Here's a letter signed by eighty people many of whom have impressive sounding titles who say the mandate difference between Barack Obama and Hillary Clinton doesn't really amount to very much in the end. It's hard for me to judge if that's right or not -- there are clearly a bunch of folks who see things the other way. In practice, I think this may not matter just because of the way the legislative process works; the relevant question is what position on this matter has the support of on-the-fence congressmen.
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Mandates: Eh?
01 Feb 2008 10:14 am
Comments (46)
Clinton keeps equating "mandates" with "universal coverage" -- she chides Obama that in order to achieve the latter, you must enforce the former. But this is logically absurd. If, as was said at the debate last night, there are 15 million people who won't pay for health care, i.e., who don't want it under any system, then these folks will always be a barrier to full coverage. The whole question is what, under either Obama's or Clinton's approach, to do about these people.
Thus I think the cite above has it correct: "There is simply no factual basis for the assertion that an individual mandate, by itself, would result in coverage for 15 million more Americans than would robust efforts to make health care more affordable and accessible."
What's more, Obama should be driving the point that the mandate focus risks making health care reform nothing more than a massive wealth transfer to insurance companies, who no will collect premiums from 45 million more insureds.
Where experience matters:If it does not matter as the experts say you don't enter the negotiating table with one key element, taken out. So, what are you going to give up next?
Surely Paul Krugman could never be wrong!
I'm an Obama supporter but agree that in an ideal world, mandates would be better. Think of it like auto insurance -- people who get into wrecks but have no insurance raise rates for the rest of us. Similarly, people without health insurance who wind up in the hospital raise insurance rates for the rest of us because we wind up paying for them.
That said, given resistance to national health insurance in the first place and Americans' aversion to nanny-state government, I think Obama's plan has a better chance of getting through Congress in some shape or form. Of course, the great fallacy of this debate is that either Obama or Clinton can put a plan in place by themselves; Congress is sure to do more than just tinker with them. We'll be lucky to get some kind of national plan, but chances are it will be quite different from the plans presented by either candidate.
The important thing is to establish the principle of universal care -- then at some date in the future, when it's taken for granted the benefits can be expanded to everyone through mandates or whatever. This is the Medicare principle -- it was a long, long struggle to get it through Congress, but now it's taken for granted and could not possibly be repealed. So incremental changes increasing coverage and benefits are easier to do.
The point, stellaa, is that you are not giving up anything by avoiding mandates, since they are not effective.
But mandates would make it easier to demagogue against any healthcare plan that contained them. What do you think Republicans could do with a plan that forces people to spend money on health insurance they don't want? They'll call it a huge tax increase, but that's nothing until the details of the "fine" people would have to pay if they don't get health insurance.
The mandate mania that's swept the center-left is really pretty hare-brained. Mandates are possibly the least important part of the awkward package of reforms these candidates are proposing; far more critical are elements like subsidies, community rating, and public-private competition. Personally, I'm convinced no health care reform bill will pass into law that has an individual mandate - it'll be far, far too easy to demonize - and I'd rather take Obama's approach of passing everything else and worrying about mandates later.
I think this debate is more about semantics than substance. Clinton is ‘for’ a mandate, but has not committed to any specific enforcement mechanism. Obama is ‘against’ a mandate, but in the debate last night said that people who tried to game the system by forgoing insurance until they actually needed health care could be made to pay some sort of penalty. At the end of the day, there’s a not a whole lot of difference between those two approaches. It seems like they both amount to sort of a soft mandate.
The one place individual coverage requirements do matter a great deal politically is that they make the insurance industry far more willing to cooperate, because they're the ones who are hurt by adverse selection. See Ron Williams of Aetna here (search for "individual coverage requirement", mandate to him means mandating specific coverages)
At a point, if you're going to mandate coverage, why not just go all the way to single payer. The penalty argument is what makes this compelling--it's really hard to answer from a healthcare advocate point. Even if it would make the system work better it's tough to say what'd you'd fine someone who couldn't afford subsidized coverage
On an unrelated note, I want to go on a man date with barack
Hillary's plan would be tough to pass. It will have plenty of opposition from Democrats and all the Republicans. Obama's will have less opposition, but would still be difficult. So I'm not sure there's much of a difference in practical terms either.
