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Tilting at Windmills

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November 30, 2007
By: Kevin Drum

THE EDWARDS MANDATE REVISITED....Writing from the land of tulips and universal healthcare, Ezra Klein says I'm giving short shrift to the political merits of individual mandate healthcare plans (i.e., the kind of plans currently on the table from John Edwards and Hillary Clinton). But I think he missed the point of my criticism (here) of Edwards' plan for enforcing enrollment in his version of IM.

As it happens, I really do think individual mandate plans are dumb on pure policy grounds. But I also realize that my preferred alternative is a political loser and that IM is (possibly) a political winner. So I'm for it. But that's exactly why Edwards' Diogenes-like effort to define his enforcement mechanism for IM in such mind-numbing detail is a bad idea: it practically forces voters to confront the fact that IM doesn't really make much sense. If you're really that dead serious about forcing everyone to get coverage, why the Rube Goldberg mechanism? Why not just tax everyone and sign 'em up for Medicare?

This is, frankly, something you want to keep a little blurry, not something you want to sharpen, and a smart politician understands this. Ezra is right when he says that IM "basically trades away certain amount of economic efficiency in order to evade the political implications of nationalizing health spending." That being the case, it's politically wise to keep things fuzzy at this point — especially since enforcement is a detail that has no chance of surviving the political process intact anyway, and accomplishes nothing except providing your opponents with an opening for demagogic attacks. Right?

UPDATE: Nicholas Beaudrot points out that all the healthcare plans on the table (including Edwards') provide various subsidies and tax credits for poor people, and that in any case, everyone has a political incentive to make sure that the middle class doesn't pay too much for healthcare. "Thus, in practice, the number of people who would actually see their wages garnished or get taken to collections would be relatively low."

Exactly. And I'm sure that Republicans all realize this and will therefore refrain from using it as an unprincipled way of panicking Harry and Louise about jackbooted IRS thugs raiding accounting departments across the country and demanding that H&L's wages be garnished. So I guess no harm has been done after all.

Kevin Drum 12:53 PM Permalink | Trackbacks | Comments (41)

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Comments

All of the Democratic candidates? Obama does not favor an individual mandate.

Posted by: Wagster on November 30, 2007 at 1:06 PM | PERMALINK

The problem with mandates is that you are taking away a person's choice. I don't care how it's done -- via the IRS, auto enrollment in MediCaid, whatever -- I just don't like the concept. At all.

Yes, it'd be lovely if everyone had health care. But forcing it upon everyone, including those who may not be able to afford even the cheapest of plans, just seems like a horrific idea.

Of course, that's just my opinion. If someone can give me a good argument as to why the government should strongarm folks into health care, I'm open for it.

Posted by: Mark D on November 30, 2007 at 1:11 PM | PERMALINK

Call me pedantic and ignorant, but I don't think "Diogenes-like" is an illuminating way to describe John Edwards' health care strategy. Does "Diogenes-like" just mean "trying really hard"? O maybe I'm misunderstanding what Diogenes was all about.

Posted by: Dr. Victor Davis Handjob on November 30, 2007 at 1:13 PM | PERMALINK

Krugman writes that Obama has adopted right-wing talking points, while praising Edwards and Clinton for covering everyone.

But why go the route of individual mandates, rather than universal coverage through one government plan? Isn't it in part so that the plan will be more attractive to the right-wing, precisely because it appears punitive? Doesn't Edwards in part also buy into right-wing talking points by suggesting that the problem is that many people can afford to go out and buy a health care plan but refuse to do so without a little aggressive prodding from the IRS?

If Ezra is right, Edwards is proposing an inefficient plan just to throw a sop to opponents of universal health insurance, and if Kevin is right, it not only won't work, it will backfire.

Posted by: Culture of Truth on November 30, 2007 at 1:14 PM | PERMALINK

Ezra Klein says:

How you enforce this on the tiny remnant who refuse to pay their premiums is a really weird place to focus...

