Health-Care "Demogoguery"?

The intensity of liberal debate around health care reform shows how agitated policy addicts can get when their preferred approaches are challenged. The word "demagogue" is being thrown around a lot by normally mild-mannered people, over differences that are more technical and tactical than ideological. It's wonk-on-wonk mayhem -- the Brookings Institution meets the WWF! I tell ya, it's getting wild out there.

Demagogue (noun) - One who makes impassioned emotional appeals to the voting public; specifically, in opposition to a policy position you personally support.

"Mandates" are the provision in insurance-based health reform proposals that require people to purchase health insurance. They were a key part of the Massachusetts reform law and are central to the Clinton health proposal. Obama's reform plan does not include a mandate provision, at least initially, although he indicated during the early debates that he would consider adding one later if voluntary programs don't succeed in getting near-universal coverage.

Clinton has been hammering Obama over this issue for months, saying that her plan guarantees "universal coverage" and his doesn't. Here's the simple fact: Mandates do not create universal coverage. When the pundits were celebrating the "Massachusetts miracle" -- including many of the same "health wonks" now touting the Clinton plan -- I was one of the few to point out that the plan was actually more mirage than miracle. It kicked the unpleasant decisions down the road so that Mitt Romney and his Democratic and labor collaborators could take an undeserved victory lap at the signing ceremony.

Sure enough, the legal authority responsible for the Massachusetts plan eventually acknowledged that the plan will leave 20% of that state's uninsured without coverage, and the real number may be higher. Why? Because there is a wide band of people who would suffer financial hardship if compelled to pay the premiums, and it's financially infeasible to subsidize them all.

The Clinton plan, should it ever be passed, will suffer the same fate. I will happily bet Paul Krugman on that point. He should know better than to claim that the Clinton plan could provide universal coverage. Experience and political common sense say that just ain't so.

That's not to say there aren't valid arguments in favor of mandates. There are, which is why they're part of conventional health policy wisdom. Mandates solve the "selection problem," where insurance costs become too high because only sicker people buy insurance voluntarily. They also allow funds that are now used to reimburse providers for treating the uninsured to be used in better ways. And I think the Obama team is over-optimistic about voluntary compliance levels.

Krugman and other supporters of the Clinton plan are now pointing to a study by the respected Urban Institute as a validation of their position. It's a good study that shows mandates are the only way to achieve something like "universal coverage" -- if you first exclude single-payer coverage from the mix. (They also exclude my preferred approach -- core basic coverage paid from tax revenues, with the ability to "buy up" into private plans through a subsidy/voucher approach.)

Here's one problem: The paper's authors admit, albeit indirectly, that they overestimated the ability of Massachusetts to achieve universal coverage. They make the same mistake here. Here's another: Sen. Clinton and the supporters of her plan have been evasive about how they would enforce this mandate, and enforcement is key to the Urban Institute's findings. In a recent interview she was forced to acknowledge, for example, that she would consider garnishing wages. And while she has boasted about tying mandate obligations to personal income, she has been equally vague about what level of personal income she might allocate for healthcare.

Those provisions are political non-starters. Massachusetts is easy compared to the country as a whole -- both in terms of political climate and the scope of the uninsured problem. Yet they had to leave 20% of the uninsured without coverage. That figure would equate to about 8 million people nationwide. If we accept Sen. Clinton's figure of "15 million uninsured" under the Obama plan (and that figure was chosen by a journalist, not a technical study), that means a difference of seven million -- in return for a plan that might actually get passed in Congress. (The gap could be filled in later, after premiums are brought under control and it becomes more politically feasible.)

And look at what mandates might do to a family of four. While Clinton won't tell us the percentage of income she'd tie to mandates, many analysts have been using 10%. If premium assistance is provided up to 300% of the poverty level, a family of four trying to survive on $75,000 could be forced to pay $7,500 to insurance companies or in health copayments. The alternative could be tax penalties or garnished wages. That's profoundly unfair. I also believe it's a serious misread of American political culture to think that kind of mandate could ever get through the legislative process.

Krugman and Ezra Klein are both strong advocates for the mandate position, and they were both outraged by an Obama ad that seemed to channel "Harry and Louise" from the 1994 anti-reform campaign. (Hey, what happened to the argument that this primary season's great way to "toughen up candidates for the general campaign"?)

Krugman, who has been arguing that Obama's position is "less progressive" (which as I explain here isn't true), goes positively reactionary in his response: Mandates are to "prevent some people from gaming the system," he writes, as if that family of four could just write out that $7,500 check if they weren't so dishonest. That check would be a financial hardship, and I think Obama's right to point that out -- although to Krugman that's "unscrupulous demagoguery."

