An Open Letter to Paul Krugman
Dear Professor Krugman,
I think you are a terrific economist and a terrific writer. Over the years, I have made hundreds of students buy your microeconomics textbook.
We have some disagreements about health policy. You have been lambasting Senator Obama for months now because he fails to propose an individual mandate. I support Senator Obama, though I in no way represent the Obama campaign.
In your view, the Obama plan will fall far short of universal coverage. In fact, both the Obama and Clinton plans will leave some millions of Americans uncovered, though both plans will cover many of the 47 million people who are now uninsured. Both plans will also address many serious failures and human tragedies that arise within our current healthcare system, and would put us miles ahead of where we are now.
No one can say how close these plans will come to universal coverage, because the devil is in the political and administrative details--details likely to be set by a future Congress negotiating with the next president.
In this morning's column, you cite a new working paper by Jonathan Gruber which supports the mandate concept. Anything that Professor Gruber writes deserves to be taken very seriously. It is, however, important to clarify that he does not specifically examine either the Obama or (especially) the Clinton plan.
In his policy simulations, Professor Gruber writes: "In particular I assume that 95% of those who would not voluntarily choose to insure are forced to insure through the mandate." This is not the Clinton plan. It is not even a "Clinton-type plan," as you prefer to say. Almost by definition, a near-perfect mandate will increase the number of people covered under any proposed health plan. Whether this nation actually would support such stringent policies is another matter. Here you presume precisely what is most in doubt.
Today's Times notes that "Massachusetts, the only state with an insurance mandate, has thus far failed to enroll nearly half of its uninsured despite imposing a modest first-year tax penalty of $219." Massachusetts will probably do better this year, because the penalties have stiffened. As I understand it, individuals are liable for half the premiums even if they are uninsured. Massachusetts provides a remarkably favorable political, economic, and administrative environment to attempt such a mandate. This is the best-case scenario, and it is not easy.
As a volunteer for the Obama campaign, I have called many primary voters. They sometimes ask about the mandate issue. Whatever health policy researchers believe, my sense from these conversations is that even core Democratic party voters don't much like mandates.
Senator Clinton's own equivocation illustrates the political dilemma. In criticizing Senator Obama, she happily takes credit for high levels of coverage. Yet she is wary in describing how she would bring this about. Today's New York Times has a story entitled "In Health Debate, Clinton Remains Vague on Penalties." It is certainly unclear that her proposed health plan comes anywhere near the near-perfect takeup and enforcement presumed by Professor Gruber, or that legislators and voters would support such policies. If Senator Clinton is nominated, Republicans will press this argument hard come November and beyond.
You are on more solid ground regarding the limitations of subsidies in achieving universal coverage. Professor Gruber notes that an important group of people--some but not all of low-income--will resist buying subsidized coverage. In the last debate, Senator Obama noted strategies to deter free-riding. This certainly merits debate, and merits comparison with what Senator Clinton actually proposes rather than a 95% perfect hypothetical plan.
More generally, you assert that Senator Obama is a less progressive candidate than Hillary Clinton because he has stopped short of imposing the individual mandate. This is a very sweeping judgment based on one political and policy calculation.
Your assessment makes an odd fit with Mr. Obama's policy view on Iraq and many other things. It runs counter to the thinking of many progressive organizations and people who have endorsed Senator Obama: MoveOn.org, Teddy Kennedy, and others. It runs counter to most tabulations of his legislative record, which often identify him as more progressive than Senator Clinton. It ignores many, many years of conscious, sometimes-justified triangulation by both Clintons regarding many social concerns.
I am puzzled by the shrillness of your columns about Obama, and your rather exclusive focus on individual mandates as the litmus test for a progressive politician.
Let's suppose, for the sake of argument, that everything you say is right. President Obama gets himself elected. He successfully enacts health reform, but he leaves out an individual mandate. Indeed, let's suppose that we later discover that too many people fail to buy insurance coverage or try to free-ride. We would have to address these problems.
In the meanwhile, all we will have accomplished would be:
1. to bar insurers from denying coverage based on preexisting conditions;
2. to provide significant financial subsidies to millions of low-income people to help them buy coverage;
3. to prevent people from losing their homes because they are diagnosed with cancer;
4. to cover all children;
5. to make safety-net providers (and the local governments that run them) more financially secure because they no longer bear the burden of treating 47 million uninsured people.