I guess I'd like to know why it is fair to characterize those who don't pay their premiums as "a tiny remnant", or simply "refus[ing] to pay their premiums"?

Without quite explicit details here about who has to pay how much under what circumstances, how can Klein presume to say that only a few people will not pay their premiums, and that, when they don't, they are "refusing" to do so, rather than being unable to do so?

Look, the idea that people might be helped out by a tax credit sounds great, until, I think, you realize who really manages to get a tax credit, typically. Under virtually all formulas the federal government employs, getting a tax credit tends to be very difficult for standard middle class taxpayers. Problem is, when there's a huge and sudden hit in income, many people don't have the means to pay ANY additional expenses, and anything but a full tax credit induces only further suffering. Yet most middle class taxpayers will never be entitled to a full or even substantial tax credit because their remaining income for the year may still place them in a middle class bracket, if a lower one.

Now you can say that they should still be able to afford the premium, because, after all, they've still got a decent income over the year, but that ignores the realities of how people live and spend. In fact, they will have made commitments to mortgages, tuitions for their kids, etc. The money just is not to be had, even if the IRS says that you must have it.

Certainly Klein can't claim to know without the details here just how many people will have problems making these payments, or whether they are refusing out of perversity or because they genuinely are over-burdened by doing so.

Now the only real solution here is to guarantee that when you have a real income, money is taken out of it for health insurance, and when not, not. In either case, your insurance continues and your access to health care open.

That, though, starts very much to resemble Medicare for All.

Posted by: frankly0 on November 30, 2007 at 1:18 PM | PERMALINK

Wagster: Right you are. My commenters are too quick for me. I was already correcting this after re-reading the post, but your comment beat me to it.

Posted by: Kevin Drum on November 30, 2007 at 1:20 PM | PERMALINK

Dr. VDH: I meant that Edwards is trying too hard to present himself as 100% honest. He probably thinks that's admirable, but the reality in politics is that sometimes it's smarter to leave things fuzzy.

Posted by: Kevin Drum on November 30, 2007 at 1:22 PM | PERMALINK

Mark D

Right...

Pleeeze, pleeeze, don't force that awful, much-higher-quality-than-America's, much-cheaper-than-America's socialized health care on me. Like you, I'll accept these superior but un-American systems only when they pry my privatized economy from my cold (and poor) dead fingers.

Also, if I win $100B in the lottery, pleeze turn it over to the pharma, health insurance and health care companies, so I can do my part to ensure that their CEOs can take home more of those $1.7B retirement bonuses. Just to make sure, I'm adding that to my will if I get a chance before I die from un-inspected poison merchandise.

Posted by: klevenstein on November 30, 2007 at 1:26 PM | PERMALINK

OK, that makes sense. I appreciate the clarification, Kevin.

Posted by: Dr. Victor Davis Handjob on November 30, 2007 at 1:30 PM | PERMALINK

With auto insurance, you can't get a plan, present your annual proof, and then drop it, or fail to pay your bills, because the insurer then is required to notify the DMV. Would this plan work in similar way?

I doubt many people would try to game the system in this way, but using annually filed tax returns just seems unwieldy. Some people don't file, some file late, some even file early. What if you lose your health insurance not long after you file? Must you notify the IRS? Start searching for a new plan? Or just enroll in the mandated plan?

What constitutes insurance, anyway? Not all plans are the same. I assume there would be some minimum coverage which would qualify.

Posted by: Culture of Truth on November 30, 2007 at 1:43 PM | PERMALINK

It bugs me that the proponents of single-payer universal healthcare funding let the lying opponents of any meaningful reform keep referring to it as socialized medicine. We need to stand up to such nonsense.

Today, expanded Medicare for all is the best available option being proposed by anyone. Those who want to keep health insurance companies on the gravy train need to provide reasons to do so. Right now, they appear to be a waste of money.