Excellent point Ryan, and this is exactly why Obama will make a difference in overcoming right wing talking points. He has the skill to disarm the opposition, it's the opposite of bi partisan kumbaya talk, its jujitsu.
Some polling (from NH) has shown that the mandate argument at least marginally cuts in favor of Obama's position.
I don't think people like to be force to do anything, and it puts the pressure on Obama to make his plan truely affordable, where Clinton can just mandate a plan, that may or may not be affordable.
blindjoedeath, I agree with you. Obama does this on many issues. He takes the conservative arguments, uses it against them, and at the end of the day they're amazed they lost the debate without realizing it and Obama won. It's an incredibly astonishing thing to watch.
As per usual, John Edwards nailed it in the SC debate. The argument Obama is using against mandates is fundamentally the same argument Bush Co. made for the privatization of social security, and against any social safety net.
Ezra Klein, has more here. His willingness to demagogue against the underpinning foundations of a social safety net are troubling, no matter what his voting record in Springfield was.
On policy terms the 'free rider' problem is particularly big once pre-existing conditions are done away with and community ratings are imposed. In layman's terms the incentives to free load go way up, with no countervailing force, and could doom the entire scheme.
In practice, I think this may not matter just because of the way the legislative process works; the relevant question is what position on this matter has the support of on-the-fence congressmen.
Whoa! Let's not get ahead of ourselves here! Right now, the relevant question is what position will get a Dem elected in the White House with coat-tails long enough to have a good majority in Congress.
A candidate needs to have enough "details"(TM) in his/her plan to ensure people that s/he can "get R done". However, details sometimes just only serve to provide ammunition to opponants.
Historically Dems. have been very bad at giving "details"(TM). They tend either to give empty catch-phrases (like Obama has done) or to give actual, controversial details which only serve to frighten people (or at least re-enforce the notion that Dems. are boring technocrats) and really don't matter anyway once the sausage making is done.
To put it in scientific terms, Dem candidates tend to have election proposals that either sound like presentations to general audiences or have the details of a scientific paper. The goal, quite logically given the nature of what a candidate needs to do, is to have the level of detail you'd put in a grant application. Let people know you have a feasible plan to accomplish things, but don't get hung up with things that ultimately will be changed depending on how the "experiments" go anyway.
I do not know who is right on the substance. I DO know John Edwards agreed with Hillary Clinton on this issue.
FWIW, people like Ezra Klein need to be consistent here.
Seems to me that the writers aren't saying "mandates are bad" so much as "the other parts are far, far more important than the mandates!"
In other words, it's more important that one of the candidates' health plans gets enacted than which one. Seems reasonable to me. Of course, as on a lot of issues, the candidates and their supporters have to fight about something, so this issue gets a lot of play.
Of course, as Robert Reich essentially pointed out a bit ago, if you have universal health care, mandates don't matter 'cause everyone will already have the mandated health care.
they're the ones who are hurt by adverse selection. - Boring Commenter
But what is the problem here and how do mandates get around it? The problem is that health insurers don't have a bunch of healthy people paying into their plans to offset the costs of sick people. What a mandate does is force healthy people to pay into the plan to, essentially, subsidize the health care for sick people ... which is actually a fine and progressive (also Communist ... but also according to Jewish/Christian/Islamic/Etc. morality ...) way of working things: make those who are able help out those who are less able.
The problem is that, the way money flows in our society, the young and able bodied are oftentimes doing jobs that, in spite of the physical and/or mental labor involved, don't really pay all that well (and changing this would involve a degree of left wing anti-market radicalism which even moonbats like me are loath to support). Hence they cannot afford to subsidize health care of others.
