Clinton and Obama on Healthcare: Mandates Mean Unity
Should you care about the flap over healthcare “mandates”? Does it really tell us anything about whether Hillary Clinton or Barack Obama is more likely to deliver healthcare reform?
In yesterday’s New York Times, Paul Krugman said “Yes.” He pointed out that Clinton’s plan favors mandates that would require everyone who can afford the premiums to sign up for healthcare insurance. Low-income and lower-middle income Americans who cannot afford the premiums would receive subsidies from the government, just as they do in Massachusetts. There, a single person earning less than $31,000 is eligible for a subsidy --as is a family of four earning less than $64,000. (There are still serious problems with the Massachusetts plan, but it offers a useful real-world examples of who would receive subsidies.)
Obama, on the other hand, does not insist that everyone enroll. The healthy and wealthy can opt out. As a result, Krugman points out, Obama’s plan “would face the problem of healthy people who decide to take their chances or don’t sign up until they develop medical problems, thereby raising premiums for everyone else.” Obama’s proposal for universal coverage would be extraordinarily expensive, requiring such steep tax hikes that it would never pass Congress.
Just how expensive would it be? Here Krugman points to a new paper by M.I.T. healthcare economist Jonathan Gruber:
“Mr. Gruber finds that a plan without mandates, broadly resembling the Obama plan, would cover 23 million of those currently uninsured, at a taxpayer cost of $102 billion per year. An otherwise identical plan with mandates would cover 45 million of the uninsured — essentially everyone — at a taxpayer cost of $124 billion. Over all, the Obama-type plan would cost $4,400 per newly insured person, the Clinton-type plan only $2,700.”
The difference in cost is tied to the fact that, without mandates, healthy young people who earn too much to qualify for subsidies might decide not to enroll, while poorer people (who qualify for subsidies) would be almost certain to sign up (as they have in Massachusetts), along with people who are older, sicker and generally more expensive to insure. Quite simply, if younger, healthier people don’t contribute their share to the pool, it will be left to taxpayers to make up the difference.
Responding to Krugman’s argument Dean Baker, from the Center for Economic and Policy Research responds weighed in here on TPM café (see below) where he agreed with Krugman that, for universal coverage to work, everyone needs to participate: “Under a reformed system, we will require [that either insurers or the government] charge a standard fee under which everyone pays the same premium regardless of their health history. However, this creates a situation in which it doesn’t make sense for healthy people to pay for insurance. Why not just deal with minor health related costs out of pocket? You can wait until you get sick and then buy into the system and pay the standard rate.
“That works for healthy people,” Baker observes, “but it would destroy the system because the only people buying insurance would be those with relatively high bills. This means that insurance would be very expensive, which of course encourages more people to play the ‘wait till I’m sick strategy.’ The end result is that the system collapses.”
Like Krugman, Baker is an economist. While some people naively believe that national health reform will suddenly, magically make healthcare cheaper, Krugman and Baker realize that if we provide healthcare for everyone who is now uninsured or under-insured, our national health care bill will not shrink. It will rise. The only way to make universal coverage affordable is if everyone-- young and old, rich and poor, sick and healthy—gets into the pool together. (And then, over time, we can work, together, to bring down health care costs.)
Unity and solidarity are, after all, major themes of Obama’s campaign. And so it should not come as a surprise when Baker reports that Obama himself has reconsidered his position , and now realizes that if we want national health reform, we need to have everyone sign up for insurance.
Here is his new plan: “Obama has suggested that we have a system of default enrollment, whereby people are [automatically] signed up for a plan at their workplace.” But this wouldn’t be a mandate, Baker explains: “People would then have the option to say that they do not want insurance, so they are not being forced to buy it. However,” Baker adds, “they will then face a late enrollment penalty if they try to play the ‘healthy person’ game. When they do opt to join the system, at some future point, they will have to pay 50 percent more for their insurance, or some comparable penalty for trying to game the system.“
What Baker doesn’t explain is what we will do with families who cannot afford to pay such stiff penalties when they finally decide they need insurance. Would we subsidize the penalties?
If not, and if everyone believed that the penalty would enforced, then how is this different from a mandate? Everyone knows that, eventually, they will need healthcare. And only the very wealthy could afford to pay 50 percent more than everyone else. So threatening free riders with a steep penalty is, in effect, putting a gun to their heads. It’s a mandate by another name.