Posted by: freelunch on November 30, 2007 at 1:46 PM | PERMALINK

Of course, that's just my opinion. If someone can give me a good argument as to why the government should strongarm folks into health care, I'm open for it.

Posted by: Mark D on November 30, 2007 at 1:11 PM

Or even where in the Constitution the federal government is given the power to have such a program. Remember that the federal government was intended to be a limited form of government that only has the power that is given to it in Article II. I don't see anything in there about giving the federal government the power to determine or interfer with my or any other American's medical care or health insurance choices or lack thereof.

Posted by: Chicounsel on November 30, 2007 at 1:50 PM | PERMALINK

Chicounsel,

I feel very sorry for you of course that, say, a program such as SS or Medicare would seem to violate your interpretation of the Constitution.

I strongly suggest that you emigrate to an Alternative Reality to get your Constitutional needs met.

Posted by: frankly0 on November 30, 2007 at 1:55 PM | PERMALINK

I'am sure that mandated health insurance will be the smash hit that auto insurance is. 4 (couples i.e. 8 drivers) out of 5 of my neighbors on this little street have been in accidents in the last 4 years....None of them were at fault (3 of them were 'collateral' damage from other cars wrecking at intersections) None of the other drivers, who caused the wrecks, had insurance.......

Posted by: landofid on November 30, 2007 at 2:03 PM | PERMALINK
Pleeeze, pleeeze, don't force that awful, much-higher-quality-than-America's, much-cheaper-than-America's socialized health care on me. Like you, I'll accept these superior but un-American systems only when they pry my privatized economy from my cold (and poor) dead fingers.

Oh sweet fucking god ... tell me where in the holy fuck I ever posted anything that would lead anyone to believe I'm against universal health care.

My point was that, without knowing exactly what plans are out there and their costs, the notion that the government should force its citizens to do something that those citizens may not be able to afford is a bad idea.

And since a tax credit in 2010 does jack shit to help pay premiums in 2009, unless there's some sort of free plans or other ways to help families pay for it, I think the government potentially putting people in financial stress is stupid.

I'm 100% behind some sort of national system, as I've posted here many, many, many times.

But I disagree with forcing people to pay for coverage they may not be able to afford.

It's not too hard to figure out unless you're someone just itching to bitch about something.

Posted by: Mark D on November 30, 2007 at 2:09 PM | PERMALINK

Culture Of Truth wrote: "But why go the route of individual mandates, rather than universal coverage through one government plan?"

Universal coverage through one government plan would reduce or even eliminate the enormous profits of the for-profit medical insurance corporations. With a few courageous exceptions like Rep. Dennis Kucinich, most politicians, Democrats as well as Republicans, are servants of America's ultra-rich corporate ruling class, and serve their interests rather than the interests of the American people. That's why we are constantly told that universal not-for-profit single-payer medical insurance under efficient, open, transparent and accountable public administration is "politically dead on arrival", "off the table", etc.

freelunch wrote: "Today, expanded Medicare for all is the best available option being proposed by anyone. Those who want to keep health insurance companies on the gravy train need to provide reasons to do so."

The reason is the greed of the ultra-rich corporate-feudalist robber barons of the for-profit medical insurance corporations. That's the only reason that matters to the politicians, both Democratic and Republican, who are the bought-and-paid-for servants of the ultra-rich corporate elites.

That's why "Medicare for all" is forbidden and anyone who suggests it -- like Dennis Kucinich, who has it as a cornerstone of his campaign for the Democratic nomination -- will be ridiculed as a whacko and subjected to questions about UFOs in televised debates. That's why politicians like Edwards and Clinton come up with insanely complicated schemes and "individual mandates" -- to preserve the profits of their ultra-rich corporate owners. And that's why "sensible liberal" pundits like Kevin begin any discussion of the issue by ruling out universal single-payer not-for-profit "Medicare for all" insurance and asserting that since we obviously "can't have that" we will have to accept something less.