So what is the solution? Well, subsidize those who cannot afford to buy the mandatory health insurance. Now does that make sense? Aside from the political issue of how to set the bar of affordability (set the number too low, and the GOP will win in 2012 on sob-stories about people not able to afford mandatory health insurance ... set the number too high and the GOP will win in 2012 with stories about people making over X$ a year who are on the gummint dole), it is just plane silly to subsidize people to pay for something that subsidizes other people.
Why not just have the government pay directly (or to the insurers at least) the money needed to offset the effects of adverse selection? This not only avoids certain political traps, but it also moves us toward the liberal goal of single payer and/or socialized medicine.
You want universal coverage? Start covering people. Enough with these layers of paying people to pay people to pay people that just re-enforce stereotypes about liberals' love of government coercion and bureaucracy!
I too don't really know how much difference the mandates make in terms of actual policy, but THIS ranks pretty high on the Obama annoy-o-meter, right up there with "Social Security is in an urgent crisis" and "we Dems need to stop disrespecting people of faith."
If Obama was for mandates...
most of you would be too.
LOL
Krugman has been consistent and CORRECT all along.
You do not concede anything in the way of rhetoric to republicans.
Give them an inch, they'll take a mile.
Mandates: Eh?
Well, Obama wants to allow young, healthy people to go without insurance if they want, then "opt-in" later in life or if they get sick.
Just imagine how much your car insurance would cost if people were allowed to "opt-in" after they had an accident?
Mandates: Eh?
Well, Obama wants to allow young, healthy people to go without insurance if they want, then "opt-in" later in life or if they get sick.
Just imagine how much your car insurance would cost if people were allowed to "opt-in" after they had an accident?
Like Social Security, do you think that should be optional as well? This is the point of insurance.
Exactly willy, if Obama was for mandates, "they" would be arguing that it's the progressive stance.
Looking glass world. You can find an expert to support any position. I don't believe in offering a half glass when you enter negotiations. I guess I am part of the old "culture war' people.
I love the feel good C-span idea of creating a national policy, gee Senator, they are called congressional hearings. Do you guys really believe there will be no closed door meetings? Disneyland.
I call this "community organizing" processing obsession that gets people no where. (I was a community organizer) Processing is just to pacify the people that they are involved, the decisions are made behind closed doors.
One question?? How are you going to enforce these mandates??? Americans like choices from our burgers to our cars... Mandates just seems so unAmerican..
So what is the solution? Well, subsidize those who cannot afford to buy the mandatory health insurance. Now does that make sense? Aside from the political issue of how to set the bar of affordability (set the number too low, and the GOP will win in 2012 on sob-stories about people not able to afford mandatory health insurance ... set the number too high and the GOP will win in 2012 with stories about people making over X$ a year who are on the gummint dole), it is just plane silly to subsidize people to pay for something that subsidizes other people.
Why not just have the government pay directly (or to the insurers at least) the money needed to offset the effects of adverse selection? This not only avoids certain political traps, but it also moves us toward the liberal goal of single payer and/or socialized medicine.
DAS is talking sense.
Edwards had a whole system in his package through the IRS.
Sorry kids, you have to give up some of your lattes and bike outfits to pay for health insurance. Tough if they don't like it.
You already pay for it when people go to emergency rooms with no coverage. What do you think is bankrupting county hospitals?
Well, the letter is undoubtedly correct in saying
that a mandate without an associated penalty would
be ineffective. But that's kinda obvious. A
mandate that you can just ignore is meaningless
political theater, not real policy.
And obviously, from a political point of view, at
this stage of the game nobody in the pro-mandate
camp wants to be talking about the details of the
enforcement policy, because it's going to sound like
something which is potentially painful, e.g. some
kind of extra bureaucracy with the power to impose
some kind of fine.
Nevertheless, if you want to get *universal*
health-care through private health-insurance
(rather than single-payer, which in my opinion is
the best approach since it gets the largest
possible risk pool and eliminates the unproductive
overhead of private insurers with their own
agenda), then a mandate with effective enforcement
is an essential part of the puzzle. Because
you can't get affordable insurance for high-risk
people unless you *force* low-risk people to
pay more than their expected share of the cost.