I'd be pretty darned happy with this outcome--although I (like you) would ultimately prefer "Medicare for All" or some other version of a single-payer system.
Obama and Clinton supporters disagree on tactics and policy details. Politics and human nature being what they are, each side is angry because the other has thrown some fouls.
It's a tough campaign because there are two excellent candidates with similar policy views, and there can be only one winner. I suppose Obama people should not send mailings that attack mandates. I suppose Clinton people should not send mailings that say Obama will impose a $1 trillion tax increase on working families by raising the Social Security earnings cap. I suppose Bill Clinton should be quieter and stay out of trouble.
Hopefully this fight will burnish the eventual nominee and unite the Democratic Party. The fact is: We share the same values and ultimate goals. Whoever is nominated, we will need each other to win the general election and to enact Democratic proposals into law. So let's fight now, but let's tone things down a bit, too. We'll be on the same side a few months from now, or maybe sooner.
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Although I am a strong advocate for Obama, I think both the Hillary and Barack plans are just tweaking what we already have in place, an Insurance and Drug company controlled system.
Obama said if we were starting from scratch he would support a single payer plan, and Hillary jumped all over him for this impudent suggestion.
In essence Single Payer or Medicare for everyone not just senior citizens is basically what this country needs.
If we are ever to have decent health care for all Americans then we must follow a not for profit paradigm, which removes the Insurance Industry as the decision maker.
The doctor and the patient, not an Insurance agent, must decide what is best for a particular individual.
It is highly immoral to put life and death decisions into the hands of a profit-making corporation that is basically concerned with stockholders and dividends.
So many civilized nations have already come to the conclusion that they want to do what is best for its citizens rather then genuflect and succumb to the demands of for profit organizations.
Aside from the fact that we have already given Hillary and Bill 8 years to accomplish Universal Healthcare and they failed miserably, I think it is time to give Obama a chance to represent what the people want instead of what powerful corprate political donors demand.
What will the private insurance companies' cut be, anyway, under the plans of the two candidates?
What will be the penalties for insurance companies and doctors or hospitals that are found be be in collusion to increase profits? Death would seem appropriate, to me...they're profiteering on people's lives, after all.
And let me guess - it will still be the insurance companies who get to yea or nay procedures?
Sounds like it is time to buy stock in private insurance companies - especially if Clinton wins.
Wake up Obama people! You're buying hype but if you look at the details, he isn't what he purports to be. His plan leaves out 15 million, a number that will surely grow with time and yet you ignore it and attack the messenger. Paul is right. Obama is not a progressive and yes mandates is the lithmus test.
I would not be happy with the results Pollack finds so appealing. Basically it plugs 5 leaks in a lifeboat with 20 leaks.
We are being too pessimistic about what can be done - both economically and politically.
We don't have to fight republicans and insurance companies because we can let those who are insured continue with their present arrangements.
As for the uninsured they can pay a percentage of their income as stated on their tax return, each social security number insuring itself individually from cradle to grave, and receive a medicare type coverage. That will transform the medicaid system because even the poorest will be contributing to health care costs from the time they take their first job. The private insurance premiums can be reduced too because they will no longer be paying for uninsured as they are now (without people knowing it). Finally, the "mandate" will be automatically affordable and finance health care over time (like social security) since the young will be paying in while not using the plan as much. When it is their turn to use the plan there will be a larger population of young beneath them to finance the care. that is how premiums will be kept down. Do the figures.
I was sitting in an auto repair shop waiting room today and the person next to me was filling out insurance forms, detaching a check from Blue Cross Blue Shield from one form and endorsing it, then she went to a plastic multi-file folder holder she had with her and took out some more forms and began filling them out.
This person had the Republican plan, the "finest system of health care in the world" and a complete joke and waste of time the likes of which should be a laughing stock.
There are areas of corporate America that belong in the museum of natural history - like the health insurance industry. Lets let them die the natural death of parasites and let the survivors get real jobs at Microsoft or Apple doing something productive.
I saw Obama commercials in Iowa that said that he was the only candidate to have a "truly universal healthcare plan". I almost fell out of my chair.