Posted by: SecularAnimist on November 30, 2007 at 2:19 PM | PERMALINK

The interesting thing about how this is how it will play out with the dishonestly of insurance companies.

Right now I don't insure not because I am morally opposed to the idea, or because I cannot afford it, but because I simply don't believe that, when push comes to shove, the insurance company will pay up. I've had enough experiences in real life, and seen enough stories in the papers, not to see the point in this one-way transfer of funds.

OK, so now I have an insurance plan that the govt FORCED me to enroll for, and the expected happens. I develop some terrible disease and the insurer refuses to pay because it's a pre-existing condition or whatever. Presumably at this point I now have open to me a whole range of interesting lawsuit possibilities against not the insurer but against the govt that forced me to pour money down this rat-hole. And given the "libertarian" tone of much of the judiciary, all the way up to the Supreme Court, I would see myself winning.

This is an extremely interesting possibility because it implies the potential for massive shakeups. Either the insurance companies have to buckle up, accept all comers, and stop throwing people out, or the program will be shut down by the courts.
Which makes one wonder the extent to which Edwards is well aware of this and that's in fact his game plan --- get people to fall in love with the program, get them livid when the courts shut it down, and have the Feds step in with medicare everyone as a replacement which Congress will finally be forced to offer?

Posted by: Maynard Handley on November 30, 2007 at 2:26 PM | PERMALINK

c'mon Kevin, you're better that this! A few weeks ago, you linked to a post by Tyler Cowen bemoaning the individual mandate proposals from Clinton and Edwards, and you fretted over how they would be enforced. IIRC, you quite explicitly asked for more detail. Now you've got it (from Edwards, at least), and you're switched to desiring less detail. This is silly.

Moreover, the argument you make in the Update - that the GOP will attack the mandate demogougically in order to panic voters into opposing reform - can only possibly work as a critique of any particular policy if you believe that the GOP is not a gang of unprincipled hacks who will attack any progressive proposal in a dishonest and fear mongering way. As I'm sure you realize, Medicare for All would be attacked as "the biggest tax increase in history" and as "taking away your health care for a new government plan." If you really think that the combination of a big tax increase and everyone having to switch health care plans, even if they have a plan and are happy with it, is somehow more objectively defensible from GOP attacks than the Edwards and Clinton plans, well, it would behoove you to present some good reasons why the rest of us ought to agree with that assessment. As far as I can tell, Ezra clearly has the better argument right now.

Posted by: Rich C on November 30, 2007 at 2:28 PM | PERMALINK

Indeed, Kevin, all these stupid programs that are designed to either keep the insurance companies in the mix, or are intended to cover up the fact that the plan is really to just make everybody eligible for Medicare are stupid.

What irks me is that we have already learned this lesson. If you actually read the Clinton health care plan, you would have seen that states were forced to erect an incredibly complicated series of oversight panels and insurance regulatory bodies to provide insurance for everybody.

Or just implement a single payer plan at the state level.

Atrios has it right. Send everybody an enrollment card. Pay for it with taxes. If people want to buy supplemental insurance or pay for lasix (OR recreational drugs like Viagra), then let them do so.

But there is no reason at all to have these ridiculous hybrid insurance plans. The Individual Mandates make that clear.

It's time to join the rest of the OECD.

Posted by: jayackroyd on November 30, 2007 at 2:38 PM | PERMALINK

OK, somebody smarter than me explain this to me:

Why can't we have a plan in which a certain fixed amount is taken out of your pay by the government each week, and that amount can either be allocated to your favorite plan (with you perhaps paying a differential), or it can be used to pay fully for a government plan. When you lose your income, you don't pay into it, but the government continues to pay for your health insurance at the previous more or less fixed rate. If you need to go to the government insurance program to save money, you do, and so have to pay nothing out of pocket.