Krugman knows that Obama has begun to talk about punishing those who don’t sign up, and so his column covered the possibility of an about-face. It won’t work, said Krugman. Obama has said so many bad things about mandates being coercive that he has painted himself into a corner. If he tries to reverse his position now, conservatives will simply quote everything he ever said about how mandates are “unfair.”
Remember the phrase “flip-flop”?
”The Obama campaign has demonized the idea of mandates,” Krugman continued,“most recently in a scare-tactics mailer sent to voters that bears a striking resemblance to the ‘Harry and Louise’ ads run by the insurance lobby in 1993, ads that helped undermine our last chance at getting universal health care.” (The flyer suggested that the Clinton plan would force low-income people to buy insurance that they can’t afford—ignoring the fact that Clinton’s plan would offer subsidies to the working class.)
So now Obama faces a double-bind: “If Mr. Obama gets to the White House and tries to achieve universal coverage, he’ll find that it can’t be done without mandates--” Krugman writes, “but if he tries to institute mandates, the enemies of reform will use his own words against him.
“If you combine the economic analysis with these political realities,” he continues, “ here’s what I think it says: If Mrs. Clinton gets the Democratic nomination, there is some chance — nobody knows how big — that we’ll get universal health care in the next administration. If Mr. Obama gets the nomination, it just won’t happen.”
I won’t go quite that far. But I do agree that Obama has put himself in a very difficult position. And I am concerned that his original opposition to mandates reveals that he hadn’t thought through the economics of health care reform. He was simply trying to appeal to some of his most loyal supporters: young, well-educated, relatively affluent Americans who might resent having to buy insurance that they feel they don’t need.
Yet that resentment illustrates just the type of division—in this case between young and old—that Obama says he wants to cure. Repeatedly, he has called for “unity” to heal the country’s problems.
In truth, the only way we will achieve meaningful healthcare reform is if we begin thinking as a community. Young and old, rich and poor—we have to watch each others’ backs. I wrote about this last week after talking to Paul Berwick, CEO of the Institute for Health Care Improvement at a Families USA conference. Berwick, who is one of the most respected figures in American medicine, described how we need to re-imagine our healthcare system while re-allocating resources to provide high quality, sustainable health care for everyone. Passionate and eloquent, Berwick combines hope with pragmatism. He ended his speech by saying, “We’re not going to achieve universal coverage by encouraging everyone to ‘pursue his or her own individual self-interest.’”
Conservatives have divided the nation. We need to begin to think collectively-- about what is best for everyone.
"We need to begin to think collectively-- about what is best for everyone."
I couldn't agree more with that statement. I do not, however, support mandates as a way to achieve universal health care.
A couple of years ago health care wonks on the left were howling about what a disaster the Medicare Part D program was. Mandates would replicate the complexity and confusion of that program and magnify it exponentially.
Universal health care is a fight worth having.
Why aren't mandate proponents willing to fight? I recognize that stakeholders in the current system will probably have to be bought off some way but why start negotiations leaving some of the worst aspects of the current system intact? It is like going to buy a new car and making your first offer the sticker price.
February 5, 2008 8:05 PM | Reply | Permalink
Why don't we admit that we've known how to do mandates for decades? It's called the payroll tax.
February 5, 2008 8:09 PM | Reply | Permalink
Taxes are mandates, and that is the only way to successfully finance a universal health care program. Surely we all know that. But, the problem is that any candidate who proposes a health care plan that requires a tax increase will never be elected.
What is missing from all of these discussions is an analysis of how such a tax financed system would affect each of us. If the effect is a tripling of our tax rate, forget it, it will never come to pass. But, if it can be shown that the increase in taxes will largely be offset by reductions in medical expenses and insurance expenses, then it has a chance. I have been patiently waiting for such an analysis for months now.
February 5, 2008 8:17 PM | Reply | Permalink
Emma, Bluebell, adn hoppycalif2--
Good to hear from you. And in hoppycalif's case--with a picture to boot! (I very much like the way tpm cafe is really bringing readers into the process.)
Emma--
Thanks for the support on a collective vision.
That, I think, is the most important thing that
Americans need to learn about healthcare.