And that's not something they would obviously
*choose* to do voluntarily - like all mandates,
it's a slightly-obscured form of tax, and who
pays their tax without the threat of the IRS ?
Obama is ‘against’ a mandate, but in the debate last night said that people who tried to game the system by forgoing insurance until they actually needed health care could be made to pay some sort of penalty. At the end of the day, there’s a not a whole lot of difference between those two approaches.
On the contrary, there's a huge difference. Mandates force people to buy insurance up front whether they want it or not, whether they use it or not, while penalties merely make insurance more expensive for those who delay purchase. The latter policy is more flexible and more accommodating of differences between people in tolerance for risk and consumption of health care resources. Some people hate going to the doctor or the hospital and don't need any economic incentives to limit their consumption of health care to what they truly need. Other people are hypochondriacs or quasi-hypochondriacs who would aggressively seek every test or drug or surgery that might possibly benefit them if there were no strong economic incentive for them to limit their consumption. Some people would be willing to take the risk of having to pay more for health insurance if and when they eventually needed it, while others would be more comfortable protecting themselves from that risk by buying insurance at a lower rate from the start. Forcing the former groups to subsidize the latter groups through a mandate on everyone to purchase insurance is unjust and likely to be deeply unpopular, quite apart from any other problems related to enforcement.
Mandates: Eh?
I didn't know you were Canadian.
"There is simply no factual basis for the assertion that an individual mandate, by itself, would result in coverage for 15 million more Americans than would robust efforts to make health care more affordable and accessible."
The key phrase is '..an individual mandate, by itself..'. What does that mean? Nothing. There is also 'simply' (indeed) no evidence that an increase in dietary fiber *by itself* will increase your lifespan. Wankery.
Stellaa, do you have tats, nose and tongue piercings, and a flat top haircut?
Just imagine how much your car insurance would cost if people were allowed to "opt-in" after they had an accident?
How much would it cost, danonj? Why don't you run the numbers under various different "opt-in" penalty scenarios and let us know.
But in fact, since we mandate only third-party liability coverage for auto insurance rather than coverage of the driver himself and his own vehicle, and since even the mandated level of third-party coverage is actually quite modest (it probably won't come close to covering your liability if you total the other guy's porsche and render him permanantly disabled), we do in fact allow people significant freedom to "opt out" even of third-party coverage.
Lars, how did you know? Man, you are just awesome, cool and brilliant.
Got to love the internets, everyone can be an asshole.
In this healthcare debate everyone needs to focus
on the one key question: who pays for the healthcare
costs of high-risk people ? The WaPo had an article
last week about families with extreme healthcare
costs due to hemophilia or other treatable-but-only
-at great-cost conditions blowing through $1M+
lifetime caps.
The people with expected healthcare costs greater
than median income aren't going to pay for
themselves because they absolutely can't.
In the current system, either these people fail
to get the healthcare they need, *or* they end
up getting it at taxpayer expense through
Medicaid or similar programs.
In the mandate+penalty+community rating plan, the
answer is basically that low-risk people pay more
than their fair share, and the extra pays for the
high-risk people who are getting an effective
discount.
In the no-mandate plan, the really low-risk people
will (rationally) opt out and pay nothing; so
the burden will fall on the smaller pool of
low-to-medium-risk people. And they'll actually
end up worse off than under the current system
where the burden is at least shared by all
taxpayers.
The other thing it's perhaps worth pointing out
is there are only so many doctor-hours and nurse-
hours and hospital-bed-days to go round, and
nobody is really proposing a vast change in the
total quantity of healthcare. So the two issues
at stake are how you slice the fixed healthcare
pie, and who pays for it. Everything else is
smoke and mirrors.
You guys all have health insurance already, don't you.
I don't.
I could buy a plan from Aetna or whomever. The plan would be about $150 a month, and give me a $5000 annual deductible. I still couldn't see a doctor with this plan, because I'd be paying 100% out-of-pocket.