Now I realize that you may have to pay slightly more for your governmentally required insurance premium while working since you are also in effect also insuring against the possibility that you will go out of work. But I don't see why people would generally object to such insurance; certainly they'd be getting greater security for what they are paying in.

But the beauty is that you never have to face the IRS and those mandates or the prospect of not being able to pay for your health insurance, since all of the money is taken out while you work and have income.

In addition, you can keep the plan you previously had, if you want.

I can't see the problem with this approach. What is it?

Posted by: frankly0 on November 30, 2007 at 3:45 PM | PERMALINK

God what a wanker you are Kevin.Oooh big bad scary gov't making you have health care.
You have some idea of how to implement any program at all. As for all you rugged individualist who don't want the govt to make them have healthcare plans provided thru the govt. Blow it out your wazoo.
What do we do continue to have those without health plans keep getting their healthcare at the emergency room.
How many men,women and CHILDREN have no healthcare plan now. How many millions? This situation is intolerable for a civilized country.

WE need to do something. Just like we needed to do something about a national energy policy when numbnuts Reagan took office. Nothing got done then and nothing will get done now unless we start to do something.

Posted by: Gandalf on November 30, 2007 at 3:50 PM | PERMALINK

I vote we all agree to start calling it "automatic enrollment" from now on, and leave the term "mandate," though not the policy behind forever. OK?

I'd guess the terminology change is worth 1% of the vote at least.

Also, we should be talking about the benifits of -mandates- automatic enrollment for people who already pay for coverage, which is cheaper insurance!

Posted by: AJ on November 30, 2007 at 4:05 PM | PERMALINK

God what a wanker you are Kevin.Oooh big bad scary gov't making you have health care. You have some idea of how to implement any program at all.

Medicare for all, competing on the open marketplace with private insurance plans, starting by covering everyone under 18 first is the best politics.

No one can be against health care for children politically and it will prove to naysayers that Medicare is the most competitive plan compared to private insurance. The "socialized medicine" meme will be defused.

Then expand it to cover everyone.

Game set match.

Posted by: Old Hat on November 30, 2007 at 5:11 PM | PERMALINK

that's exactly why Edwards' Diogenes-like effort to define his enforcement mechanism for IM in such mind-numbing detail is a bad idea: it practically forces voters to confront the fact that IM doesn't really make much sense.- Kevin

Perhaps that is precisely what is needed. Maybe voters will come to the conclusion that what you currently think is politically impossible, but "better" is what in fact needs to be done. This way you can test the public and see if you've got enough of a consensus to push for the right thing in the first place: single-payer.

Posted by: Doc at the Radar Station on November 30, 2007 at 5:13 PM | PERMALINK

frankly0

The reason this doesn't make sense is that your health care requirements are not related to your income. Even worse, your health care costs are inversely related to your income. When you are very young or very old or very sick, you don't have much income, but you need more health care. For most of us (almost all of us) these periods of time are relatively brief.

You can make the argument as George Lakoff et al make here: Don't think of a sick child that there is a simple moral argument at play. Societies should take care of the sick and the infirm because it is the right thing to do.

But you can also make the very practical argument that a program of universal health care provision funded by progressive taxes is actually the best system of all, in terms of efficiency. It solves the problems with mandates Kevin is talking about. It solves the adverse selection problem that underlies it. It holds that there is no moral hazard problem--that people will not endanger their health because they know they will get care (and I claim this is even true of cirrhotic alcoholics. Liver transplants haven't increased the alcoholism rate.)

Moreover, it recognizes that insurance really doesn't work as a health care model. In the old days of fee for service, with doctors as gatekeepers, it didn't work. Doctors overtreated performing unnecessary operations, and there were incentives to lengthen hospital stays.

The PPGP reform didn't work either. Rather than encouraging preventative care, it created incentives to exclude people from coverage entirely, either beforehand, or after treatment.

