Man Dates

For the past week or so, Jonathan Cohn, Ezra Klein, and Paul Krugman have teamed up to attack Obama’s lack of an individual health care mandate more or less non-stop. Obviously, these are three of the smartest liberal commentators working today, but I think they get this one wrong. There have been literally dozens of posts written on the matter, and it’s impossible to respond to all of them, so here I’ll stick to Cohn’s article defending individual mandates at TNR Online.
Here’s Cohn’s theoretical defense of individual mandates:

The logic of a mandate begins with understanding exactly why Obama’s essential diagnosis of the problem–that it’s all about affordability–is wrong. It’s certainly true that cost is the single biggest reason 45 million Americans don’t have health insurance today. That is why all three Democrats have proposed adopting the same set of strategies to make insurance more affordable: Requiring insurers to sell to everybody, at the same price, regardless of medical condition; creating a public program into which anybody can enroll; cutting down on wasteful treatments that drive up the price of medicine unnecessarily; and offering financial assistance to those people who might still need help paying for coverage. Make those changes–in other words, make insurance affordable–and most of the uninsured will leap at the chance to get coverage.
But not all of them. If you stop there, as Obama’s does, some large portion of people–about a third of the uninsured, maybe more, if you believe the projections–will remain uninsured because they will still choose not to get it. Some of these people will make a decision to take their chances on a health catastrophe, figuring insurance isn’t worth the price. Another group of people simply won’t take the initiative on their own, because, quite simply, they won’t give it that much thought. Some will be relatively well-off, some not. In all of these cases, however, the only way to make sure these people get insured is to compel them to do so–in other words, to make it a legal requirement. That’s a relatively simple matter if you have a single-payer, government-run system; you just enroll everybody at birth. (That’s one more reason why folks like me continue to talk up this option, even though none of the leading candidates have taken to it.) But if you want to provide universal coverage mainly through private insurance–which seems to be where we’re heading at the moment–then you have to make people buy it.
Why interfere if people are choosing not to buy insurance and risk the consequences? For one thing, they may not actually grasp the consequences, which in the very worst cases can include bankruptcy or–in the case of those who have to forgo necessary medical care–death. If that sounds paternalistic, then consider that we use a very similar rationale for taking payroll taxes out of people’s wages in order to finance Social Security. We know from the days before Social Security that, left completely to their own devices, large numbers of people will make poor financial planning decisions and end up destitute. So, in order to provide everybody with a guaranteed pension, we compel all Americans to pay into the government’s retirement system. An individual mandate would rest on the same argument: In order to provide everybody with guaranteed medical coverage, we would compel everybody to pay for it upfront (although, again, we’d also offer financial assistance to those who need it).

This explains exactly where Cohn, Klein, and Krugman lost me. I – and apparently Obama too – thought the problem with the health care system was that people weren’t getting the care they needed because they couldn’t afford it. That’s what concerns me about the current health care system, not that young and healthy people don’t buy insurance. I’ll grant that not buying health insurance when you can afford it is a poor decision, but it’s not one that requires nanny state intervention, as Cohn proposes. If forcing people to buy insurance they don’t feel they need sounds paternalistic, that’s because it is.
Cohn’s analogy to Social Security is fallacious. If Social Security consisted of the federal government creating 401(k)s for every American and forcing them to pay in every year, then the analogy would work. But Social Security as it currently exists – as a tax-supported stipend system for seniors – is nothing like that. Indeed, it would be better if it shed the pretense of being a social insurance program and instead functioned as straight-up, means-tested welfare. I recognize that that can’t happen because it would destroy SS’ political base, but it would result in a far more justifiable program.
Cohn goes on to argue for the practically of individual mandates:

Still, the most important rationale for a mandate may be a more practical one: It’s necessary to keep other reforms from unraveling. If you make insurers sell to everybody, even people with pre-existing conditions, but let people choose whether or not to buy it, people in good health will be more likely to wait until they’re sick before buying coverage, figuring there’s no point in forking over premiums while their chances of needing care are so low. This will cause a chain reaction. As healthy people opt out, insurance programs will be left dealing with a population of sicker and sicker people. Since insurance relies on contributions from healthy people to offset costs from sick, it will become more expensive–which will cause even more healthy people to opt out. The cycle will repeat over and over again, with the cost of insurance going up and enrollment going down. Wonks call this the “adverse selection death spiral.” And it’s hardly theoretical. By the late 20th Century, most of the nation’s Blue Cross plans had stopped offering insurance to all comers, regardless of pre-existing condition, because their competitors–who didn’t make the same generous offer–had stolen away all the healthy patients.

