Coverage v. Coercion
Suppose you were choosing between two employers. Both offer the same Blue Cross insurance to employees who pay 25% of premiums. But one employer says, "Choose us. We provide more universal coverage because we make our employees take the insurance even when they don't think it is worth the 25% contribution." Does this argument sound persuasive? Sure doesn't to me. I'd say both firms are offering the same coverage, with one adding a heaping dosage of coercion that doesn't really sweeten the deal.
Yet Hillary Clinton is basically making the argument of the coercing employer. There is no serious claim that the Clinton plan would offer cheaper health care coverage than the Obama Plan. They both subsidize premiums for lower income persons, and the Obama plan, if anything, does more to lower premiums because it adds an innovative reinsurance plan that lowers insurer costs and invests more in information technology to lower medical costs. But Clinton keeps arguing her plan offers more universal coverage because of one thing: she adds a mandate that forces people to take the insurance even if they would rather not.
Now a national health care plan does have plausible reasons to include mandates. But the case for mandates has nothing to do with solicitude for those who cannot afford health insurance. It instead has to do with a very debatable policy question about whether free riding problems merit coercing citizens to force them to pay their fair share.
The free rider problem is this. Hospitals cannot legally deny people emergency care. Thus people who do not buy insurance can go to emergency rooms for care even when they cannot afford it. This might induce them not to buy insurance in the first place.
But it is quite unclear how large this free rider problem is. After all, it is not as if hospitals do not bill the uninsured for their emergency care. If they pay those bills, there is no free rider problem. And if they cannot pay the bills, they usually could not have afforded insurance either.
One also wonders how many people who could afford health insurance really are tempted to forgo it for the limited care provided by emergency rooms. After all, emergency rooms need only provide care to people with real emergency conditions, and even then need only stabilize those patients. They also make patients wait for hours, and often try to avoid treating nonpaying patients. Not surprisingly, the empirical evidence is mixed on whether a free rider problem exists at all.
In any event, this free rider problem would at most justify mandating the purchase of insurance covering emergency care, and cannot explain mandating full insurance coverage.
Nor is it clear how effective mandates would be at curbing any free rider problem. The Clinton campaign keeps saying their plan would insure 15 million persons left uninsured by the Obama plan. But this argument has two doubtful premises. First, it assumes their mandate would be 100% effective. Massachusetts has a health insurance mandate, and so far the evidence is that 20% of uninsured don't comply, which given 45 million uninsured would mean the Clinton plan would also leave 9 million uninsured, and thus able to free ride if we think that is going on. Second, the 15 million figure is quite debatable, and the Obama campaign presents reasonable data to say that only 2 million would fail to accept coverage under their plan.
But the debate about whether the correct number is 2 or 15 million misses the real point. If Clinton campaign is right that 15 million would reject health care coverage without a mandate, then she is effectively claiming that 1/3 of the uninsured would conclude they are worse off under her plan. I'm not sure why this should count as a point in its favor.
The bottom line is this. If you are worried about paying for your own health care coverage, there is no reason to favor the Clinton Plan over the Obama Plan, and the latter is probably a bit better. If your concern is other people not paying for emergency care, then the Clinton plan is more responsive. But it isn't clear whether that concern is significant or how effective mandates are solving it, and in any event a mandate covering all health care would be an overboard solution.
Einer Elhauge is Petrie Professor of Law at Harvard Law School, Director of the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, and an unpaid member of an Obama Health Care Advisory Committee. This op-ed does not purport to reflect the views of the Obama campaign.
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Obama explains his plan in such circular logic that it doesn't make any sense at all.
He says anyone who wants insurance under his plan will be able to get it.
He says the only reason he doesn't have a mandate (for adults without children) is because he doesn't want people to be forced to buy insurance they can't afford.
In order to make his two statements work together, you must assume that people who can't afford insurance under his plan also don't want it. Because if everyone can afford insurance under his plan, then his whole reason for not having a mandate goes away.
What he is really offering is for people who can afford insurance, to not buy it if they don't want to. This really means that young healthy people who don't think they will need insurance won't buy it. Thereby making the pool of insured people smaller and forcing the cost of insurance up for everyone else.
I live in Massachusetts and I know folks that are simply too inept to sort through the paperwork of setting up their health insurance. This is an underreported factor in the state's 20% uninsured rate. What happens to such people? Fines. Yes, fines. I can see the rationale in mandatory catastrophic coverage. Aside from this, I think it is safe to say that Clinton's health care plan would be about as popular as her own candidacy.