What has worked is what the rest of the OECD does--pay for medical care using progressive, or proportional, taxes. This is not a debatable issues at this point. The rest of the OECD delivers better care to more people for half the cost than the US. The only argument for retaining the role of insurance companies is inertia--and graft.

Posted by: jayackroyd on November 30, 2007 at 5:14 PM | PERMALINK

And since a tax credit in 2010 does jack shit to help pay premiums in 2009
Posted by: Mark D on November 30, 2007 at 2:09 PM

Mark, the current health care tax credit
for people on UI can be done on a monthly basis. You send 35% of your premium to the IRS, then they turn around and add the other 65% to your premium and the IRS then pays the insurer 100% of the premium every month.

Posted by: Doc at the Radar Station on November 30, 2007 at 5:29 PM | PERMALINK

Medicare for all, competing on the open marketplace with private insurance plans, starting by covering everyone under 18 first is the best politics.

I also think that some way of gradually expanding Medicare is a good way to go -- because Medicare is already here, and it works, and people trust it.

The problem there is that you will have to increase income (or SS?) taxes to expand coverage, and then the critics will say that people who already have insurance are being made to pay for the insurance of others.

The best solution would be a drastic change (convert everyone to Medicare), but drastic changes are politically (and tactically) hard to implement. Incremental solutions, on the other hand, have inherent contradictions. It's just not an easy problem to solve.

Posted by: JS on November 30, 2007 at 5:37 PM | PERMALINK

um.. insurance by mandate isnt insurance at all. Its a way to funnel a government like safety net through the insurance industry and shake out as much money as possible. If you accept all comers it fails to be an 'insurance' where you are hedging your bets against the future.. ideally everyone in an insurance plan pays and noone plays. ..they mess up occasionally and actually have to pay up. This is how they play it.

Without that kind of selection process it merely becomes a management mechanism. A shell game that moves money from one pocket to the next.

Posted by: david b on November 30, 2007 at 6:20 PM | PERMALINK

Who pays for IM when laid off? Unemployed? Married? Student?

It'll never be workable until right-wing asshats force you into debtor's prison with all your assets liquidated - and then they'll say you don't deserve it because you're shirking work by being in prison.

Posted by: Crissa on November 30, 2007 at 6:30 PM | PERMALINK

If you want to see how a strong, determined, and committed democratic presidential candidate would handle the penny-ante criticisms I see coming out of this segment I direct your attention to Edwards' speech at the DNC. You are not going to get this kind of campaign from either of his two principal rivals. See the link at http://www.democrats.org/a/2007/11/john_edwards.php

Posted by: popudem on November 30, 2007 at 6:30 PM | PERMALINK
Yes, it'd be lovely if everyone had health care. But forcing it upon everyone, including those who may not be able to afford even the cheapest of plans, just seems like a horrific idea.

Um, the people who can't afford the cheapest plans are given a tax credit to cover the cost so they can. Further, a large portion of those who wouldn't be able to afford even the cheapest plan under the system Edwards proposes are and would be eligible for existing programs like Medicaid or Medicare and, thuswould not be "forced" to pick a plan anyway, since only those not covered by Medicaid and Medicare would be mandated to pick a plan from the system.

Posted by: cmdicely on November 30, 2007 at 6:33 PM | PERMALINK

Mark D:

And since a tax credit in 2010 does jack shit to help pay premiums in 2009

It does if it is advanced monthly (as some current tax credits are or can be), or if unpaid premiums are collected as part of your year-end taxes without penalty or interest (which seems to be the plan.)

Crissa:

Who pays for IM when laid off? Unemployed?

The individual, possibly with a tax credit, presuming they aren't eligible for, e.g., Medicaid.

Married? Student?

Neither of those statuses are likely to be relevant, though either might figure whether and how much of a tax credit is available to subsidize the cost.

