up Medicare for everybody" effect begins to kick in as the insurance industry starts to prove itself incapable of getting the job done in a more heavily regulated environment, or if the necessary subsidies start to become too onerous, and the government realizes Medicare for everybody who wants it is simply going to be cheaper.

Anyway, I think the merits of the various healthcare plans boil down to how highly one values universality. Edwards's plan gets us there -- in substantive and robust fashion -- from the getgo. I think Hillary's does the same. I'm not suggesting all Democrats will use this metric as the deciding factor on whom to to support in the primaries, but it will be my guiding principal, being the UHC stalinist that I am.

But substantial numbers of Americans have a stubborn and instinctive aversion to the government making them do something they were not made to do before - even when it's good for them; even when it's probably something they would do on their own anyway...Could I also point out the extreme political awkwardness of going into the general election with a plan that is now associated in the public mind with the Commonwealth of Massachusetts?

You mean the radical socialist plan launched by Everybody's Favorite True Christian Mitt Romney? Yup. There's definitely some sharp political logic in that statement.

I think the whole "mandates will be terribly unpopular" meme is way overdone, principally because most people -- indeed the vast majority -- won't be affected. But also because most people -- I suspect the vast majority -- don't think it's unreasonable to ask everybody to contribute to the system, given the fact that, as a civilized society, we don't let people die on the streets bleeding from automobile accidents. Universal mandates can be sold -- much as in Massachusetts -- as ending the evil, unamerican practice known as "free riding."

Provided subsidies and out-of-pocket cost caps are genuine and robust, most Americans will support mandates, because it appeals to their sense of justice and fair play. And if it gets us quickly on the road to Matt's bountiful world of socialist medicine, what's not to love? It's not a mystery why the first reasonably robust and workable UHC law in America uses individual mandates as a key tool in achieving universality.

Posted by Jasper | December 8, 2007 2:20 PM

Dan Kervick, - or they notice a lot of freeriders and high costs and say: god, clearly that was a lousy idea in the first place.

Posted by abb1 | December 8, 2007 2:40 PM

abb1,

Nope. Too late. By that time, there's no going back: too many people are in love with the highway. The only lousy idea seen from the future perspective of the new world of the shiny highway was the idea of letting some people get away with not paying for it.

Jasper,

My impression was that Romney is having a very tough time with his Republican friends, and can't run away from Massachusetts fast enough. I've lived in New England all my life, including 10 years in Massachusetts - except for the three years when I lived in southwest Virginia. There I discovered that Massachusetts as seen from Virginia is sort of like Mississippi as seen from Massachusetts.

I'd love to get on the slippery slope to socialized medicine, but first we need to get on the slippery slope to the slippery slope. The policy proposals that go over without a fuss in a party primary dominated by activist true believers sometimes become massively controversial and emotional hot button issues in the general election.

Posted by Dan Kervick | December 8, 2007 3:15 PM

I don't think Edwards will get us to single payer, for two reasons:

1. The subsidies he proposes will be cut by Republicans (or simply not allowed to rise at the same rate as health care costs), resulting in the poor being forced under the mandate to buy crappy HMO policies that deny care.

2. The public program will be the subject of interest group rent seeking to weaken it, just like the Direct Student Loan program that is in competition with private programs.

If you want to get to single payer, drop the phony "universality" (an individual mandate is not the same thing as giving everyone a health insurance policy) and instead start expanding Medicare brick-by-brick, as Matt once proposed.

Posted by Dilan Esper | December 8, 2007 4:05 PM

I'd love to get on the slippery slope to socialized medicine, but first we need to get on the slippery slope to the slippery slope.

Interesting, though, that if you explain or rephrase "socialized medicine" as, say, "medicare for everybody", you'll probably find that 70-75% of the population think it's a great idea. Yet in order to get there you feel we need two slippery slopes because of all these "messy realities of politics". Will, at this point, maybe it's easier to change these realities, rather than keep maneuvering thru them. These realities are inconsistent with the main concept of the political system.

Posted by abb1 | December 8, 2007 4:12 PM

I could definitely see a spot for Edwards in an Obama administration, especially since he's not a sitting senator whose seat would have to be fought for.

Something that I've been thinking about lately: as much as I hate to admit it, Edwards' Presidential campaign is probably going to be essentially over by Feb. 6.

Meanwhile, back in NC, Elizabeth Dole is generally regarded as extremely vulnerable, but the NC Dems don't have anyone well-known who's willing to run against her.

Anyone else see an opportunity here?

Posted by low-tech cyclist | December 8, 2007 4:17 PM

Dan Kervick,

If you want mandates, here's how you get to them: You first enact a set of reforms from which there is no turning back, but in which the problems of free-riders and spiraling costs become glaringly obvious in fairly short order. Before long, the public will forget their earlier "don't tread on me" impulses and cry out for mandates, so that healthy and would-be healthy young freeloaders are forced to pay their fair share, and providers will at that point eagerly join in the calls.

Well, that's one theory. Alternatively, the public will not forget their "don't tread on me" impulses but will instead cry out for repeal of the regulations on private insurers that created the free rider problem in the first place.