And I, too, think that the Medicare Advantage program--which pays private insurers a huge premium to administer Medicare and offer drugs to Medicare patients--was a terrible mistake.
But mandates are not designed to benefit private insurers.
Under both Clinton's plan (as well as Edward's plan) people would be required to sign up for insurance--but they would not have to sign up with private insurers.
They would have a choice between a private insurance plan and a public sector plan that would be roughly equivalent to "Medicare for All."
MOreover, private insurers would be forced to compete with Medicare for All on a level playing field. They would not be allowed to cherry pick healthy patients. They would not be allowed to turn down sick or older patients-or charge them more.
They would have to provide insurance that is at least as comprehensive as Medicare for all. No cheap "Swiss Cheese" policies that are full of holes.
At the outset, many people who have employer-based insurance might well opt to stay with it. And many people who couldn't afford their employer's insurance will be able to afford it because Hillary's plan offers subsidies to all low-income and lower-income famlies.
But I'm reasonably certain that the public sector "Medicare for all" plan will be able to offer more coverage at a lower cost. And over time, many people will decide to move to the public sector plan. Many private insurers will simply wither away.
Most Americans don't want a single-payer plan right now because so many (80 percent) have an empoloyer-sponsored plan that they like. That's why we can't move to single-payer today. We need to give people a choice--and a chance to see how the public sector "Medicare-for-all" plan works out.
But we won't be able to finance the public-sector plan unless everyone (includng young, healthy, relatively affluent people) contributes to the national health care fund.
Bluebell- You are absolutely right. The mandate requiring that everyone sign up for health insurance is no different from the mandate that we now have requiring that everyone contribute to Social Security and Medicare.
And we could save a lot in administraive costs and paperwork if people paid for their health care insurance. on a monthly basis, through their paychecks--just as they now pay for Medicare and SS.
Hoppycalif2--First, if everyone contributes to national health insurance--including the young and healthy--we won't need enormous tax increases.
Nevertheless, covering everyone will cost more--unless we put a break on healthhcare inflation by reducing the waste in our system--all of the redundant tests, unnecessary, unproven and ineffective procedures, and the over-priced "bleeding edge" drugs and devices that are not better than the less expensive, older and less risky drugs and devices that we already have.
I have written about this here http://dartmed.dartmouth.edu/spring07/html/atlas.php
If you have been waiting for someone to explain, in detail, how we are going to pay for this, I think you'll find this story heartening.
There is plenty of money sloshing around in tbe system. $2.1 trillion is enough to provide everyone with high quality care. Countries like Switzerland do it for 60 percent of what we spend.
Okay, we have more poor people--and, as a result, more sick people. But the extra amount that we now spend is more than enough to cover that. We just need to spend the money wisely. (If you have any trouble with the link above, just Google my
name and "Dartmouth Medicine" (the magazine where the story appears) and "Spring 2007".
February 5, 2008 9:18 PM | Reply | Permalink
The question raises other questions, like why do we have more poor.
Caution is required in looking at utilization. Still, I agree there are perverse incentives in our system, including physicians that own testing equipment or shares in a lab. Controlling those costs frees up more money for sound medicine.
Nice to hear you on NPR.
February 5, 2008 9:49 PM | Reply | Permalink
I agree with you Maggie and everyone knows I'm no Obama supporter but... is it fair to say that Obama demonized mandates?
You yourself have written many times that mandates face pretty natural opposition because people don't like to be told what to do.
If that's the case then mandates are unpopular anyway. I'm not arguing efficacy here, just popularity.
So Obama's taken a position that might not be the best practically but that takes the public will into account.
It's been argued many times here that the problem with all of these plans is that they make room for private insurance. Whenever we make that argument to you, you rightly say: "Most people like their current health insurance so they have to be given the option of keeping it, and that means a role for the private insurers."
You say that even though you seem to agree that single payer really would work best.
In any event, all Obama has done is to take the majority opinion on the mandate issue. That's the same thing that both he and Clinton have done, according to you, on the role of private insurers in the system. So why is one okay and the other "demonization?"
February 5, 2008 10:08 PM | Reply | Permalink
Glad to see you bringing the HealtBeat good sense into the debate on this forum. I wanted to link to it earlier today but there are ongoing issues with the site "upgrade" here, that prevented me from so doing at the time.