Obviously Obama feels that universal healthcare is a winning issue even though he doesn't have the political courage to actually propose it.
I, for one, am grateful to Paul Krugman for being one of the few journalists to give Obama's plan the meaningful scrutiny it deserves, especially in the face of the Obama campaigns' intentional disinformation.
I wondered how long it would take Arianna to get someone to go after Krugman, lest one note of anti-Barackian sentiment or fact be left intact. Please, Harold and fellow Obamaniacs, stop cramming your candidate down our throats. More than half of us (Dems) do not want him as president, and nothing Ted Kennedy or Oprah can say will change that. Yesterday, Oprah magnanimously 'gave women permission' to vote for Obama, saying we don't have to feel like we HAVE TO vote for Hillary. Wow, what gall. Hope you all saw Hillary on Dave. She was fabulous.
What no one is discussing re the Health Care issue is the Alpha-and-Omega bedrock of American politics: Race, identity politics, socio-economic politics, entitlements, and the politics of fear (or to be more precise, paranoia). That is, that any "entitlement" health care system could be abused as a cash cow by "welfare queens" (code for "minorities") or unscrupulous doctors.
This perception (that health-care availability as a walk-in-right would be abused by 'freeloading' welfare cheats) is so prevalent - dominant - in our culture that we Americans now tolerate a system where insurers often kick people OUT of their insurance policies the moment they get an illness, simply ilustrates how strong the racial and class divides in America are.
The first and most important means to combat this shortcoming in such a critical social system that is so driven by FEAR (and corporate profits) is to assemble a top-notch team of mathematicians, statisticians, and medical experts to define and QUANTIFY medical procedures on a STANDARDIZED cost, complexity, and frequency basis. Using the statistics - what patients need what care, which patient care regimens cost the most, and thus detract from prevetative care for others - compiled from this study, the study could identify the most expensive bottlenecks in the system, and pour some government investments into, for example, computerized blood testing equipment that would make blood testing almost as simple and AFFORDABLE - and thus UNIVERSALLY AVAILABLE - as over-the-counter pregnancy testing. i.e., Harness the magic genie of technology to bring some frequent and repetitive costs down.
The government could also encourage ORGAN DONATION, by, for example, tax rebates for those who make their organs available.
And, as well, corporate America contributes to the health care crisis in other areas, for example, smoking and high sugar sodas and other food items that lead to obesity.
These issues aren't even being addressed in the "health care REFORM" debate... but they (and government subsidies for doctors willing to spend a few years in public health) should be the focus of any new health care plan.
The Solution to our nation's health crisis must improve the Supply side (How services are provided and at what costs) and cut out unnecessary costs, as well as the funding side (who will pay for what services). Secondly, in terms of a mandate, we must think in terms of Levels of Medical services, like triage, from Emergency/Gotta Have Now services to Elective ones, like a third facelift. There must be rewards for people who eat better and exercise, etc., and disincentives for smokers, non-emergency ER treatments and non-starters such as heart transplants for deathrow inmates and non-citizens/illegalls.
Jumping into bed with Hillary and Universal Health care would be like jumping from the kettle to the fire. We need honest, tough-minded discussions about Who will get What services, and more importantly, how to streamline our kluged delivery system and eleminate unnecessary layers of administrative costs and bureaucracy that contribute nothing to the healthcare, but that private companies and Medicare/Government have built up in a fools' errand attempt to prevent crooks from Gaming the system. This is a complicated problem, and like Iraq, we better Look before we Leap. A national, triaged system that fronts ER's with neighborhood workers/volunteers who pre-screen and provide nurse practitioners and referral/educational services would be a good place to start. Referring ALL suspect illegal activity to law enforcement for prosecution is needed as well.
When I hear Hillary's mantra for Universal Healthcare, I get a shiver: does she has any clue what the roll out of such a system would look like? Has she ever had to deal with exorbitant premium increases, denials/ lapses of coverage, longs waits in ER's where you get sicker before having a chance to get better, or , even worse, No medical attention for serious health problems or medically-induced bankruptcy. It may be academic for her and Klugman, but not for the millions of American citizens who face horrible medical dilemnas each day, and deserve much more than a desperate polititian's attempt to promise anything to win an election.