Posted by Mixner | December 8, 2007 4:20 PM

The subsidies he proposes will be cut by Republicans.

Right. Tens of billions of additional revenue for the health insurance industry will be "cut" by the Republicans, but basically destroying the health insurance industry by imposting Medicare for All is a sure sell. Yup. I get it. Can I also get some of what you're smoking?

Posted by Jasper | December 8, 2007 4:22 PM

Interesting, though, that if you explain or rephrase "socialized medicine" as, say, "medicare for everybody", you'll probably find that 70-75% of the population think it's a great idea.

Then tell them how much their taxes will have to be raised to pay for "medicare for everybody" and watch them fall away again.

We're not even paying enough to fund our current Medicare committments. Fix that first, then you might be in a position to ask for more.

Posted by Mixner | December 8, 2007 4:46 PM

I highly doubt that medicare for everybody would cost them more than they are paying now to the private insurers (assuming the same level of coverage). You'll have to tell them that too, then see what happens.

Posted by abb1 | December 8, 2007 4:56 PM

If you're convinced that Obama's cost reduction, outreach and auto-enrollment plan won't succeed without a mandate, fine. Propose a "trigger" mechanism in the law so that a mandate will automatically come into effect if people who are financially able to pay for insurance choose to free ride instead. But wait! Obama already did that.

What was the objection to his plan again?

Posted by Rachel | December 8, 2007 5:01 PM

Then tell them how much their taxes will have to be raised to pay for "medicare for everybody" and watch them fall away again.

Mixner: It looks to me like the most likely candidate for expansion of Medicare is a Hillary or Edwards-style plan that allows the non-elderly to opt into a Medicare-like product provided by the federal government. Both of these candidates feature this provision in their plans.

As far as I know, both of these plans utilize premiums as a funding device -- not general taxation. As long as they're voluntarily, I suspect this concept would be pretty popular. Having a premium of, say, 5% deducted from one's paycheck would be a pretty good deal to a lot of people, if they were thus relieved of the burden of having several hundred (or sometimes a lot more) dollars a month deducted from their checks to pay for private sector health insurance. People are already paying "tax increases" in the form of rising premiums and declining benefits. Many workers would likely appreciate the fact that the Medicare plan isn't going to play "gotcha" with respect to preexisting conditions. They'd no doubt approve of the fact that the Medicare plan is fully portable, and isn't going to be canceled when job and paycheck loss occur. Again, these are significant advantages over private sector insurance; I fail to see why such a voluntary system wouldn't be popular. And premiums collections from millions of youngish, largely healthy people might actually improve Medicare's finances, at least in the short term.

Posted by Jasper | December 8, 2007 5:07 PM

You don't even need a mandate to solve the free rider problem. You could do it in a number of other ways.

And community rating creates free rider problems of its own. People who consume lots of health care resources as a result of their own unhealthy behavior and lifestyle (smoking, drugs, alcohol, poor diet, lack of exercise, etc.) get a free ride on the backs of people who look after themselves and stay healthy. Even among people of similar health, some will tend to use much more health care resources than others. Some people hate doctors and hospitals and try to stay away from them, and others are hypochondriacs who constantly seek medical attention whether they really need it or not. Forcing all of these people to pay the same for health insurance is unjust.

Posted by Mixner | December 8, 2007 5:19 PM

A small co-pay ($10) will cure most hypochondriacs.

As far as people allegedly engaging in unhealthy behavior because of healthcare being available to them (which I find hard to believe), that would be a problem for any insurance, public or private; government-paid premium doesn't add anything to this (imaginary) problem.

Posted by abb1 | December 8, 2007 5:31 PM

abb1,

A small co-pay ($10) will cure most hypochondriacs.

And you know this, how? The lower a co-pay, the less it will discourage hypochondriacs. The higher a co-pay, the more it will discourage people who need more frequent health care through no fault of their own. And if you accept the principle that people who use more health care ought to pay more than people who use less, it doesn't make sense to demand that everyone pay the same premium.

As far as people allegedly engaging in unhealthy behavior because of healthcare being available to them (which I find hard to believe), that would be a problem for any insurance, public or private; government-paid premium doesn't add anything to this (imaginary) problem.

I didn't say "because of healthcare being available to them." The argument applies regardless of the reason. And you've completely misunderstood the argument, anyway. The payer is not the government, it's the individual mandated to purchase a community-rated policy.

By the way, I love the "allegedly." You don't think smoking is unhealthy behavior?

Posted by Mixner | December 8, 2007 5:46 PM

I highly doubt that medicare for everybody would cost them more than they are paying now to the private insurers (assuming the same level of coverage).

I highly doubt it wouldn't.

Posted by Mixner | December 8, 2007 5:53 PM

Mixner, in any case hypochondriacs are a problem for any insurance, public or private. Smoking can be penalized by any insurance, public or private. The point of any insurance, public or private, is to spread the cost; if you think it's unjust, then you're against any form of insurance.