Everyone truly interested in the health care issues (not just universal insurance but all the other ancillary issues, as well), should beat feet to www.healthbeat.org. Oh yeah, and buy the book, too!
http://www.powells.com/biblio/61-9780060765330-0
;-)
Thanks.
mp
February 5, 2008 10:13 PM | Reply | Permalink
My thinking is that both plans will fail unless they are able to control and bring down health care costs. To start they will be extremely expensive and have limited appeal except to the poor and those with pre-existing conditions.
Many of us would be willing to pay more for the good of all. Unfortunately, a significant percentage of our population would not.
So, yes my belief that Obama's plan will be easier to pass is important. But, we also clearly need some time to move forward with policies like direct price negotiation and prescription drug importation to make insurance more affordable and attractive.
If Hillary gets the nomination I will vote for her. If she gets elected I will encourage my representatives to support her health care plan. But, I have little hope that she'll get it passed and if she does that it will prove the victory we all hope for...
February 5, 2008 10:18 PM | Reply | Permalink
Thanks to Maggie for a much more sensible version of the objections I'd tried to raise in a comment on Dean Baker's post. She's also got a fuller elaboration at HealthBeat (and thanks to Michael P. for reminding me of the name, so that I could catch up with more of her posts) of an objection she doesn't dwell on as much here, that Dean's articulating what amounts to mandates anyhow. I commented that it was the worst of both worlds: mandates for all, but not coverage for all, and mandates that become more costly when one tried to ignore them and then got sick. Indeed, that isn't just the case of someone "gaming the system." There's a natural hope that quickly becomes a belief when money's tight that it won't happen to you.
February 6, 2008 10:28 AM | Reply | Permalink
BTW, never mind looking for my comment on Dean if you were inclined to try. It appears never to have "took." I couldn't post on this thread at all, more obviously: it told me I wasn't registered, even though the comment box was there with "Hello jhaber" above it. I found, speaking of gaming the system, that I could post if I first logged out and then logged in again, but only here, where the comment box should appear. Page top was useless.
February 6, 2008 10:44 AM | Reply | Permalink
Sorry for the string of comments, but one should note that Obama himself is firmly promising no mandates, in a way that seems to undermine Dean's argument. Via Ezra Klein via Kevin Drum: "[I] mean, if a mandate was the solution, we can try that to solve homelessness by mandating that everybody buy a house. the reason they don't have a house is they don't have the money."
February 6, 2008 10:52 AM | Reply | Permalink
Thanks for the personal response, Maggie.
I think you are seriously underestimating the ability of insurance companies to cherry pick through targeted marketing and indirect adverse selection. Maybe I am missing something but I cannot see any essential difference between community ratings with automatic inclusions and an ordinary group insurance plan. Insurance companies have lots of experience marketing and de-marketing(?) group plans. Unless part of the mandate plan is to assign communities to insurers and cap premiums, I don’t see how you avoid Medicare-for-all ending up with all the Superfund communities and insurers with all the college towns.
February 6, 2008 12:34 PM | Reply | Permalink
Doesn't Hillary's plan have exactly the same problem? She has not answered the question -- raised by Obama in the last debate -- as to how she's going to enforce the mandates. If it's a fine -- as with mandatory car insurance -- and people can't afford to pay the fine, will that be subsidized?
I disagree that Obama's plan is a defacto mandate. It respects the freedom of the individual to choose but makes him face the consequences of those choices. That is the essense of what freedom really means -- not the right to make any choice and then get bailed out if it doesn't work out. That's what freedom has been corrupted into.
No, because of what I said above. He is preserving the choice of the individual, which is as much a respect thing as it is a policy thing -- and that's what all of you mandate folks don't get.
February 6, 2008 12:42 PM | Reply | Permalink
Insurance companies had only very limited ability to cherry pick right now, since they are required to take on anyone who signs up for healthcare at work-- and that includes workers with expensive health problems (who may be healthy enough to continue working) and also their dependents. Cherry picking mainly occurs in the individual health insurance market, which is a small fraction of the total market.