The "gaming the system" language, like John Edwards' "shared responsibility" phrase, is a right-wing frame that demonizes people who make tough choices with their personal budgets every day. We already have a mechanism for "shared responsibility" and it's called taxation. Adding 10% to struggling families' financial burdens is nothing more than a highly regressive tax to be paid to wealthy insurance companies, which is why insurance companies prefer the Clinton plan.

Ezra Klein's a reasoned and articulate advocate for mandates, and we've disagreed on this topic in a courteous way for months. But he was furious at those ads, too. Yet neither Klein nor Krugman voiced outrage over Clinton's many boasts that her plan will achieve "universal coverage" - although they must know Clinton keeps dodging the tough questions, and that even Massachusetts couldn't get to "universal." Those "universal coverage" taunts have sounded as demagogic to me as Obama's ads do for Klein and Krugman. That leads me to what might be the only statement we can all agree on during this campaign:

Demagoguery is in the eye of the beholder.

______________

UPDATE - Speaking of demagoguery, several commenters have excerpted the following from my bio: "He also held senior-level positions at several major insurance carriers." True, and I've deliberately revealed that in the spirit of full disclosure, although I haven't done any work for health insurers in some time. (FYI, the work I have done is technical in nature.)

My political writing has reduced my income significantly, particularly since I often take positions contrary to the insurance industry's interests. This piece is a good example: Clinton-style mandates will be a windfall for health insurers, yet I oppose them.

It's funny: As a technical expert with past experience in this industry, I'm not to be trusted. Yet politicians who are raking in fat contributions from them now are above criticism. Hmm.

And here's a little more food for thought:

http://en.wikipedia.org/wiki/Ad_hominem

I guess this issue has become a proxy for Clinton/Obama hostility, and is therefore emotionally overheated. Too bad - it's an important topic that could and should be discussed collegially. There are valid arguments on both sides.

Peace and love, RJ

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Comments

[AmeriGus]

Krugman's article has taken vague proposals and done what appears like scientific number crunching. Unconscionable bias like this makes Krugman rival Bill Kristol as poster boy for the Times' bad judgment.

Both "plans" can only be seen as faint outlines for what the candidates would try to get pushed through Congress.

If HillaryCare is mandated, will she garnish wages? What agency will enforce this? Krugman doesn't consider these questions. Obama's vision to reduce costs is not factored back in to Krugman's comparison either.

Both primary-season plans are meant to be vague. Krugman assumes far too much, hoping undecided voters will swallow his "calculations".

People need to read between the lines. Primary-speak is deliberately open for interpretation, meant for voters to see their own ideals reflected somewhere in poetically phrased vagaries.

Hillary stresses that 'everyone should be covered' while Obama emphasizes that costs will be reduced, for example using government re-insurance policies for employers to keep premiums low and investigating other ways to bring costs down.

To me it sounds like Obama is hinting at cutting middleman profits - the most obvious solution for our nation's healthcare problem. He can't say such now because big health will pull their money and instead swiftboat him. The industry has given Obama $2 million hoping for a "place at the table". Hillary has already promised this to them for the $2.5+ million they've given her.

So the vagueness isn't just to hornswoggle voters, it's to keep the barbarians at the gate. Big health is making so much off this health system, they'll do anything that will prevent their ox from being gored.

I worked at a printshop in the early 90s and had an insider-only healthcare industry newsletter come across my desk every month. Their primary focus was banding together to fill their "war chest" so they could lobby for favorable legislation and target specific Congressional races to fund supporters of middleman profiteering.

The worst irony was in one ad I saw regularly offered low-cost policies to industry insiders only which included "catastrophic coverage" to dramatically reduce premiums.

[LeeFromVA]

Hillary's health care plan is flawed. She had the best of intentions but she didn't think it through. You can spin it anyway you like, but forcing people to buy health insurance is just a bad idea. We live in a free country and we should have the right, the freedom, to chose for ourselves. There are people who don't want anything to do with doctors or hospitals. Should they also be forced? It's an unAmerican approach. Obama's plan makes better sense, make it as affordable as possible and ultimately let them decide. Personally I like the Single Payer approach, but short of that Obama's is a better proposal.

[SamanthaJaneSalem]

3 Reasons Hillary’s Health Care Plan Won’t Work:

1. It won’t pass.

Congressional Republicans won’t want to go back to their states and districts and say they voted for “Hillarycare,” and vulnerable Democrats in more conservative areas also won’t want to support a plan which forces everyone to buy insurance, maybe costing them their seats.