But the healthcare system without insurance - without spreading the cost - is unrealistic, unfortunately. One day, when they invent a pill that cures all illnesses and costs a nickel a dozen, it won't be the case anymore, but for now it is.

Just like when they invent a pill that enables us to fly like birds we won't need any roads, but for now we have to all chip in and build roads, even though some people drive a lot and others don't drive at all. C'est la vie.

Posted by abb1 | December 8, 2007 6:07 PM

abb1,

Mixner, in any case hypochondriacs are a problem for any insurance, public or private.

Community rating makes the problem worse. It forces responsible users to subsidize frivolous users even more. It forces people who live a healthy lifestyle to subsidize people who live an unhealthly lifestyle even more. This is not only unfair to people who behave responsibly, it also encourages irresponsibility.

Smoking can be penalized by any insurance, public or private.

How is smoking going to be penalized?

The point of any insurance, public or private, is to spread the cost; if you think it's unjust, then you're against any form of insurance.

You still don't get it. The injustice lies not in spreading the cost, but in forcing everyone to buy insurance and to pay the same premium.

Posted by Mixner | December 8, 2007 6:18 PM

Re: But substantial numbers of Americans have a stubborn and instinctive aversion to the government making them do something they were not made to do before

Most Americans would be unaffected by the mandates since they have health coverage either through their jobs or through a government program. By the way one reform I would very much like to see if we are going to have private insurance still would be for the unemployment system to pick up the tab for COBRA.

Re: In my view the insurance industry won't survive in its current form if it's required to take all applicants and it's no longer allowed to engage in price discrimination.

Currently it does precisely that with group plans (which is the majority of private coverage). Everyone in the group pays the same price and, since 1996, there has been only a limited ability for insurers to exclude anyone. Not only has the insurance industry survived, it has been pretty profitable.

Re: Under these circumstances it begins to pretty much look like a public utility.

And this is a problem how? Public utilities work, and are sometimes profitable investments.

Re: The subsidies he proposes will be cut by Republicans (or simply not allowed to rise at the same rate as health care costs), resulting in the poor being forced under the mandate to buy crappy HMO policies that deny care.

???
Why wouldn't they just sign up for the public plan Edwards proposes?

Re: The public program will be the subject of interest group rent seeking to weaken it, just like the Direct Student Loan program that is in competition with private programs.

One word: Social Security. Yes, there are private retirement plans, in fact they abound. But none of them have weakened Social Security, and attempts at this have been politically radioactive. I suspect that healthcare would be a lot like Social Security, since everyone would be involved one way or another, and not very like student loans, which involve only a small fraction of the population, hence limiting public resistance to tampering with them.

Re: People who consume lots of health care resources as a result of their own unhealthy behavior and lifestyle (smoking, drugs, alcohol, poor diet, lack of exercise, etc.) get a free ride on the backs of people who look after themselves and stay healthy.

Almost nobody stays healthy forever for the simple reason that no one stays young forever. We Americans need to drop the silly myth that one can be healthy forever and that all disease is a form of punishment for lifestyle sins. The only exceptions are people who die in sudden traumas (which most of us would rather not). Sooner or later everyone else ends up old (or sometimes not so old) and very sick and running up huge bills. The people with unhealthy habits have this happen at a younger age, but I don't see how it matters from a financing standpoint that someone runs up a 100K hospital bill at 50 instead of at 90.
Moreover if pain and misery and premature death cannot deter people from unhealthy habits then a big hospital bill most certainly will not.

Posted by Jonf | December 8, 2007 7:16 PM

You still don't get it. The injustice lies not in spreading the cost, but in forcing everyone to buy insurance and to pay the same premium.

Shorter Mixner: I hate social insurance. Why the hell should some portion of my taxes go to pay for the hospital bill of some old biddie who had the bad form not to die before she got old, and so needed a few days in the hospital shortly after her 73rd birthday when she came down with pneumonia. It's so unfair to me, Mixner, a healthy 38 year-old! That's a wicked convincing argument, Mix.

Posted by Yazooie | December 8, 2007 7:26 PM

"John Edwards, who's publicly hinted around about his plan as designed to put us on a slippery slope to the bountiful world of socialized medicine, is a clear winner here in my view."

Or we could just do what Kucinich says, an immediate conversion to universal health care. I believe he has a similar plan for iraq--immediate withdrawal---no political parsing, no triangulating, no doublespeak.

And--the people we depend on to enlighten us could give the other 5 candidates the time to tell us their positions and compare/contrast with the top 3 in the polls.

The reason kucinich and paul resonate with so many is they vote their convictions, (look it up in the record) and their passion to protect and defend the constitution.

Matt, I'm new to this giving a crap who gets elected thing. Why shouldn't I vote Kucinich?? He's my guy? Why are you (the liberal net, collectively) doing the thing we hate the msm for--choosing sides? I thought the whole point of primaries was to vote your conscience, knowing the delegates you elect will force the eventual candidate to move more towards your position. If it's universal healthcare, or withdrawal from iraq, isn't Kucinich miles better than the frontrunners?? Shouldn't you be mentioning that in your posts?