February 6, 2008 2:16 PM | Reply | Permalink
" 'Would we subsidize the penalties?' Doesn't Hillary's plan have exactly the same problem? If it's a fine -- as with mandatory car insurance -- and people can't afford to pay the fine, will that be subsidized?" I don't see that as a problem, since the whole idea of universal health insurance includes making it affordable for people. If they could never pay the fine, they would be less in a position to be fined.
The only reason it's a problem for Dean's plan is that it all but guarantees that a lot of people will be fined or otherwise mandated only once medical care has pushed them into the category of nonpayers. It's as if the social-security system mandated payments in only when it came time for payments out. That's a formula for bankrupting either the recipient who needs help or else government and the system itself. Either way, the plan fails and health care loses.
February 6, 2008 2:43 PM | Reply | Permalink
Making it affordable is not just some magic switch that's turned on as soon as you mandate it. Costs are out of control. Whatever number is given for subsidies will prove too small. Whatever coverage is provided will prove too little for those with significant health care needs. I believe Obama's plan will cover those who need it most while giving us time to make fixes to the system. If Hillary has her way the benefits will be attacked with each budget overrun and opponents to universal healthcare will have plenty of stories to tell how the insurance proved too little to help this one or that one.
February 6, 2008 3:04 PM | Reply | Permalink
Tom, destor 23, mp,whoffman, jhaber, Emma, Common Dreamer, Jon F311--
It's good to hear from all of you.
Tom--Yes, the question "Why do we have more poor" goes to the heart of the matter. The answer, I'm afraid, is a lack of solidarity. The French feel that nothing is too good for other Frenchmen. We don't feel that way about each other. Instead, we tend to think individually--in terms of what we want for ourselves and our families.
Meanwhile, poverty is the single greatest cause of poor health in America. If we really fought poverty--and brought inner city schools up to the level of the best public schools in the nation--we would do more to improve the health of the nation than any insurance program ever could.
Destor 23-- I think Obama "demonized" the mandate issue with the flyer that looks so much like the "Harry & Louise" ads that the insurance industry used to demonize hillarycare in the early 1990s.
Just as in those ads, Obama's flyer shows a couple sitting at a kitchen table. There's a pile of bills on the table. They're worrying about how they are ever going to be able to afford the
insurance that they are going to be mandated to buy.
Using the "Harry & Louise" ad as a model was
just way over the top. And Obama ignores the fact that Hillary's plan offers subsidies for low-income and lower-middle income people so that they can afford the insurance. Some will get a 100% subsidy. No one will pay more than 5 percent of income. She is very clear on all of that--and Obama knows it.
So, if the poor and lower-middle-class are going to get subsidies, then who would object to
having to buy insurance?
Most people over the age of 35 or so realize that they really need health insurance, as does anyone with a family. They are not likely to object to it--particularly if one of their options is Medicare--for-everyone. Relatively few people object to paying into Medicare--and they really look forward to getting it when they are 65.
The main people who object to mandates forcing them to buy insurance are young, healthy people in their 20s and early 30s who are single or childless and affluent enough that they wouldn't qualify for a subsidy. They feel that they personally don't need health insurance, and many are not particularly interested in contributing to a pool that would help older, sicker, less lucky people (and would also help them when they become older, sicker .)
Who are Obama's most loyal supporters? Young people, under 30, who are well-educated, and elite enough that they are not likely to be eligible for subsidies.
So Obama came out against mandates to pander to his base in a way that seems to me very different from accepting the fact that most people want to keep their employer-based private insurance (if they have it.) I understand why people want to keep what they have and are familiar with.
I'm less sympathetic to young
people you say, "I don't think I need insurance, and I could care less about those who are older and sicker than I am."
Obama is appealing to the resentment that some 20-somethings and 30-somethings feel about baby-boomers--they are concerned that they'll have to support the boomers as they age. (In fact, there is plenty of money in Social Security to take care of the last boomers--the boomers put a huge amount into SS.)