But this is not a legitimate critique of Obama’s plan, which contains an employer mandate. Unless a majority of young, healthy people are unemployed, it’s doubtful that they would eschew insurance en mass when their employers are giving it to them anyway.
And here Cohn just gets annoying:

According to Jonathan Gruber, a Massachusetts Institute of Technology economist, it’s impossible to peg the likely impact of a mandate with even the very rough degree of precision he and other economists use for other estimates, simply because it requires making even more assumptions. But he also stressed that the question isn’t whether a mandate will make a difference–it’s how much of a difference and how close to full, 100 percent coverage an individual mandate system would get. Nor is Gruber alone in this assessment: It’s pretty much conventional wisdom among policy makers. Just yesterday, the Wharton School’s Mark Pauly–another highly regarded health economist, but one who tends to embrace more conservative views–co-signed a letter with Gruber and the New America Foundation’s Len Nichols affirming that an individual mandate is essential for achieving universal coverage.

But how many people lacking insurance in a mandate-less plan would be uninsured against their will? That’s the real question. If everyone who wants coverage has it, I don’t know what Cohn thinks the problem is.
That’s what really bugs me about the mandate pushers. They repeatedly complain that Obama’s plan isn’t really universal, which, while technically true, is totally misleading. I want universal, or near-universal, coverage because there are millions of Americans who want coverage and can’t get it. Whether people actually want insurance doesn’t seem to concern Cohn, or Klein, or Krugman; universality in and of itself does. Until they convincingly explain why forcing 20-something unemployed kids to get health care they don’t want should be a major national policy priority, I’ll remain skeptical.