What do you know, that I don't?

Posted by bluebill | December 8, 2007 10:16 PM

Here's an approach that would not have a death spiral.

www.plan.bipartisanhealthplan.com

Posted by Robert Blandford | December 8, 2007 10:20 PM

Right. Tens of billions of additional revenue for the health insurance industry will be "cut" by the Republicans, but basically destroying the health insurance industry by imposting Medicare for All is a sure sell. Yup. I get it. Can I also get some of what you're smoking?

Jasper, Republicans cut Medicaid spending every chance they get, despite that a fair amount of that money goes through private plans.

As for the political saleability of Medicare for All, Medicare for 55 and over is saleable. Medicare for all kids is saleable. Just get it to creep towards universal coverage over time.

And we can do it without siccing the IRS or the FBI on poor people for the "crime" of not buying health insurance that Dictator John Edwards and Henchman Jasper ordered them to.

Posted by Dilan Esper | December 9, 2007 12:41 AM

One word: Social Security. Yes, there are private retirement plans, in fact they abound. But none of them have weakened Social Security, and attempts at this have been politically radioactive.

The reason cutting Social Security is radioactive IS THAT THERE IS NO COMPETING PRIVATE SECTOR RETIREMENT PLAN THAT IS FUNDED BY GOVERNMENT REVENUES. In other words, cutting Social Security cuts benefits-- it doesn't simply force people to choose a private sector plan.

If you create a single payer with NO COMPETING GOVERNMENT FUNDED PRIVATE PLANS, then it will become untouchable too. But where you have competing private plans, the Republicans and industry-friendly Democrats will always cripple the public plans. It is happening in Medicare, and it already happened with student loans.

Posted by Dilan Esper | December 9, 2007 12:46 AM

Just get it to creep towards universal coverage over time.

Dilan: No thanks. I don't have the patience for "creeping" to universal coverage "over time." We've been creeping since Harry Truman's day. That, in a nutshell, is the main difference in our positions. I want universal health insurance as soon as possible. Like yesterday. By any means necessary.

What happens under your strategy to people who don't qualify for Medicare via one of the incremental "creeps" when, say, they're too rich to qualify for Medicaid but too poor too comfortably afford insurance? What happens to those with preexisting conditions? What about portability and job lock?

I live in the real world, and in the real world private health insurance covers the majority of Americans. A lot of Americans are very pleased with their coverage. Private insurance -- despite your feverish nightmares -- is not intrinsically incapable of yielding a high degree of customer satisfaction any more than government-run programs are incapable of delivering misery (read any of the British papers recently?).

The easiest way to universal health care -- if unlike you one is not prepared to wait through another five administrations -- is to get everybody covered, to prohibit the most egregious behaviors of private insurers, to open up Medicare-like plans to those who want to join, and then see what happens as a result of this major shakeup of US healthcare delivery. I mean, the simple act of opening up a federally financed, government-run Medicare plan to any non-elderly person who preferred it would be a profound shock and truly radical change to the system. John Edwards calls it a means of allowing Americans to decide whether or not they want single payer. I like the sound of that.

Nope, sorry, Dilan. I'll pass on your milquetoast creeping incrementalism.

Posted by Jasper | December 9, 2007 1:35 AM

Re: The reason cutting Social Security is radioactive IS THAT THERE IS NO COMPETING PRIVATE SECTOR RETIREMENT PLAN THAT IS FUNDED BY GOVERNMENT REVENUES.

Not true. You get a nice healthy tax break for every dollar (up to a limit) you sock in an IRA or 401K. That means for every dollar you save (assuming you are middle income) in such private plans the govermment is funding 25 cents of it.

Posted by Jonf | December 9, 2007 1:46 AM

What astonishing contortions this post goes through to avoid noticing the obvious! Reading it without knowing the three candidate's proposals one would think that both Obama and Clinton had staked out almost indistinguishably flawed policy positions on health care, with Edwards clearly to their left.

But of course the plain truth is that it is Obama who is the odd man out--the one who has staked out a significantly more conservative position than either of his major rivals, between whom there is very little policy daylight on this issue. And the news here is that, having staked out such a position, and having been criticized for it not only by a rival campaign but now also by one of the leading progressive public intellectuals, Obama has dug in his heals, and shot back at his critics from their right flank.

In the past you've discerned, through what you claim is a pattern of subtle signals, a greater willingness to resort to military force, and a weaker commitment to diplomacy, on Clinton's part, relative to both Obama and Edwards. Maybe there is something to this contrast, and maybe not. No such doubt is possible about the candidates' positions on universal health care. Yet somehow the heart of the contrast eludes you.

Posted by Amileoj | December 9, 2007 2:41 AM

Mixner, The injustice lies not in spreading the cost, but in forcing everyone to buy insurance and to pay the same premium.

People pay the same premium now as well, group rates. Employer negotiates with the insurance company so that everyone working for this employer will pay the same rate. It makes sense, commercial sense. The larger the pool of insured is, the less need to differentiate. When you have 300 million insured by the same entity (government agency), there is no reason to differentiate at all. It's not more unjust than the fact that 100lb person and 300lb person are paying the same price for a plane ticket. It's simply a fact of life.