The trouble with mandates is that I'd be forced to buy this plan, and it'd STILL be useless--ESPECIALLY with a president who's in the pocket of insurance.
Clinton's plan is to give universal health INSURANCE, whereas we need a plan aimed at getting universal health CARE. Obama's, while actually immediately WORSE, seems more likely to EVENTUALLY result in a single-payer system.
Anything short of a single-payer system is a loss.
As a practical matter, the difference between Sen. Clinton's and Sen. Obama's approaches come down to timing and sequencing. Mrs. Clinton wants a mandate first, believing that enrolling the younger and healthier will help reduce costs for everyone else. Mr. Obama thinks forcing people to buy health insurance before it's affordable isn't realistic. He wants to lower health costs first, and is willing to consider a mandate only if necessary.
Thank you for citing our letter and my Huffingtonpost column. I myself am an Obama supporter because I believe he is the most likely to win and get health reform passed. Individual mandates are one pertinent issue, but are far less important than people are saying.
Anything short of a single-payer system is a loss.
Single-payer health care isn't "universal health care" and more than universal health insurance is "universal health care." As the Canadian Supreme Court put it in its criticism of that country's single-payer system: "Access to a waiting list is not access to health care."
As reported here, a recent survey of doctors in Britain's single-payer National Health Service found that:
One in three [family and hospital doctors] said that elderly patients should not be given free treatment if it were unlikely to do them good for long. Half thought that smokers should be denied a heart bypass, while a quarter believed that the obese should be denied hip replacements.
Wecome to the wonderful world of "universal" single-payer health care. Try selling that to the American people.
But since single-payer isn't even on the table, this is all academic anyway.
Ah, Mixner's here to spread its bullshit, instead of making goo-goo eyes at McMegan. How sad. (Here's a small hint: the NHS isn't single-payer. Thanks for playing. Now fuck off.)
I like Atrios's take on mandates.
Even recognizing the political realities of the situation, it seems that the way to sign everyone up is to... sign everyone up. Instead of having "mandates" requiring that people sign up to some plan, just sign them up. Instead of mandating that they pay their premiums every month, just pay for it out of general tax revenues (adding a new payroll tax or raising top marginal rates or whatever to do so).
Make it an opt-out, not an opt-in.
the NHS isn't single-payer.
Yes it is. The NHS is the quintessential example of single-payer health care systems.
Make it an opt-out, not an opt-in.
He's not proposing to allow people to opt out. The plan he's describing is tax-funded single-payer health care, which isn't even on the table.
The NHS is the quintessential example of single-payer health care systems.
Uh, no. Sorry. You lose, silly glibertarian. Now go and suck up to McMegan, because you're much better at that.
Shorter "Universal Coverage and the Presidential Candidates' Health Care Proposals":
Ineffective mandates would be ineffective. We should focus on making health care affordable and accessible but not, you know, universal.
Obama, his advisers and most of his supporters do not support universal healthcare. Given his financial backers and the demographics of his support I am stunned people still can't grasp this reality.
Right, jjim, and you can see why. All we hear are analogies with required car insurance, but in fact young people pay (much) more for car insurance because they are at higher risk. Meanwhile, mandate proponents propose making young people, who have less money and are at less risk, to pay the same as older people in order to subsidize them.
I don't have any opinion on mandates. I am fortunate to have health insurance and honestly can't figure out what other people should or should not be required to do. I imagine if the Democratic congress put mandates in, Obama would not veto it, and if the congress takes them out, Clinton would not veto it. So I suspect it is a fake issue.
Comments closed February 15, 2008.
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Heads in the Sand
Mandates really do not matter to universal health care and are pretty bad. If someone doesn't want to have health insurance why should he be forced to have it? It's like saying everyone should be forced to buy a car just because many people want to. Obamas lack of mandates makes his health care plan superior to Clintons. It guarantees universal health care but also gives people more freedom in choosing their own health care system even if that means not having insurance at all.
Posted by TLM | February 1, 2008 10:36 AM