Obama also has had some very unkind things to say about boomers. His message is "unity"--but he seems to want to unite everyone except the young and the old. His casual disdain for the boomers is worrisome. In an interview in the Nation he even referred to the late Senator Paul Wellstone as a "gadfly."
mp--thanks for plugging the blog and the book (For those who are interested, my blog is www.healthbeatblog.org) There I talk about healthcare and health related issues that spill over into poverty, politics, etc. If you're interested in the book, you'll see it on the blog. If you click on the picture, you can buy it, used and in very good condition, on Amazon for a very low price.
whoffmann-- HRC actually has very detailed plans for bringing down the cost of care. See my analysis of her plan here http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
What is very important is that Clinton understands all of the Dartmouth research--which offers a very clear picture of why healthcare in the U.S. is so expensive: one out of three dollars is waste on unncessary tests, unproven procedures, over-priced "cutting-edge" drugs and devices that are not more effective than the older products they have replaced. (See my link to the Dartmouth research in the post on her plan.)
From the very outset, there are cuts to be made in what Medicare (and Medicare for all) covers including statins like Lipitor for all women, men over 65, and men who have not had a heart attack.
Last week's Business Week cover story confirmed what many doctors have known for a long time--there is no evidence whatsover that statins help anyone except men under 65 who have already had a heart attack. And we're not sure how statins help them. We do know that the supposed link between high cholesterol and heart disease just doesn't hold up. Meanwhle, the side effects of statins are terrible--particularly for older men. I'll be writing about this on www.healthbeatblog.org in a couple of days.
Yet, we spend a fortune on drugs like Lipitor.
We also spend a fortune on treatments for early-stage prostate cancer--with no evidence that they are any better than no treatment (The New York Times wrote about that today; I have written about it in the past and did an update on healthbeat today.)
Does this mean Medicare and Medicare for all shouldn't cover treatments for early-stage prostate cancer? At the very least, Medicare should insist that patients be involved in "shared decision-making"-- getting full information on the life-changing side effects of all current treatments, plus the lack of any evidence that the treatements "affect the course of the disease" in any way. Here, I'm quoting the National Cancer Institute. The American Cancer Society no longer recommends PSA testing for early-stage prostate cancer. But urologists keep on doing it.
Patients need more information before going ahead with treatment. Most don't know that there is no scientific evidence of effectiveness.
I could go on. But there is a lot of low-hanging fruit where waste could be cut out of the system. Clinton also is committed to negotiating lower prices from drug-makers.
And whatever Medicare and Medicare for all do in refusing to cover unncessary or ineffective treatments, private insurers will follow suit.
No, controlling costs won't be easy. But Hillary already knows a huge amount about this subject. Unfortunately, Obama doesn't. Healthcare just isn't really one of his main interests. (I have interviewed Obama's health care advisor a few times.)
Also, in terms of which plan could get through Congress--many Republicans like mandates. They see mandates as forcing people to take "personality responsibility." As long as we provide subsidies for lower-income people, and guarantee (as Hillary does) that they will have comprehensive coverage and that it won't cost more than 5 percent of income, that's fine with me.
Emma -- You need to read Hillary's plan.
See my description of it here: http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
You are right that insurers know how to target young healthy people. But under Hillary's plan they would not be allowed to sell low-cost
"Swiss cheese" policies filled with holes--policies that don't cover maternity and pregnancy, for instance, or don't cover rehab after surgery, etc. etc.
All private insurers would be required to sell policies that are at least as comprehensive as the public sector "Medicare for all" plan. They could offer more than that--which would make their plans very expensive--but not less.
They also would not be allowed to charge older people more.
Clinton is determined that they compete "on a level playing field" with the public sector plan. All in all, Hillary's plan makes it virtually impossible to cherry-pick.
Commondreamer-- I respect the fact that you value the "choice of the individual." But Clinton, like
many other progressives, realizes that when it comes to a necessity like healthcare, we have to think collectively. That means we all get into the pool together, and contribute for the welfare of all.
Conservatives always emphasize individual choice. Progressives emphasize equity--everyone having access to healthcare, etc.
As for how Clinton would enforce her mandate--she is not talking about fines. She would enforce it the way we enforce the mandate that everyone contribute to Social Security and that everyone contribute to Medicare.
The least expensive mechanism would be to pay for it out of our paycheck--just as you now pay for Medicare, or pay your share of a private insurance premium if you have employer-sponsored care.
Those who don't have a paycheck (the self-employed) could pay for it on their income taxes--the way they now pay for Medicare. Many of the unemployed would qualify for a full subsidy, so they wouldn't have to pay for it.