As far as forcing everyone to buy insurance. Suppose we agree that some kind of a health insurance scheme is absolutely necessary. The government wants to take the responsibility (because the people feel it must) for everybody having an insurance. And now re-read the post - if his thesis is correct, then a health insurance scheme without coercion is impossible. Market failure. It happens, market failures do exist, see The Market for Lemons, for example. So, some coercion will be necessary, hey, it's an imperfect world.

Posted by abb1 | December 9, 2007 4:31 AM

This issue doesn't give me confidence in both Obama and Krugman. Obama should have responded that his plan like those of the other two candidates, mandate EMPLOYERS to provide insurance to their employees. So the issue is really about mandating Individuals to acquire insurance. The issue about free riders can be resolved through reinsurance which is also in Obama's plan. See Robert Reich's post on his blog.

Posted by MGJ | December 9, 2007 8:27 AM

Dilan: No thanks. I don't have the patience for "creeping" to universal coverage "over time."

Then come up with a plan that can be passed now that gives insurance to everyone rather than simply making criminals out of the uninsured.

Otherwise, I, and millions of other liberals, will oppose it full-throat.

Maybe if we can establish that YOUR unfair blame-the-poor plan is "unpassable", you'll give a second look to fighting for single payer.

Posted by Dilan Esper | December 9, 2007 2:00 PM

"Republicans cut Medicaid spending every chance they get"

Yup. Medicaid is a program for poor people. Programs for poor people always have funding struggles.

Universal healthcare is a universal program. Universal programs always have strong political support.

"I, and millions of other liberals, will oppose it full-throat."

This is why we have elections. And we're going to beat you and Mixner at the ballot box, Dilan Esper. And then we're going to beat you again.

Posted by Petey | December 9, 2007 2:10 PM

"Maybe if we can establish that YOUR unfair blame-the-poor plan"

A program which provides healthcare to the poor for free is a "blame-the-poor plan"?

You have all the honesty of George Bush, Dilan Esper.

Posted by Petey | December 9, 2007 2:13 PM

What happens under your strategy to people who don't qualify for Medicare via one of the incremental "creeps" when, say, they're too rich to qualify for Medicaid but too poor too comfortably afford insurance? What happens to those with preexisting conditions? What about portability and job lock?

They will get covered eventually when they get to to single payer. And they will get very good insurance.

Seriously, your same argument is an argument against passing Medicare in the 1960's. After all, what happens to 60 year olds who didn't qualify.

I live in the real world, and in the real world private health insurance covers the majority of Americans.

NO, YOU DON'T LIVE IN THE REAL WORLD. You live in Fantasyland. In your world, there are no insurance lobbyists to come in and gut the public program in the Edwards/Clinton plan. In your world, there are no Republicans who will cut spending to the poor, or simply not allow it to rise enough to keep up with health care spending. In your world, you create this perfect scheme and there is no law of unintended consequences, much less any political actors with a vested interest in stopping you.

Further, in your world, there is nothing wrong in your mind with solving a problem that poor and working class people have by putting a gun to their heads and forcing them to do something they can't afford to do, and shovel the money forcibly collected to insurance companies. In your world, the only way for liberals to get a program passed is to endorse totalitarian corporatism.

A lot of Americans are very pleased with their coverage. Private insurance -- despite your feverish nightmares -- is not intrinsically incapable of yielding a high degree of customer satisfaction any more than government-run programs are incapable of delivering misery (read any of the British papers recently?).

The easiest way to universal health care -- if unlike you one is not prepared to wait through another five administrations -- is to get everybody covered, to prohibit the most egregious behaviors of private insurers, to open up Medicare-like plans to those who want to join, and then see what happens as a result of this major shakeup of US healthcare delivery.

Stop telling me you live in the real world. I have given you real world examples of exactly the things I say will happen to your pretty little fascist evil individual mandate scheme if it were really passed. You ignore them. Haven't you paid attention to the Direct Student Loan program? To Medicaid cuts?

A lot of Americans are very pleased with their coverage. Private insurance -- despite your feverish nightmares -- is not intrinsically incapable of yielding a high degree of customer satisfaction any more than government-run programs are incapable of delivering misery (read any of the British papers recently?).

For the zillionth time, Jasper, I DON'T OPPOSE PRIVATE INSURANCE. I don't support it, but I don't oppose it either.

You need to talk to people with BARE-BONES HMO COVERAGE about THEIR policies. Yes, I am satisfied with my health care. But I don't have a policy where every time I want to go outside the network, or go to a different doctor, or see a specialist, or seek anything but the cheapest treatment, I have to go to a review board which denies every request, ensuring that only a small number of people who take the time necessary to appeal and get covreage.

That is the reality of the crappy HMO. And millions of people with cheap employers or Medicaid already live within it.

I have shown pretty clearly how your beautiful pristine fascist individual mandate will force the poor into BAD healthcare. Repeat after me. Not ANY private healthcare. BAD private healthcare.