This is just an unbelievably stupid argument. Clinton has mandates. Obama has mandates for children and can't articulate why it's okay in one case but not in the other.
Then we have the fact that both candidates are recipients of considerable and essentially equal largesse from the health insurance industry. Why? Because both plans mean more income and more profit for these leaches. It isn't just that we spend 24 cents of every healthcare dollar on administration and profits. To maximize their profits they control how much healthcare we get, or even whether we get it. Most of that 24 cents saving could extend coverage to the 47 million uninsured, provide preventive care, dental care and more, including an overall reduction in costs.
ALL agruments about healthcare that are not based on a single-payer system are a diversion, a waste of time. It's Medicare for all. It doen't matter whether you call it a premium or a tax, it's still something you pay for healthcare.
Those arguing against a single-payer system, mandantory and paid for by taxes, can make the very same argument for privatizing Social Security. Those who want to give all of that money and control to the companies are either confused on the subject or happy that corporations rip us off and control us.
Je pense, donc je suis populiste.
Both plans guarantee hundreds of billions in profits for insurance companies, that is hundreds of billions that won't be going to curing or healing patients! (A portion of it would, presumably, make it into campaign coffers.) By leaving these companies in charge, we will continue to have C EO's and boot licking middle managers denying medically necessary procedures to real people, the bottom line being their main concern.
You have one of the best non de blogs ever.
Je pense, donc je suis populiste.
There's no point in blathering on about which system will work best as long as insurance companies are involved. They will figure out immediately how to reduce their risk by excluding applicants or hiking premiums at every opportunity. The Medicare Part D plan is an example. Many companies offer plans at various prices. They have to accept any Medicare recipient. But as soon as they get a fix on how much the claims are costing, they hike the premiums to cover their payout, and, I suppose, their profit needs. I have a plan whose premium tripled in year two, as the vendor realized what it was costing. I imagine this plan's premium will maybe double next year.
The only viable national universal health-care scheme is a single-payer plan that automatically covers every citizen from birth to death and that doesn't have to provide billions of dollars in profits for stockholders and CEOs.
I cannot believe why a single payer government plan is such anathema to so many people. It seems to make a hell of a lot more economic sense to have a single non-profit plan that provides basic coverage to all citizens from cradle to grave. It seems to work fine in every other country that has such a plan. Statistics show those countries' citizens are healthier than are we and their corporations aren't going broke trying to pay for for-profit health insurance for their workers. Many factory jobs in the U.S. have gone to countries such as Canada for just that reason. The health insurance companies and the for-profit hospitals are spending millions lobbying the Congress to screw more money out of sick people. When will a truly honest politician in the Congress join with Dennis Kucinich in calling for a truly universal health care system? It would save so much money and go a long way to stopping the job drain.
Okay, both plans sucked but then you knew that already and did not voice your opinionns and let
the good candidates go? Now who is to blame, look in the mirror.
This is the article I've been waiting for! I've been railing on these points, especially the reinsurance issue, for weeks. The distortions and falsehoods that people believe about Hillary's healthcare plan are astounding. Fed and nurtured by Hillary. There are people out there who think her plan is going to be free, for God's sake!
Obama should have pushed the reinsurance issue better. He didn't do a decent enough job of selling his program. And no matter what, either program would get torn apart and rebuilt in COngress anyway. And who in the hell is Hillary going to get to work with her? She's incapable of building coalitions and working majorities.
I hope the good people of Texas, Ohio, Rhode Island and Vermont read this post today. There's still time to get us the more effective president.
The only reason Hillary Clinton and Barack Obama have talked about healthcare at all was to get John Edwards to shut up. Since they have been largely successful, it seems almost quaint to still be arguing about mandates. I'm convinced that universal healthcare will remain something we can hope for in the afterlife.
But hope reigns eternal, so I will contribute to this futal, medieval discussion by pointing out that contractual agreements between a government and its citizens are not really a bad thing. When a populace is required to hold health insurance, it pays for the right to demand fairness, competence, affordability, and a shared burden. Without a mandate, health insurance remains a priviledge to be bought into. This actually places MORE of a burden on the insured than the insurer, since a priviledge is more easily denied than a right is. It is also more difficult to demand quality or affordability, since you can always choose to opt out. If everyone is required to have it, then the burden is placed on the government to make sure everyone can afford it and that the quality is adequate.