Posted by: cmdicely on November 30, 2007 at 6:37 PM | PERMALINK

"OK, somebody smarter than me explain this to me:

Why can't we have a plan in which a certain fixed amount is taken out of your pay by the government each week, and that amount can either be allocated to your favorite plan (with you perhaps paying a differential), or it can be used to pay fully for a government plan. When you lose your income, you don't pay into it, but the government continues to pay for your health insurance at the previous more or less fixed rate. If you need to go to the government insurance program to save money, you do, and so have to pay nothing out of pocket.

Now I realize that you may have to pay slightly more for your governmentally required insurance premium while working since you are also in effect also insuring against the possibility that you will go out of work. But I don't see why people would generally object to such insurance; certainly they'd be getting greater security for what they are paying in.

But the beauty is that you never have to face the IRS and those mandates or the prospect of not being able to pay for your health insurance, since all of the money is taken out while you work and have income.

In addition, you can keep the plan you previously had, if you want.

I can't see the problem with this approach. What is it?"

-----------------------------------------------

Ok, just to start with, I don't think people here are getting how refundable tax credits can work. To begin with, refundable tax credits give you the money even if your tax burden is zero. Secondly, tax credits can be set up as "automatic," which means they're divided up into twelve monthly payments that are sent out to you instead of as one yearly payment. Think of it like income tax withholding, but in reverse.

Now to address your suggestion directly, frankly0.
To begin with, what you've suggested is functionally the same as what the end result of the Edwards plan would be, given the fact that under such plans if you lose your job your health care would be paid for by subsidies/COBRA/Medicaid.

However, having it be a fixed sum is a bad idea - some people can afford less, other people should be charged more if they sign on for fancier or more expensive plans. In addition, this would be effectively a mandate on EVERYONE, including the 80% of those who have insurance who like their insurance, who would freak out if someone told them their health insurance was being re-done for them.

And if you have the choice to opt for your old plan, it's essentially the same thing as the Edwards plan except that instead of you paying the bill, it's directly deducted from your paycheck. How would this be better?

Posted by: StevenAttewell on November 30, 2007 at 10:01 PM | PERMALINK

"Exactly. And I'm sure that Republicans all realize this and will therefore refrain from using it as an unprincipled way of panicking Harry and Louise about jackbooted IRS thugs raiding accounting departments across the country and demanding that H&L's wages be garnished. So I guess no harm has been done after all."

What do you need Republicans for? Barack Obama is already doing just that. A man so interested in winning that he is willing to trash the chances of a decent health care bill from the get go.

Posted by: debcoop on December 1, 2007 at 12:51 AM | PERMALINK

ok...help me out here. isn't the single payer system supposed to be less expensive than the private insurance policy you have now? if so, then you'll see a net benefit, more cash for you to spend on whatever you like. it's a windfall. what's to complain about?

and as far as tax credits not being accessible to middle to low income folk, the earned income tax credit is an example of a tax credit that works, right?

Posted by: marydem on December 1, 2007 at 4:49 AM | PERMALINK

It's "garnisheed" with two e's. Nice word though.

Posted by: James Wimberley on December 1, 2007 at 1:10 PM | PERMALINK

"trades away certain amount of economic efficiency in order to evade the political implications of nationalizing health spending." -Klein

Right, because cowardly evasiveness and half-assed ideas are so persuasive.

Posted by: Gary Sugar on December 1, 2007 at 4:54 PM | PERMALINK

Just two points:

First, why not go directly to "medicare-for-all" or some other public sector plan that covers everyone? Because then the government (or "socialized medicine")will be blamed for all of the things that people won't like about health care reform:

1) that reform will rely on "comparative effectivness research" to decide which drugs, devcices and procedures are most effective and should be covered. All three leading Democratic candidates are calling for this type of research to decide what national insurance will and won't cover--based on medical evidence. (This means many Americans will be told "no" you really don't need x, y or z. We know it's newer, but it's more expensive and no better. In fact it may be riskier.)