Also, if health isurance is mandated, and you sought medical care form a hospital or doctor, you would have to show your insurance card. If you didn't have one, they would automatically enroll you in the public sector plan (using your social security card) and then treat you.
Later, if you wanted to, you could switch to a private plan.
Keep in mind that virtually every other developed country in the world requires that everyone have health insurance --and almost no one objects.
Jon F311--
YOu are right that there is less cherry-picking in the employer-based insurance market.
But, employers often offer a choice of plans, and in those cases as Emma points out, insurers have become pretty good at targeting younger healthier workers--with discounted plans--particularly in places like California.
Also, they charge different small and medium-sized businesses different prices--depending on how healthy their employees are. (In businesses where employee pay is low, employees are likely to be less healthy and premiums are higher--making it less likely that they'll sign up.)
Jhaber --you rightly compare the steep fines Dean Baker describes as equivalent to "the social-security system mandating payments in only when it comes time for payments out. That's a formula for bankrupting either the recipient who needs help or else government and the system itself. Either way, the plan fails and health care loses."
whoffman-- We now spend $2.1 trillion on healthcare--twice as much as the average developed country and in many areas, our health care is not as good (particularly when it comes to preventive care and managing chronic diseases.)
$2.1 trillion is enough to provide high quality care to everyone including the subsidies that lower-middle-class and low-income people will need.
We have more poor people than many nations, so we need to spend more. But we spend 40 percent more than the second highest-spending country--that's enough to take care of the poor if we spend the money wisely.
Yes, there will be complaints when national health insurance refuses to cover every unproven drug that you see advertised on TV. But this isone reason why it is a good idea to have private insurance as well as public sector insurance. When Medicare for all cuts out an ineffective treatment (or will cover it only for the relatively small group of people that it will help) private insuers will follow Medicare's lead--as they do now.
So people won't be able to say "the government is rationing care--or taking away something I need." Everyone will be "rationing care" in the sense of paying only for effective care.
And for-profit insurers will be helping the govt explain why, in fact, this drug or treatment is no better than an older product or procedure--and could be hazardous to your health. More care is not always better care. The newest cutting-edge techniques and products are often not better. All that can be said for sure is that we know less about them. Which is why, three or four years later, so many are withdrawn from the market.
February 6, 2008 5:38 PM | Reply | Permalink
Tom, destor 23, mp,whoffman, jhaber, Emma, Common Dreamer, Jon F311--
It's good to hear from all of you.
Tom--Yes, the question "Why do we have more poor" goes to the heart of the matter. The answer, I'm afraid, is a lack of solidarity. The French feel that nothing is too good for other Frenchmen. We don't feel that way about each other. Instead, we tend to think individually--in terms of what we want for ourselves and our families.
Meanwhile, poverty is the single greatest cause of poor health in America. If we really fought poverty--and brought inner city schools up to the level of the best public schools in the nation--we would do more to improve the health of the nation than any insurance program ever could.
Destor 23-- I think Obama "demonized" the mandate issue with the flyer that looks so much like the "Harry & Louise" ads that the insurance industry used to demonize hillarycare in the early 1990s.
Just as in those ads, Obama's flyer shows a couple sitting at a kitchen table. There's a pile of bills on the table. They're worrying about how they are ever going to be able to afford the
insurance that they are going to be mandated to buy.
Using the "Harry & Louise" ad as a model was
just way over the top. And Obama ignores the fact that Hillary's plan offers subsidies for low-income and lower-middle income people so that they can afford the insurance. Some will get a 100% subsidy. No one will pay more than 5 percent of income. She is very clear on all of that--and Obama knows it.
So, if the poor and lower-middle-class are going to get subsidies, then who would object to
having to buy insurance?
Most people over the age of 35 or so realize that they really need health insurance, as does anyone with a family. They are not likely to object to it--particularly if one of their options is Medicare--for-everyone. Relatively few people object to paying into Medicare--and they really look forward to getting it when they are 65.
The main people who object to mandates forcing them to buy insurance are young, healthy people in their 20s and early 30s who are single or childless and affluent enough that they wouldn't qualify for a subsidy. They feel that they personally don't need health insurance, and many are not particularly interested in contributing to a pool that would help older, sicker, less lucky people (and would also help them when they become older, sicker .)