I live in Germany, which has provided excellent healthcare under a flawed but universal health-insurance system since the 19th century. People here place the emphasis of the mandate on the government. They believe a civilized state carries the responsibility to provide quality healthcare to ALL of its citizens.
A few years ago, when I was diagnosed with a very rare form of cancer, I received expedient, competent treatment that saved my life, without demanding that I justify it first. I have read about Americans with the same type of cancer who have been denied treatment. I love the US, and having a pre-existing condition makes it unlikely that I will be able to return. But I am thankful every day that I got sick in Germany. I'm not at all sure I would be here to tell about it if I hadn't.
The most successful propaganda America's political parties have gotten people to buy into is the twisted argument that any burden placed on the government is really a burden on the populace. It is how they get us to let them tax us without demanding they provide anything in return. But shouldn't healthcare for everyone fall somewhere under the rubric of life, liberty and the pursuit of happiness?
Disingenuous. Healthcare has been a major issue for democrats for years. Every democrat was going to address it in this election.
This country will not pass single payer health care yet. Even John Edwards understood that. It's a political reality. These plans (and I prefer Obama's, for the reasons in this article) will at least push us in that direction.
Oh, they've been talking about it for years all right. And they'll continue to talk about it for years to come. And they'll keep coming up with bad plans that can't work to make you think they're doing something. So who is really disingenuos? At least my argument is based on experience.
I had a similar experience in Germany. I had an obstetrical emergency that could easily have cost both my life and my son's. I was hospitalized for nearly a month, and since I was unable to care for him during that period, my son remained in the hospital nursery until I was released. Before moving to Germany, I was a graduate student, covered by a student health policy that excluded all costs attributable to pregnancy. Had the emergency occurred while I was still in the States, my husband and I would have been financially ruined. In Germany, I was admitted immediately (no questions about my health insurance) and was in surgery within minutes of arriving at the hospital. We never received a bill.
Opponents of governmental universal health insurance call this "socialized medicine" and tell appalling lies about how it works and the quality of the care provided. Witness Guiliani's false claims about the favorable outcomes of treatment for prostate cancer in the U.S. as compared to the U.K. Any moderately informed person knew as the words came out of his mouth that they were a lie. Ask any Canadian whether they prefer their health system to ours. Ask any German, Frenchman, Brit. Ask any American manufacturer (if you can find one) how the burden of providing health coverage to workers affects our ability to compete in the world market.
But political realities are what they are. The only way we are ever going to get universal single-payer health coverage in this country is through a system that allows people to opt out of the current system in favor of a governmental policy that encourages them to do so by means of lower costs. When enough people have opted out, the insurance companies will be defanged and maybe we can join the rest of the civilized world in providing universal care.
I have no problem with choosing private insurance or choosing to opt out in favor of government-funded insurance, as long as everyone is insured. That is an option in most countries. What I disagree with is the notion that universal healthcare without a mandate is not a contradiction in terms.
What is the motive for not requiring that people have health insurance? If it is mandated, the government will have to do something to make sure everyone has affordable access to it. They twist the argument to make it sound like the burden would on the citizen, when really a missing mandate absolves the government of a responsibility I think it should have.
Good piece.
Hillary's plan is a godsend to the insurance industry mafia -- it guarantees them sole ownership of the gatekeeper position as far as access to healthcare is concerned. Everyone has to go thru them to get to hospitals, doctors, etc. -- and if you don't care to play their game, guess what? You have to anyway, 'cause it's mandatory!! And Hillary will take it out of your paycheck, if you're going to act stubborn about it>
Geeeesch! Why are all the Clintonistas bragging about this piece of shit plan? It's a cave-in to Big Business, that's all.
No third term for Bill! No third term for McBush! Vote Obama!!
Because Hillary says things like this statement from Ohio last week: "Obama doesn't want you to have healthcare. He only wants children to have healthcare." With those sorts of Rovian distortions to an electorate that isn't paying tons of attention, the lies work.
She really is Bush in a pantsuit. She'll be a disaster as a general candidate and as a president. She's built a house of cards and will not have an ideologically obsessed party to insulate her and protect her, like Bush did.