The only way subsidy and mandate is even theoretically acceptable is if it creates a guaranteed entitlement to a policy equivalent to what upper-middle class professionals have. I.e., GOOD private healthcare. Otherwise, you are replacing the nightmare of being uninsured with the nightmare of being insured by a policy that makes it impossible to get benefits. And you are likely going to end up taking money out of poor people's pockets (because the subsidies will eventually be cut) to do it.

So if you want to have private healthcare plans involved, that's not a dealbreaker. But you need to spend the money to make sure that the poor and middle class get GOOD private healthcare. And to do that, you need to spend more than Dictator Edwards is willing to spend.

Lastly, pass your plan and it will be even more difficult to get to single payer, because the problem will be proclaimed to be "solved", no matter how underfunded the program gets.

Posted by Dilan Esper | December 9, 2007 2:13 PM

Not true. You get a nice healthy tax break for every dollar (up to a limit) you sock in an IRA or 401K. That means for every dollar you save (assuming you are middle income) in such private plans the govermment is funding 25 cents of it.

JonF, you aren't allowed to avoid paying payroll taxes by placing money in IRA's. You still pay into social security, and you still get the benefit. Social Security is a single payer system.

Direct Student Loans is a multipayer system, and the public plan gets gutted in that situation because of the power of private industry.

Posted by Dilan Esper | December 9, 2007 2:15 PM

Universal healthcare is a universal program. Universal programs always have strong political support.

Petey, the SUBSIDIES in the Edwards plan are NOT universal. They DO NOT go to the wealthy. They go to the poor and lower-middle class. They are a welfare program.

Just because the subsidies are presented as coupled with an individual mandate doesn't mean the Republicans won't decouple them and cut the subsidies.

Or, in the alternative, the Republicans won't cut the subsidies at all. They just won't let them rise enough to keep up with health care cost inflation.

Either way, your assumption that the subsidies-- which do not go to everybody-- will be treated as a "universal" system shows you to be a total Pollyanna about the political process.

Again, supporters of individual mandate programs should stop pretending that their program is any more politically pragmatic than single payer. It isn't.

Posted by Dilan Esper | December 9, 2007 2:19 PM

You have all the honesty of a cockroach, Dilan Esper.

Posted by Petey | December 9, 2007 2:20 PM

A program which provides healthcare to the poor for free is a "blame-the-poor plan"?

1. The subsidies will be cut, leaving the mandate-- see above.

2. The mandate blames the poor, by criminalizing the status of being unable to afford health insurance.

(By the way, I just realized that the individual mandate is probably unconstitutional as well, as a law criminalizing status. Just one more strike against it.)

Posted by Dilan Esper | December 9, 2007 2:20 PM

"By the way, I just realized that the individual mandate is probably unconstitutional as well, as a law criminalizing status."

And you're a moron too, Dilan Esper.

Posted by Petey | December 9, 2007 2:23 PM

Does anyone have any idea how many people who make more than $100,000 don't have health insurance? I'd bet it's vanishingly small.

Assuming that wager is correct, how do mandates solve the free rider problem? I mean, sure, the free rider 20-somethings have to get health insurance, but then the rest of us have to subsidize it (under the Edwards plan). Is that really more efficient?

And Petey, you're right that universal programs are "strong" in the sense of not being under-funded or killed. But that doesn't mean they're intrinsically better at what they do. Medicare isn't universal, and it's pretty good. Public schools are universal, and they're no prize.

Posted by southpaw | December 9, 2007 2:29 PM

"And Petey, you're right that universal programs are "strong" in the sense of not being under-funded or killed. But that doesn't mean they're intrinsically better at what they do. Medicare isn't universal, and it's pretty good. Public schools are universal, and they're no prize."

I'll amend:

Universal programs tend to consistently have stronger funding support in our federal Congress than programs for the poor.

"I mean, sure, the free rider 20-somethings have to get health insurance, but then the rest of us have to subsidize it (under the Edwards plan)."

Given that the $120 billion / yr of subsidies in the Edwards plan are funded by repealing Bush's tax cuts for those making more than $200k/yr, it'd be more accurate to say that those of us making more than $200k/yr have to subsidize them.

The Edwards plan ends up being a pretty effective redistributionist program that will be politically strong.

Posted by Petey | December 9, 2007 2:40 PM

And you're a moron too, Dilan Esper

Under Robinson v. California and Jones v. City of Los Angeles and other cases, it is unconstitutional to criminalize status as opposed to conduct. Thus, you can punish drug possession, but you can't make a crime out of the status of being a drug addict. You can punish loitering or stalking or trespassing, but you can't make a crime out the status of being homeless.

Petey, your precious individual mandate scheme criminalizes the status of being uninsured. It is unconstitutional and will be struck down, by both the liberals (who believe very strongly in this constitutional rule) and the conservatives (who would love to strike down a health care plan sponsored by Democrats) on the Supreme Court.

Stop your name calling and answer my arguments.

Posted by Dilan Esper | December 9, 2007 2:44 PM

Universal programs tend to consistently have stronger funding support in our federal Congress than programs for the poor.