12 thoughts on “Man Dates

  1. The #1 cause of injury, disability, and DEATH in America is, Health Care. More people die now from contact with the American Medical Health Care system than from any other cause of death. More than from Cancer, Heart disease, or Stroke. More than any other country in the world. Many times more than any other people in the world. This fact is a catastrophic indictment of the entire US Health Care System.
    Driven by greed. And a rush to profit. Thousands of Americans are killed, and injured daily in America. By compromised health care. Cutting corners. Over, and under treatments. And poisonings with all manor of toxic, poisonous pharmaceuticals. Especially the children. America only makes up 2-4% of the world population. But Americans buy, and consume 50% of all pharmaceuticals world wide.
    But the tide has turned. I can see it. Hear it. And feel it. The message is getting out. And taking hold about the fact that we have a very serious, and major health care crisis going on in America. Hurting everyone. Especially our precious little children. Rich, and poor alike. And most all Americans seem to understand now that “HR 676 Not For Profit Single Payer Universal National Health Care For All (Medicare For All)” is the way to go. Like all the other developed countries have done. I have seen numbers as high as 90% of Americans want government managed health care Now. Medicare for all. Like other developed countries have. And like older Americans have now.
    BRAVO!!! America. YOU GET IT! YOU REALLY GET IT! See sickocure.org.
    It’s NOW TIME to bring out the BIG GUNS!! The BIG GUNS!! are you. The American people. And anyone else that wants to help. From now until HR 676 is passed into law. I want every person to reach out and touch their fellow Americans every day if you can. I want you to take a phone book. And call at least one of your fellow Americans every day. And ask them to pickup the sword of HR 676 Single Payer Not For Profit Universal Health Care For All (Medicare For All).
    Call more than one each day if you can. And ask them to do the same as you are doing if they can. And also to put maximum pressure on their politicians to get HR 676 done. And to make sure their politicians support HR 676. Accept no substitute. HR 676 is a no-brainer. It’s the best way to go on health care. It’s the only moral, and ethical way to go. That is why every other developed country has done it. Most did it years ago.
    I know that many of you have been doing a fabulous job of spreading the word by talking it up with family, friends, and co-workers. And putting pressure on the politicians to get HR 676 done ASAP. The phone calls to your fellow Americans will increase the pressure. And grow the movement at an astonishing, and exponential rate. And I know many of you have been wanting to do something more to help. The phone calls to your fellow Americans is something you can do every day to help.
    Trust me. It will be something to see. But you have to keep the focus, and pressure on getting HR 676 passed pronto. They will try to distract you. With all manor of other crises, and catastrophes. And other plans. Don’t be distracted. HR 676 Single Payer Not For Profit Universal Health Care is the #1 concern of the American people. Thousands of Americans are dieing daily now. And you or your loved ones could be next.
    There is no good reason HR 676 cannot be passed into law well before the coming elections. Do not tolerate delays. If it is not passed before the coming elections. All America will know which politicians are on the side of the American people. And which are not when they vote. Well before the elections.
    Everyone can do this. Most of you are well informed about HR 676. This truly is one of those no-brainers. Be considerate of your fellow Americans when you call. But be comfortable about calling. These are your fellow Americans. Some will be receptive. And some will not be. Some maybe rude, and mean. Just thank them, and move on to the next. Most will be with you. And if you get a call from one of your fellow Americans about HR 676. Let them know you are already on board. And thank them for calling. Build them up. And keep them strong. They are fighting for all of us.
    I will try to make a second post with just a few of the reasons everyone with 2 working brain cells agrees HR 676 is the best way to go. But you can also look them up for your-self. And read some of the positive informed post on many of the message boards too.
    Lastly, I am sick and tired of hearing how the candidates, and politicians health care plans are going to protect, and preserve the private for profit health insurance companies that have been killing, and ripping off the American people. And now the politicians want to mandate (require) that every American has to support the private for profit insurance company’s that have been killing, and ripping you off. Or you will be fined, and PENALIZED. Thats right. PENALIZED. Ridiculous! The politicians really think you are all detached idiots. CASH COWS! To lead to the slaughter. Don’t put up with that.
    So get on it America. Get those phones going. Chat it up! Save some lives. You want all of America talking about HR 676 becoming law, Now! Before more die needlessly. Make it happen. And to my fellow cyber warriors. You have been doing great! I see it! Keep it up. 1 of 2 post…
    Below are a few reasons why “HR 676 Single Payer Not For Profit Universal Health Care For All (Medicare For All) is a no-brainer. And some reasons why private for profit health insurance is a stupid idea, and injuring, and killing you and your loved ones.
    Medicare cost 2-3% to administer. Private insurance cost 30% to administer.
    Under HR 676 everyone would be covered from birth to death. No co-pays. No-deductible. No out of pocket cost. Plus Dental. And Vision. For less cost than we pay now under private health insurance.
    With private insurance. You have 47 million Americans with no insurance.
    And 89 million Americans that had no insurance part of the time from 2006-2007.
    And over a 100 million that are under insured.
    18-30 thousand Americans that die each year from lack of health care.
    Health Care bills as the #1 cause of personal bankruptcy. And loss of homes.
    Under HR 676 health care is moral, and ethical.
    Private for profit insurance is immoral. And unethical.
    Profit is the primary motive of the private insurance companies.
    They make profit by charging needy, vulnerable, sick Americans as much as they can charge them.
    Then they make more profit by denying them care when they most need it. And are most vulnerable and unable to fight back. When they are sick. Or trying to recover from major illness.
    Yep! I know you are getting angry. I’m sorry. But I have to continue.
    Under HR 676: we will save 300 billion dollars in administrative cost each year.
    With private insurance: we spent more per capita on health care than any other country in the world. Over twice as much as most other developed country’s. Yet we have 47 million with no health care.
    We rank at the bottom in quality of health care #37.
    Americans have a shorter life expectancy than people from all other developed countries. We rank # 42 in life expectancy. Down from #1.
    For the first time in American history. The life expectancy of American children is less than that of their parents. American children are dieing at a record rate. And are in terrible health generally.
    People from other country’s enjoy a much higher level of general health than the best privately insured Americans.
    Americans are also shrinking. We used to be the tallest people in the world. Now we are down to # 10.
    People from other country’s never have to worry about going bankrupt, or loosing their homes over medical bills if they get sick.
    Maybe you should go take a break for a while before I go on. I know this must be upsetting. But this is just a small part of the sad truth about private health insurance that HR 676 can fix.
    Under HR 676: Health care will be based on need. Not on profit. And high standards, and quality will be enforced, and patients protected by the Government through a dedicated civil service. With the power, and resources to rain in abuses of patient care. Like they do with Medicare now.
    With private insurance: Medical care is base on ability to pay. And profit. Tens of thousands of patient are killed, and millions are injure, crippled, and mutilated each year under private for profit health care, and insurance.
    By insurance companies denying needed care to increase their profits.
    By hospitals cutting corners. And using the cheapest least experienced personnel, equipment, and standards they can get away with.
    By doctors that over treat, and under treat. Who injure, mutilate, and kill patients with unnecessary test, procedures, surgery, and invasive diagnostic test for profit. Who poison, kill, and injure millions of Americans with all manor of unnecessary pharmaceuticals for profit. Men, Women, Children, and babies.
    Americans makeup 2-4 % of the world population. But Americans buy, and consume 50% of all pharmaceuticals world wide. This is a monstrous evil. And immorality.
    And lastly, by politicians that take blood money from all these despicable groups and turn blind eye’s to this slaughter of the American people. And the slaughter of their own loved ones. And them-self.
    Well I could go on. And on. But I think this is enough to get you started making your daily phone calls to your fellow Americans to support HR 676. And to help them understand how important it is that each of them join the fight. And bring the MAXIMUM pressure to bear on all individuals, parties, and especially your politicians, and Representatives. To get HR 676 passed into law immediately.
    This is an emergency. America is in a crisis. More Americans have died from this health care crisis than have died in all the wars in US history. Do your best. Millions of Americans lives are counting on each of you. Including your own life. Remember, you are Americans. You know how to fight for your country when you have too. The whole world is in your blood. I’m with you.
    All the best… 2 of 2