We will probably get some kind of healthcare plan passed if she becomes president. But it will be a windfall for insurance companies. She has built her house of cards on the backs of lobbyists and industry hacks. We'll get what we deserve if the good people of Texas, Ohio, Rhode Island and Vermont fall for this shill.
This good Texan already voted for Barack, and my wife and I will be caucusing for him tonight, too.
I'm really not all anti-Hillary - I just think Barack is much better. But if Hillary beats him for the nomination, I'll vote for her over McCain (of couse, voting for a Dem in the general in Texas is like shooting a tank with a squirt gun).
I've read Hillary's plan on her website, and I can't seem to find that famous "mandate" in it. On one occasion, she mentioned garnishment of wages to pay for her mandated insurance - the mere mention of which, of course, would doom her candidacy in November. But "mandate" language isn't written in her plan.
I think the mandate part of her plan is more campaign rhetoric than anything. I think she had no intention of pushing that in the first place - in fact, she even mentioned during one of the debates that "the mandate is what you start negotiating with", implying that it's a negotiating ploy at most. In short, Hillary has no idea that she can, or will even attempt to, mandate insurance. Which brings us to a curious point - her mandated health care plan is the only real policy distinction between herself and Barack, and she's made mention of "her health care plan covering everyone while Barack's leaves 15 million people uninsured". If her mandate is not a serious, integral part of her plan, then her campaign rhetoric is a simple campaign lie.
Hillary intends to use the lie that she'll insure "everyone" to get the nomination, then drop the mandate part of her plan for the general election, leaving her with, basically, Barack's plan. By that time, of course, the Democratic voters will have already cast their votes and, if the "insurance for everyone" campaign promise was integral in their decision, they'll be victims of the old bait-and-switch.
Individuals: will be required to get and keep insurance in a system where insurance is affordable and accessible.
This is cut and pasted from her healthcare plan from the website. That's a mandate.
But how are they required to do it? What happens if they don't? That's the point - a mandate isn't a mandate unless there's an "or else" portion. Othewise, it's just rhetoric.
It seems to me that the person missing the point is Mr Elhauge. Why choose either option. There are other workable systems, that don't involve insurance companies at all.
In the UK, they have the NHS, which I believe is totally free. It is funded by general taxation.
In my own country Australia, we have medicare which provides free basic health care for all citizens and is funded by taxation also. If you want to upgrade from a public hospital to private one then you need private insurance but most public hospitals are fine. We pay a 1 1/2 percent tax levy specifically for this purpose.
We also have a Govt. program called Pharmaceutical Benefit Scheme which oversees the pricing of drugs to ensure that manufacturers can't charge whatever they like.
Everything is more or less affordable and no one went broke because they became sick. Don't listen to lawyers like Mr Elhauge talking about different plans. Demand govt responsibility for providing decent affordable healthcare for ALL. It is possible and many countries do it well. Just not yours....yet.
Then again, political feasibility
You are absolutely right that this is a better system though. From the Trumanplans to the Carter vs. Kennedyplans to the Bill Clintonplan: radical reforms have just proven to be not politically feasible because they can be presented as anything the opposition wants to suggest it is. I'd rather have incremental changes that have a real chance of changing the reality of the medical system than great, revolutionary plans - because they will not get through congress. This is why Clintons plan, especially her mandates, will not become reality if she gets the presidency. She won't draw a significant number of coattails in Congress and if she wins the election she will never have acquired enough political clout to realize these plans. Sad but true
less --
You don't get it.
The assholes running things in DC could give a rat's ass about the healthcare of ordinary Americans, much less our lives, otherwise, the problem would have been addressed decades ago, like other countries have done.
Anything seen as taking away corportate profits is automatically labled as being "communist!" and is therefore, out of the question. The facts don't matter. Money does. And that's the bottom line.
Corporate welfare -- good. Individual welfare -- bad. End of story.
Einer Elhauge,
From what Michael Moore is saying, it seems that both Obama and Hillary are just selling insurance policies for the big insurance companies. They aren’t changing much except for forcing everyone to buy insurance. Below is an excerpt from Moore’s website:
Nurses and consumer advocates agree. The government should be protecting us from insurance companies, not forcing us to buy their products. Especially while insurance companies can still charge as much as they want and still deny you care when you are sick.
