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POLICY: Do mandates matter? with UPDATE

Former Labor secretary Robert Reich has appealed to Democrats (in other words Paul Krugman and Obama’s
camp) to stop squabbling over healthcare mandates. Basically he says that Clinton would have to let some people who couldn’t afford health care out of the mandate (as is happening in Massachusetts) and that Obama’s plan would get us close enough to universal coverage that the difference isn’t worth arguing about.

Writing in THCB last week Robert Laszewski pointed out that the cost of buying insurance is sufficiently high that a subsidy would have to be so large and go so high up the income scale that it wasn’t politically realistic — and certainly wasn’t working in Massachusetts. So in his view Obama and the Republicans (Robert is actually generous enough to give some of them credit for having thought about this) are right not to push for a mandate.

But then of course, with no mandate you’re not getting everyone into the pool. So what do you end up doing with those who don’t have insurance when they need care? You end up with what happened in Hawaii, where universal pay or play ended up in 90% insurance.

Which leaves me convinced that we need to divorce health care
"insurance" purchase completely from income–in other words everyone
gets the same voucher (or whatever), but that voucher gets paid for in
some transparent way that is unconnected to the user (i.e. a dedicated
global tax, or we just pay for coverage out of general tax revenue.

Even if we create a full subsidy program with the best of
intentions, the required subsidies for those with lower incomes won’t
remain big enough. As John Cohn says, programs for the poor get treated
poorly. So an explicit individual mandate without a radical re-jigging
of the tax system and the way low income people buy insurance won’t get
us to universal coverage.

So I agree with both Roberts, but I go past Robert L in my
conclusion of what ought to be done.  But I’m realistic enough to know
that in the current fiscal climate means what will be done is not
enough to get us where we need to go, and any individual mandate
"reform" will need to be re-fixed in a few more years.

UPDATE: Commonweatlh Fund released a survey this a.m. suggesting that 68% of Americans are in favor of mandates. That’s about the same share that backs universal health care usually in surveys. It breaks down as 80% of Democrats, 68% of independents and 52% of Republicans. You’d think that would mean more support for Hillary than for Obama, but that hasn’t played out yet. So my assumption is that most Democrats don’t see the difference between Obama and Hillary that we wonks do–they just think both will fix health care. Michael Millenson’s reporting from the doorsteps of Iowa suggests that this is true.

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Steve KirkMartin TrussellChris JohnsonPeterbev M.D. Recent comment authors
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Peter
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Peter

“In my opinion, not one of the leading candidates of either party has put forward a workable plan to address the issue. Oh sure, there are plenty of crocodile tears and blustery ‘me too” rhetoric, but no one has the mental acumen, breadth of vision or plain old intestinal fortitude to have put forward something other than well-crafted but vacuous populist drivel.” Steve, have you ever seen an election and election issues where this wasn’t true? If we look at what the Republican candidates are saying about saving the Michigan economy, does it sound familiar? McCain started out with the… Read more »

Steve Kirk
Guest

In my opinion, not one of the leading candidates of either party has put forward a workable plan to address the issue. Oh sure, there are plenty of crocodile tears and blustery ‘me too” rhetoric, but no one has the mental acumen, breadth of vision or plain old intestinal fortitude to have put forward something other than well-crafted but vacuous populist drivel. We need something that makes perfect sense. Steve blogs daily at http://www.theperfectsense.com.

Martin Trussell
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I agree with the comment posted by bev M.D. that the “broken system” is the primary reason people cannot afford health insurance. I also think that any politician who thinks they can single handedly “fix” the system is suffering from delusions. We haven’t forgotten Hillary Care have we? I do, however, think that politicians who are encouraging free-market solutions to the health care coverage issue are, by virtue of encouraging innovation and entrepreneurship in the provider sector, indeed touching the system, albeit with a ten foot pole.

Chris Johnson
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A universal access system that continues to use as its principal instrument insurance companies (with their accompanying high overheads that add no value) will end up functioning as a revenue transfer plan to those insurance companies. So with all its many warts (and there are a lot) I’m a single payor guy myself.

Peter
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Peter

I would like to add a video now circulating on the internet that may add more than we want to know about what a huge problem immigration will have on our ability to pay for healthcare (and everything else) and about access for us all. I don’t know who the speaker is, or what if any, group he represents, but the numbers he gives are staggaring. I’d like comments as to the legitimacy of the scenario presented if this is not too far off topic.
http://www.youtube.com/watch?v=n7WJeqxuOfQ

Peter
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Peter

Healthcare costs is a big hole we’ve dug ourselves into. But not the only hole that is now too deep for us to be able afford a solution. Ask yourslf how you see the present policies of this country solving ANY pressing issues. How do you see us paying for any of the problems that were not addressed in the 20th Century? Global warming, energy, infa-structure investment, job exports, manufacturing losses. It’s not just that we have one or two to solve, but all of them at the same time. Where will the money come from? With predictions that American… Read more »

bev M.D.
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bev M.D.

As I said in one of my very first comments upon discovering this blog, one cannot fix the insurance part without addressing the broken system simultaneously. I know this is not a new or unique concept and has been stated by many others also. However, just a reminder that the broken system remains a primary reason why people cannot afford to buy insurance and therefore mandates are not feasible. I don’t see the politicians touching this part with a ten foot pole.