  2. (Maybe an involuntary summary of the previous 1800-word “comment” would be in order.)
    I – and apparently Obama too – thought the problem with the health care system was that people weren’t getting the care they needed because they couldn’t afford it.
    It has never been that simple. Once society accepts a public goal, opt-outs hamstring the effort. Suppose that someone opts out of medical coverage but then asks to opt in when he gets sick. Then what? Or, suppose that certain people know that they are very healthy and unlikely to need much medical care for a long time; while others are very sick and know that they can’t pay for their care. The effect of opt-outs is then predictable, and a big part of the problem that we have now.
    Essentially we have already accepted the paternalistic tenet that people deserve to be treated for serious illnesses. No one wants to see people die on the street. Hospitals are required to accept patients for emergency care. This has also become a loophole that is used by non-paying patients for substandard non-emergency care. (Care which is free for them and expensive for the system.) So the argument about paternalism is basically over. The real debate is whether people can take responsibility for their medical expenses with an individual or corporate approach. I don’t see that those approaches can work.
    Consider also these analogous cases that have had unintentional opt-outs, or for which one could propose opt-outs:
    1. Desegregation, but you can opt out by moving out of the city. This is how it turned out in many US cities, e.g. Chicago.
    2. A fire department that lets you opt out. Will they let your house burn down if you didn’t pay?

  3. Clearly I feel very strongly about our health care crisis. And how best to fix it. I do not see it as a liberal, or conservative thing. Or as a Democratic, or Republican thing. Or a rich, or poor thing.
    I see it as a very serious moral, and ethical issue. Probably the greatest moral and ethical issue of our time.
    I also see it as a matter of national security. We have a lot of nuclear power might. But we are increasingly becoming a very weak nation. Because the health of the American people is so poor. And declining. Especially that of our youth. And other country’s know this. And often refer to our weakness. And inability to handle any protracted challenge well.
    Lastly, It has been shown unequivocally that single payer not for profit government administered health care is the most cost effective, and efficient way to provide health care. And also results in the highest quality care available for your health care dollar. Nothing less is acceptable in matters of health, life, and !!DEATH!!
    This is not rocket science. Every other developed country did this years ago. And many of those country’s have since done full, and rigorous reevaluations of this. And they always come back to the same conclusion. That a single payer not for profit government administered program of universal health care for all is the best, and only way for a developed country to go.
    Thank you for your comments. The most important freedom is the freedom to exchange ideas, and opinions.
    Sincerely
    Jacksmith…

  4. Greg – I like the firehouse analogy. That’s why eliminating the words “over 65” from the Medicare statute (or, alternately, something like Pete Stark’s AmeriCare proposal) would be the best option. But a firehouse isn’t really analogous to forcing people to buy private insurance. It’s just analogous to making insurance publicly run and funded. Which is a good idea, but not exactly on the table.

  5. I’m conceding that public insurance with automatic enrollment is better than private insurance. And with Obama the only candidate who’s stated repeatedly that he wants to implement single-payer with his current plan as an intermediate step, I’m comfortable where he’s sitting.

  6. I want public insurance from which one can opt out.
    That’s not how you described it before. You said that you liked the firehouse analogy and that the best option is to extend Medicare to all citizens. That would mean no opt-out.

  7. That would mean no opt-out from payment. I want everyone to be taxed. But if someone would rather bear the tax and buy private insurance instead anyway, I wouldn’t object. It’s the same policy we have with public/private schools.

  8. Well, in as much as additional insurance options and subsidies provided in the plan – all $80-100 billion per year of them – are paid for by general income tax revenue, then yes.

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