2. Hillary is a poor communicator.

Suppose it is a good plan. But Hillary was slow to offer it (though she has cared about this issue all her life) and quick to dismiss any other plans. She will anger and alienate health care experts, members of Congress, and regular voters, by not being open to alternative ideas. Without her husband’s communication skills, even good ideas will far short because she won’t be able to “sell” them to the American public.

In an interview with George Stephanopolous, Hillary said: “And the reason why I think there are a number of mechanisms, going after people's wages, automatic enrollment, when you are at the place of employment, you will be automatically enrolled, whatever the mechanism is not as important as, number one, the fundamental commitment to universal health care . . .”

But the phrase Republicans can use against her is: “going after people’s wages.” Sounds spooky.

3. It would be a huge increase in the bureaucracy.

The main reason health care in America is so expensive is the amount of paperwork involved– all the administrators at many levels moving files around. If you have mandates requiring every adult to purchase health care, you’ll have to enforce that, and that takes massive agencies and long lines like at the DMV. This puts more burden on the taxpayer and negates some of the positive effects of lower premiums from mandated universal coverage.

[TXfemmom]

I knew that the taxes and fees assessed the Canadians and their employers was low, but last night on CNN, David Gergen mentioned that the auto companies were moving production to Canada because the average health care premium for their employees in the United States is $6,500, whereas the employer pays around $800 a year in taxes to cover their Canadian employees. Think about that. The employee has to pay a matching amount, and some very wealthy do purchase a policy which supplements their basic care, but every employer and every employee must pay that. No one can get around it.

That puts everyone on a level playing field.

Meds are not automatically covered under this plan, but they are on sliding scales, based on income, and the low income do not have to pay for theirs. Besides, they pay up to 60% less for namebrand drugs, than do the people in the United States. THINK ABOUT THAT.

Then add that they do not have to pay costs in automobile, worker's comp, and other insurances for health care portions because each individual IS COVERED. Think of the savings.

We are reaching the point where we are going to become, if not already there, a third world country because we permit the health insurance companies and the drug companies and the medical facilities and others force these horrendous costs upon us. The French system requires that each employer, employee, self-employed, etc. pay and not much more in taxes, than do the Canadians, but they pay half what we do for technology, and once again, far less than fifty percent for their meds.

[MPeter]

Here is a brilliant presentation, point by point as to why Hillary is wrong for the country and this particular period of time.
http://www.youtube.com/watch?v=EdDzvmY1XPo

[WorkingClass]

TXfemmom: Thanks for this info. Very helpful. Neither Hillary nor Obama is going in the right direction. They are owned by the very people who's interests lie in perpetuating our problem. I would suggest that this "election" cannot possibly reform health care for "we the people". We don't even have a dog in the fight.

[MyThought]

You are so wrong, very wrong. Because the US have never had it they can't imagine it can happen.

Other countries have it - it works. Yes, there are problems in other countries, mostly because of a shortage of doctors and nurses.

Yes it can happen, it does and it works.

You've been brainwashed into thinking otherwise all of your life.

[ystasino]

No other country has the monstrosity Hillary is and Edwards was proposing. No other country penalizes the poor for not being financially able to buy healthcare.

No other country has started from this debacle of healthcare.

Now if Obama had the votes in the Senate I truly believe he would go for single payer. There is an outside chance we might get more than 60 senators and 60% democratic house.

While Obama's priority will be to execute the modest but realistic plan he has put forth there is a distant chance we can get single payer. Deal with the realities but aim high.

Hillary's and Edward's plans only serve northeastern narcissistic armchair liberals who want mandates for the sake of mandates.

Obama is more liberal than either but is more reformist, pragmatic and result-driven.

[RobertH]

There will be no such thing as universal health insurance until the health insurance companies are out of the equation. Money spent on health care should go to care itself and the necessary administrative costs. Let the non-essential industries worry about profits. The free market may be giving us better Buicks, but it certainly isn't giving us care for everyone.

[Norm]

As a Massachusetts resident, I cannot fathom why Obama has been so weak in attacking Hillary's mandate plan. Forget Harry and Louise. All Obama needs to do is haul a few MA residents who are getting mauled by the current state system to the large states, like Texas, and use them in ads. Massachusetts
forces people to buy insurance that does not cover them or be fined. The weak link is co-pays and deductibles which make it impossible for the newly insured to go to a doctor's office. It punishes middle and low-income residents who want insurance, but can not afford the insurance choices provided. By law, they must pay a premium for insurance they can not afford to use.

There are folks, like me, who can not work over 29 hours or be forced into their employer's plan in lieu of the state plan. In a sense, many Mass. residents must game the system this way in order to be insured. Would this not happen under Hillary's plan? While no plan is perfect, I trust Obama to make a better effort toward getting ultimate universal coverage than Hillary. Take a big chunk of change from my check and I don't eat. Simple as that.