2) Some people also won't like the fact that in order to have universeal health care that covers everyone no matter how sick or old they are, we must require everyont to pay into the pool, acccording to their ability to pay, even if they are young and healthy (I explain why below)

3)Some Americans will object to the fact that low-cost catastrophic insurance will no longer be available. Under all of the proposals, everyone will be required to have insurance that covers preventive care and manages chronic illnesses. Again, that's the only way we can have high-quality, affordable, sustainable care. We can't let people skip preventive care until they are very sick--and then expect the rest of us pick up the bill.

All three Democratic proposals wisely avoid a situation where the government is blamed for all of the things that many Americans won't like about evidence-based universal health insurance.

By letting private sector insurers compete with the public-sector plan (with private sector insurance regulated so that the two are competing on a level playing field), the candidates are creating a situation where the private sector insurance will share the blame for using comparative effectiveness reserach to decide what to cover. And it will share the blame for charging young, healthy people as much as it charges older sicker people.

Private sector insurers will have to do these thigns because, if they don't, their insurance will be very, very expensive and won't be able to compete with the public sector insurance. (Private sector insurers may offer some extremely expensive "cover anything you want anytime you want" plans for people for extremely wealthy people who don't mind throwing money away, but this will be a tiny percent of the population.

In the meantime, while people may be unhappy when they find out that their insurance won't cover the new pill they just saw advertised on TVm they won't be able to blame the government or say that it's because the Socialists have taken over WAshington. Private insures will be saying "no" too--otherwise private insurers won't be able to compete on price.

On the question of mandating insurance: As Clinton and Edwards understand (and Obama understands but isn't admitting becuase he's trying to appeal to younger voters) if you want to insist that insuers cover everyone--no matter how sick they are-- and if you want to say that insurers can't penalize the sick by charging them
exorbitant premiums--then you have to say that everyone must sign up for insurance.

If you didn't mandate insurace, young healthy people wouldn't enroll until they became sick. And then they would sign up, knowing that insurers would have no choice but to take them, and couldn't charge them more because they are sick.

Why should young Americans pay as much for insurance as older Americans, in effect subsidizing the elderly? Becuase this is the only way we can afford universal care that provides subsidies for those who earn below a certain amount.

It's important to realize that proposals for reform put a cap on how much of your income you can be required to pay for health insurance. This means that younger workers who earn, say $25,000 a year will receive subsidies. They won't be paying the full amount. The only younger people who will be paying the full amount are those in high-income brackets, who earn as much as upper-middle-class and upper-class older workers.


Posted by: maggie mahar on December 2, 2007 at 12:48 PM | PERMALINK

Maggie: Exactly.

Our society needs to decide if health care should be a "private good" (like a car / house / TV) or a public good (like police, defense, highways). The case that it should be a public good should be made clearly and forcefully -- with all carrots and sticks exposed. People should realize that private insurance is something they can lose -- just when they need it most -- and their lives can be ruined as a result.

Once a decision is made that health care should be a public good, then requiring everyone to participate just follows. Paying for public goods cannot optional. But, as Maggie points out, a government program can be progressive -- easier on the poor. We pay for emergency health care for the poor now anyway -- bringing them into the system and making them eligible for preventive care as well will actually lower the costs.

Posted by: JS on December 2, 2007 at 1:11 PM | PERMALINK

I'm glad people are really discussing this issue. It helps clarify exactly how Edwards is leading and the other candidates are faking it or are doing less.

Edwards for President -- This is what Real Leadership looks like!

Posted by: MarkH on December 2, 2007 at 8:16 PM | PERMALINK
Mark, the current health care tax credit for people on UI can be done on a monthly basis. You send 35% of your premium to the IRS, then they turn around and add the other 65% to your premium and the IRS then pays the insurer 100% of the premium every month.

Posted by: Doc at the Radar Station

Oh ... well I'll just STFU, then.

My fault.

:-)

Posted by: Mark D on December 3, 2007 at 11:34 AM | PERMALINK
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