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.