[SethBLiNK]

As a fan both of Barack Obama and his health care plan I am frustrated at his willingness to conduct this argument on Hillary's terms.

He continues to use the word mandate instead of putting a Republican style spin on it. What Hillary's plan would do is take insurance you already don't have and then penalize you for not buying it. It would be one thing if it mandated that your state or your employer cover you, but mandating that we each cover ourselves, while it might be a nice idea, I don't see where the voter appeal is.

Plus, isn't car insurance mandated? Aren't there millions of people still driving around without car insurance. With car insurance, at least there is a privalege (driving a car) that can be revoked for violators. What are you going to revoke from somebody who doesn't purchase health insurance... their health? No, you're going to place a financial penalty on somebody who didn't buy health insurance because it was already too expensive. Brilliant!

Barack's gotta stop using Hillary's word (mandate) which just validates it and start breaking it down so regular people know just what the two are arguing about.

[mtbrain1]

Damn you are so right. He dooa not explain it too well to expose her for what it is and pressure her again. Flip it to show the american people she is putting their choice in the hand of insurance companies and the government to to right by you.

[realitytrumpsbull]

Sign right here, and we'll fix that right up for ya...careful, don't bleed on the loan papers, or we won't be able to process em.
SHOULD you get 'bled' at the front door to the hospital? Hmmm....sa­y...that's a pretty nice Bentley you got there, 'doctor'...doctor of WHAT, exactly...how's those Pfizer shares?

LOL
WHAT a racket...

[PigLipstick]

Dennis Kucinich was the only candidate pitching a true single payer system that doesn't include the insurance companies.

Dennis vanished from the scene a few weeks ago because a very well funded Democrat was challenging his Senate Seat in Ohio and he had to concentrate on saving his existing position. Intersting that a member from his own party with a lot of money would go after him when he was making head way toward a true single payer system.

If you think that the Insurance Mafia will ever embrace a government operated single payer healthcare plan, I've got a bridge I want to sell you. Both parties have now embraced their big money corporate handlers and the future of average Americans is very much in question. Their thugs are eliminating the few individuals who dare to speak in opposition. Sounds like a fascist state to me !

[Nutcase]

Dennis wanted to wait 15 years to implement a single-payer system. Read his position papers. Two years is sufficient.

cognito ergo populistae

[leftLibertarian]

The only thing I want to see Congress do is impeach the criminals Bush and Cheney.

All else takes back seat.

[Nutcase]

Let's see. You are against mandates. So, let's get rid of the ones we already have. Social Security? Car insurance? Taxes? Laws?

cognito ergo populistae

[LeeFromVA]

Poor people can't afford health insurance, so what's the answer? Just force them to buy it anyway, then we can say everybody has it. Yea! What a brilliant plan. Now all those nice health insurance companies won't have to struggle any more.

[Nutcase]

How about getting rid of all of the health insurance compnaies with a single-payer plan - Medicare-For-All? It would be funded the same way Medicare and Social Security are.

Have someone read to you. Your response mentions a 'brilliant plan.' How did you get that from one of my questions? How did you get support for insurance companies from that post by someone who wants to eliminate them? Those are mistakes my youngest grandchild, aged 5, would be embarrassed to make.

cognito ergo populistae

[pls413]

I am not interestes at all in Sen.Obama.He is a great speaker ans should have gone in the ministry not into political campaigns.

[research]

Obamas health plan has mandates:

"(4) mandate all children have health care coverage;"

http://www.barackobama.com/pdf/HealthPlanFull.pdf

[LeeFromVA]

...so, are you for or against them?

[research]

I'm against them, but more importantly I'm against people making false claims that obama's plan has no mandates.

[Yasmine]

THANK YOU RJ .........FINALLY someone who sees the truth of Hillary's plan (a copy of Mitt Romney's mandate).
But while Hillary has been able to fool most people and attack OBAMA's plan, unfortunately OBAMA has not been able to defend and attack hers with any clarity and forcefulness.
I hope that people realize that what is important is the INTENTION and DETERMINATION to give healthcare for all as a right.......
No plan will be perfect or able to pass as a Bill.
I believe that if the Repulicans care so much about the HMO and health insurance companies ..........they should accept that these companies run the HEALTHCARE .....but that UNCLE SAM pay the BILLs.
ALSO WHY DOES NOT ANYONE TELL US WHAT IS EXACTLY THE PREMIUMS THAT OUR REPRESENTATIVES PAY FOR THEIR HEALTH CARE.
I FIND THIS IDEA THAT WE THE PEOPLE SHOULD HAVE ACCESS TO THAT PLAN .......EXTREMELY LOGICAL AND BEST SO FAR.
.