But as I said, that is irrelevant because the subsidy component of the Edwards plan is not universal. Unlike Social Security, it is means-tested. And therefore, it will be decimated by Republicans and right-wing Democrats just like every other means-tested program is.

Posted by Dilan Esper | December 9, 2007 2:47 PM

"Petey, your precious individual mandate scheme criminalizes the status of being uninsured. It is unconstitutional and will be struck down, "

As stated, you're a moron, Dilan Esper.

Nobody is "criminalized" under the Edwards plan. They're just automatically enrolled in healthcare coverage.

"Stop your name calling"

But you deserve name calling. You're a liar and an idiot. You're actually stupider than Mixner, and that's perversely impressive.

Posted by Petey | December 9, 2007 2:48 PM

"Unlike Social Security..."

Social Security is also redistributionist. How have attempts to gut that worked out over the past 73 years?

Do you think mandatory Social Security is fascistic too, Dilan Esper? Is Social Security another nefarious screw-the-poor program, you slimy idiot?

Posted by Petey | December 9, 2007 2:53 PM

Given that the $120 billion / yr of subsidies in the Edwards plan are funded by repealing Bush's tax cuts for those making more than $200k/yr, it'd be more accurate to say that those of us making more than $200k/yr have to subsidize them.

The Edwards plan ends up being a pretty effective redistributionist program that will be politically strong.

This is fair enough. If implemented, it will be an effective economic redistribution program. It may or may not improve health care outcomes or efficiency.

But here's where I think our agreement ends: before implementation, redistribution is a political liability.

Americans tend to vote like they will be wealthy one day. So you don't want Republicans to be able to effectively argue, "They're selling you healthcare, but you're buying socialism." Edwards' plan is weaker on that front than Obama's because the individual mandate's primary selling point is entitlement expansion, not better or cheaper health care.

Posted by southpaw | December 9, 2007 3:04 PM

Nobody is "criminalized" under the Edwards plan. They're just automatically enrolled in healthcare coverage.

Not true. IF the government can find money to confiscate, they will be automatically enrolled. If no money is found, they will be in violation of the mandate, which is presumably illegal.

In any event, I am not sure you are drawing a distinction with a difference. If the STATUS of being alive and uninsured is made illegal, that may be unconstitutional even if the only penalty is asset confiscation.

Look, I think the central problem here is that a bunch of people, yourself included, decided that there was a political problem enacting single payer or managed competition and decided that the way around it was with this elegant looking Edwards plan. The problem is that you ignored that the Edwards plan just creates a bunch of different problems that probably make it MORE politically impossible than simply expanding Medicare.

And then, when people point these problems out, the Edwards people call them idiots, because it has all been thought out already and it is so elegant and there can't be any problems with it!

The fact of the matter is that the Edwards plan cannot pass because many liberals will stop it (because they will conclude as I have that it will make things worse, not better), and it cannot work because it is easy for conservatives and the insurance industry to undermine (by gutting the public plan, underfunding the subsidies, and using the mandate to create a regressive tax against the poor). Further, as I noted, there is a good chance that ANY individual mandate scheme with respect to health insurance (which is based on status, unlike car insurance, based on voluntary choice to own a car) is unconstitutional.

So you have a plan that won't pass, won't work, and won't be permitted to be enforced by the courts.

You hit the trifecta. I guess all this calling other people morons is pure projection.

Posted by Dilan Esper | December 9, 2007 3:05 PM

"Not true. IF the government can find money to confiscate, they will be automatically enrolled. If no money is found, they will be in violation of the mandate, which is presumably illegal."

As stated, you are a slimy liar, Dilar Esper.

Posted by Petey | December 9, 2007 3:08 PM

Social Security is also redistributionist. How have attempts to gut that worked out over the past 73 years?

Petey, SS IS redistributionist, but that wasn't my point. It is also SINGLE PAYER. You have to pay into it, and everyone gets it. You can't opt out of it to choose a private program instead. THAT'S why it is so hard to cut the benefits. It's hard to cut a universal SINGLE PAYER program.

On the other hand, it will be EASY to gut the Edwards / Clinton public plan, because the private alternatives will be available. None of you guys have answered why this is different from the Direct Student Loan program, which is universal, MULTIPLE PAYER with private sector participation, and has been gutted.

Posted by Dilan Esper | December 9, 2007 3:08 PM

As stated, you are a slimy liar, Dilar Esper.

Learn how to respond to an argument rather than calling names, Petey.

Posted by Dilan Esper | December 9, 2007 3:10 PM

Re: JonF, you aren't allowed to avoid paying payroll taxes by placing money in IRA's. You still pay into social security, and you still get the benefit. Social Security is a single payer system.