The real question: who is best positioned to actually pass a progressive agenda? If the debate were simply about, say, the best health care system, we would have just supported Kucinich. I am extremely concerned that a Clinton presidency, while perhaps rhetorically satisfying to the base of the party, will actualize nothing but watered-down compromises at best. We will all complain loudly at how her great initiatives were blocked by the dastardly Republicans, but in our quieter moments we will find ourselves imagining what could have been accomplished with real visionary leadership.
Parse it any way you want: the Obama plan is short on details, and Krugman got it right.
Dear Paul, Hillary has already promised that economics chief job to several others, so you can withdraw your comments, which were foolish, and safely vote for the next president, Mr. Obama.
In the second paragraph, Mr. Pollack states, "I support Senator Obama, though I in no way represent the Obama campaign."
In the eighth paragraph, Mr. Pollack states, "As a volunteer for the Obama campaign, I have called many primary voters."
He doesn't represent the Obama campaign, but he volunteers for them? A bit of a glaring contradiction here, no?
Another poster posed an excellent point, that we're probably only looking at half of what "mandate" actually means. Yes, there is the possibility that some might have to pay more out of pocket in terms of taxes or fees, but, in turn, the government is then contractually obligated to negotiate for the best prices, responsible for maintaining the integrity of health care services and the enforcement of tighter standards.
Mr. Krugman also makes an excellent point that, while Hillary's plan in its current state is unlikely to survive intact as negotiations move forward, the baseline she has set is much higher than Obama's, who will also be subject to the same negotiations. With a higher baseline, the more likely a better progressive policy will survive the process. With Obama, this would be less likely. That's just a political reality that Obama's supporters have yet to reconcile. In the end it all boils down to politics - Mr. Obama, on health care, looks very inexperienced indeed.
Don't hope for the best, vote for the best.
Hillary '08!
Universal healthcare will not work unless it is mandatory. To suggest that it be volunary is the equivalent of saying Social Security should be voluntary. The associated step would be to privatize it. The problem is that healthcare is already privatized. Those are hardly Democratic or progressive approaches.
Actually, what is needed is a single-payer system. It could be Medicare-For-All. The savings by going to a single-payer system through Medicare would be about 18-19 cents out of every dollar just by eliminating the costs and profits of the health insurance companies. If people wanted to purchase health insurance they could but Medicare would cover them otherwise.
It doesn't matter whether you call it taxes or premiums, it's still money out of your pocket. The savings would be more than sufficient to cover the costs of all of the uninsured. Getting to the physician's office sooner and preventive healthcare would futher reduce costs. Reduced costs would even help our manufacturers be a bit more competitive,
There are other problems in our healthcare system but the cost savings would provide us with a little breathing room to deal with them.
The plans of both Clinton and Obama provide more income and more profit to the drug and health insurance corporations. Those increases come out of the pockets of the people. Neither plan is really workable in the long term nor likely to be even in the short term. I will not trust either candidate until they return the donations from the drug and health insurance industries and really support a single-payer system.
cognito ergo populistae
Seriously, isn't this a lot of quibbling about what two candidates who still a full year away from possibly taking office would like to do?
We can split every hair, but the chances of either policy being passed and implemented as currently proposed are low, very very low.
Wisconsin and Oregon have gotten tired of waiting; my feeling is that the rest of the states should do the same. The fed can step in to make sure that a minimal level of coverage is provided and that our policies transfer easily if we move or if we get sick/have an accident in a different state.
Waiting for the federal government to do anything besides start a war is a lot like waiting for the second coming: it always seems like its just around the corner, but never quite gets here.
every election, the number one priority of nearly all candidates and media gets quickly achieved: i.e., to marginalize and destroy any candidate that disturbs the big insurance stranglehold on allocation of medical care- no exception this year. big insurance soaks up health care money and pays billions to it's executives in salaries. all candidates will assure this continues to be the case. mandating these companies be paid is actually to impose a tax that is paid to these companies- just like states compel people to buy auto insurance from private companies.
so the major developement isn't marginal improvement to health care delivery. it is, long term, the trend to government forcing people to pay private corporations for services. what the political industry- candidates and media- are really paid to do is make people reject what is good for them and embrace what is good for the rich. usually they are told other options are "socialist" or "unamerican"; and that closes the deal. this year is no exception.
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