So why are politicians still calling for mandates? Forcing people to buy health insurance isn't universal healthcare. It just means more profits for the big insurers.
http://www.guaranteedhealthcare.org/
Mrs Clinton"s position on health-care, is not a working blueprint as she"d have you, the media, and her supporters to believe. Every last detail of her plan is not nailed down. Her health-care plan is just a set of bullet points, and no more detailed than Mr Obama"s outlined proposal. Besides, she has not even said how her "individual health insurance mandate " will be enforced. The individual health insurance mandate is the crucial difference between her"s and Obama"s. She has not explained how she is going to enforce it, because she can"t. And the chances of her being able to enforce anything as President, and getting anything passed by Congress, are shrinking by the day. Surprised?
The first thing that will be jettisoned will be the mandates because republicans won't stand for it. End of discussion. This total nonsense about the fine details of all the policies is nuts. Everything will get torn apart and parsed and bought and sold before it becomes legislation.
The issue is, who is effective at persuading the American people to support that legislation and get it passed? Can you honestly imagine Hillary being able to convince Republicans and Independents to support policies in their best interests? When she treats everyone who doesn't agree with her like they're stupid, shakes her finger and scolds. She has never, in her 35 years of "experience" shown any gifts for that kind of motivation. And her hatchet-in-hand vanquishing stance against Republicans -- oh, come on. She was never able to stop them before. Only when she caves to them do they work together. That's her true "experience".
Only Obama can motivate that effectively.
His Blueprint for Change is the most progressive platform we've seen in decades. Do you people forget how un-progressive the Clintons really are?
I'm ashamed that the Rovian tricks seem to have worked so well for HIllary. Rewarding that disgusts me.
Mandates are analogous to the notion of 'privatizing Social Security' by turning that system over to Wall Street. Mandates guarantee additional revenue to Big Insurance. That's why they're part of the plan, and, NO, they are not going away that easily.
You're right on the money, as usual. I couldn't agree more.
I can't speak for the rest of the nation but the number of uninsured people in California is sufficient that it is quite literally bankrupting hospitals whose ER facilities serve as primary care facilities for those lacking coverage. In California, we have voluntary coverage available to anyone who doesn't have health insurance andcannot afford it. It is under used and in no way mitigates the problems facing all public hospitals and many private ones. I suspect other states face comparable circumstances.
Elhauge makes one valid point: Neither Clinton nor Obama plans offer a real solution to the healthcare problem although either would be a start to fixing an abysmal situation. What this country needs and what it will eventually establish is a single payer system with the government acting as the payer. Such a plan could roll together Medicare, state Medicaid programs, and VA systems into a national plan that covers everyone. I oppose any system that fails to cover everyone: No insurance carries, no exceptions, no alternatives, no self insurance, no optional coverages, nada. Coverage should be paid for with taxes and the amount of money businesses save by not paying for this benefit should be passed on to workers not kept by owners. Government should set fees for all products and services including physicians, hospitals, tests, therapies, and drugs. I'm not holding my breath for such a system since it probably won't happen in my life time but it will happen since it is the only system that really makes a lick of sense.
I loved the common sense solution in Elhauge's article: mandate emergency health care insurance. That makes total sense. I wish I'd thought of this before.
Mandate or no mandate, healthcare costs will contiune to rise, making nonsense of this entire argument. Healthcare is already charging as much as the market can bear. The healthcare crisis is not a crisis of coverage, it is a crisis of cost. The 47 million are not gaming the system, they can't f*ing afford it.
Nudging around on the edges of a solution will produce single digits of cost reduction in a double digit inflating system. The notion that this system can survive even another decade is a complete fantasy. Either cost are reduced and increases come on par with American paychecks and small company bottom lines, or it will have comitted suicide in the name of profits and for the sake of capitalist ideology.
I ask healthcare professionals, from orderlies to CEOs, whether they think a revolution should happen now, when there is a chance that private medicine can survive, or later when that opportunity has evaporated from the minds of every soul on Earth.
'Mandate or no mandate', costs are extremely high & going higher. Eliminating the insurance companies would be impossible, probably. Corporatism, Big This & Big That rule the day. What can be done is to insist on progressive rates, as with income taxes, so that those who are more able to pay for health care, pay more than those who can't afford it. With the current cost situation, there is just NO WAY that the non-wealthy can pay as much as the wealthy and still have universal coverage.
But, once the Repo Man is again in office, all this talk about Universal Coverage is going back into the dustbin of history from whence it came. 'Life is beautiful', or beautiful enough anyway.
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Posted March 3, 2008 | 06:54 PM (EST)