I’m not sure where our argument is, but maybe we could start over? You claimed the GOP would try to cut a public health program if we enacted one. I’m not arguing about the “try” part. Of course they would! My point however is that their ability to do this would be very limited by the public’s tolerance for such cuts. My use of Social Security was a bad analogy, I will agree. Medicare is perhaps a better one: the GOP certainly does do Medicare cuts. But note how these cuts are structured: they are not cuts in benefits, but rather in reimbursement rates to the providers (which they are forbidden to make up by charging patients more). And sometimes they are increases in the amount enrollees must pay for coverage under Part B. It would be politically impossible to actually cut the benefits themselves, to tell people “We won’t cover procedure X any more; you have to pay for yourself” (OK, there may be rare examples of that happening when there are medical reasons why Procedure X is no longer deemed appropriate or effective). The same tactic is used with Medicaid, often on a more draconian scale. What’s more, this is how foreign governments handle the need to reduce payouts from their public health plans: everything is still covered, they just pay the providers less.
So yes, the GOP would periodically take the paring knife to the public health program, cutting reimbursement rates and jacking up the buy-in rate. But oytright benefit cuts would be unlikely.

Posted by JonF | December 9, 2007 3:14 PM

"Americans tend to vote like they will be wealthy one day. So you don't want Republicans to be able to effectively argue, "They're selling you healthcare, but you're buying socialism." Edwards' plan is weaker on that front than Obama's because the individual mandate's primary selling point is entitlement expansion, not better or cheaper health care."

The problem with the Obama plan is that it is essentially non-functional. By providing strong incentives for healthy consumers to go without insurance, it would, as the title of Matthew's post, create a death spiral for the system.

If you're looking to 'heighten the contradictions', it's great. If you're looking for a successful reform, not so much.

And, of course, Edwards isn't going to be selling the redistributionist aspect of the system to the electorate, just like FDR didn't sell the redistributionist aspect of Social Security. Edwards is going to be selling the fact that it means everyone will always have healthcare, which is a popular notion - especially since those happy with their current situation will face no pain.

Posted by Petey | December 9, 2007 3:15 PM

But note how these cuts are structured: they are not cuts in benefits, but rather in reimbursement rates to the providers (which they are forbidden to make up by charging patients more).

That's true. But that's because it is a single payer system and that's the only sort of cut you can get away with.

In contrast, Edwards' subsidies-- which will be seen as a welfare program for the poor and lower-middle class-- will be ripe for attempts to simply "slow the rate of growth" or "cut across the board" or "trim the fat" or simply "grow at the rate of inflation", i.e., the CPI, which rises at a much slower rate than health care costs.

These subsidies will be so easy to cut that I am shocked that anyone is arguing that we will possibly be locked in stone with sufficient funding as far as the eye can see.

Posted by Dilan Esper | December 9, 2007 3:18 PM

"In contrast, Edwards' subsidies-- which will be seen as a welfare program for the poor and lower-middle class"

Right. A subsidy program being paid to 80% of Americans will be seen as a welfare program for the poor and lower-middle class.

"Learn how to respond to an argument rather than calling names"

I am responding to your "argument". You keep lying, and I'm responding by identifying what you're doing.

Posted by Petey | December 9, 2007 3:24 PM

Right. A subsidy program being paid to 80% of Americans will be seen as a welfare program for the poor and lower-middle class.

Petey, college grant programs originally had quite liberal eligibility, with lots of middle and even upper-middle class people eligible.

Eventually, they were replaced by loan programs for all but the poor. And then, as I noted, the government loan program was created, and it was later gutted because of industry lobbying.

Social Security and Medicare are truly universal. SS involves people paying into a program which maintains the illusion that you are getting back what you paid. Medicare has universal eligibility for seniors.

In contrast, Edwards doesn't guarantee a defined benefit. All he does is say we will spend a sum of money. It is SO easy to cut that type of a program-- as I said, you don't even have to cut it; just don't let it grow enough.

Again, this whole debate is about a bunch of people who thought they found the magic bullet and in fact did not.

I should mention this is all probably irrelevant anyway, because Edwards and Clinton sealed their fate in the Democratic primary with a single vote in 2002.

Posted by Dilan Esper | December 9, 2007 3:37 PM

The problem with the Obama plan is that it is essentially non-functional. By providing strong incentives for healthy consumers to go without insurance, it would, as the title of Matthew's post, create a death spiral for the system.

If that's true, we've got two different models, neither of which operates as advertised. I can barely contain my excitement for the general.

Like Matthew, I'd like to see Obama elected, but neither health care program particularly quickens my pulse.

On a broader level, I don't mind asking people to put up their money for a good program, but redistribution primarily for its own sake won't get my vote. Good luck with it, though.

Posted by southpaw | December 9, 2007 3:43 PM

Gosh, Petey, are all die-hard Edwards supporters as childish and petulant as you?

Your behavior here and elsewhere is not doing your candidate any favors, you know.

Posted by Jason | December 9, 2007 5:15 PM

offered without comment

Posted by southpaw | December 9, 2007 9:26 PM

But you deserve name calling. You're a liar and an idiot. You're actually stupider than Mixner, and that's perversely impressive.

Posted by Petey

Translated to English: You're making arguments against John Edwards that I can't answer, so I'll sit here and splutter with rage.

Posted by J.B. | December 10, 2007 12:58 PM