Who are Obama's most loyal supporters? Young people, under 30, who are well-educated, and elite enough that they are not likely to be eligible for subsidies.
So Obama came out against mandates to pander to his base in a way that seems to me very different from accepting the fact that most people want to keep their employer-based private insurance (if they have it.) I understand why people want to keep what they have and are familiar with.
I'm less sympathetic to young
people you say, "I don't think I need insurance, and I could care less about those who are older and sicker than I am."
Obama is appealing to the resentment that some 20-somethings and 30-somethings feel about baby-boomers--they are concerned that they'll have to support the boomers as they age. (In fact, there is plenty of money in Social Security to take care of the last boomers--the boomers put a huge amount into SS.)
Obama also has had some very unkind things to say about boomers. His message is "unity"--but he seems to want to unite everyone except the young and the old. His casual disdain for the boomers is worrisome. In an interview in the Nation he even referred to the late Senator Paul Wellstone as a "gadfly."
mp--thanks for plugging the blog and the book (For those who are interested, my blog is www.healthbeatblog.org) There I talk about healthcare and health related issues that spill over into poverty, politics, etc. If you're interested in the book, you'll see it on the blog. If you click on the picture, you can buy it, used and in very good condition, on Amazon for a very low price.
whoffmann-- HRC actually has very detailed plans for bringing down the cost of care. See my analysis of her plan here http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
What is very important is that Clinton understands all of the Dartmouth research--which offers a very clear picture of why healthcare in the U.S. is so expensive: one out of three dollars is waste on unncessary tests, unproven procedures, over-priced "cutting-edge" drugs and devices that are not more effective than the older products they have replaced. (See my link to the Dartmouth research in the post on her plan.)
From the very outset, there are cuts to be made in what Medicare (and Medicare for all) covers including statins like Lipitor for all women, men over 65, and men who have not had a heart attack.
Last week's Business Week cover story confirmed what many doctors have known for a long time--there is no evidence whatsover that statins help anyone except men under 65 who have already had a heart attack. And we're not sure how statins help them. We do know that the supposed link between high cholesterol and heart disease just doesn't hold up. Meanwhle, the side effects of statins are terrible--particularly for older men. I'll be writing about this on www.healthbeatblog.org in a couple of days.
Yet, we spend a fortune on drugs like Lipitor.
We also spend a fortune on treatments for early-stage prostate cancer--with no evidence that they are any better than no treatment (The New York Times wrote about that today; I have written about it in the past and did an update on healthbeat today.)
Does this mean Medicare and Medicare for all shouldn't cover treatments for early-stage prostate cancer? At the very least, Medicare should insist that patients be involved in "shared decision-making"-- getting full information on the life-changing side effects of all current treatments, plus the lack of any evidence that the treatements "affect the course of the disease" in any way. Here, I'm quoting the National Cancer Institute. The American Cancer Society no longer recommends PSA testing for early-stage prostate cancer. But urologists keep on doing it.
Patients need more information before going ahead with treatment. Most don't know that there is no scientific evidence of effectiveness.
I could go on. But there is a lot of low-hanging fruit where waste could be cut out of the system. Clinton also is committed to negotiating lower prices from drug-makers.
And whatever Medicare and Medicare for all do in refusing to cover unncessary or ineffective treatments, private insurers will follow suit.
No, controlling costs won't be easy. But Hillary already knows a huge amount about this subject. Unfortunately, Obama doesn't. Healthcare just isn't really one of his main interests. (I have interviewed Obama's health care advisor a few times.)
Also, in terms of which plan could get through Congress--many Republicans like mandates. They see mandates as forcing people to take "personality responsibility." As long as we provide subsidies for lower-income people, and guarantee (as Hillary does) that they will have comprehensive coverage and that it won't cost more than 5 percent of income, that's fine with me.
Emma -- You need to read Hillary's plan.
See my description of it here: http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
You are right that insurers know how to target young healthy people. But under Hillary's plan they would not be allowed to sell low-cost
"Swiss cheese" policies filled with holes--policies that don't cover maternity and pregnancy, for instance, or don't cover rehab after surgery, etc. etc.
All private insurers would be required to sell policies that are at least as comprehensive as the public sector "Medicare for all" plan. They could offer more than that--which would make their plans very expensive--but not less.
They also would not be allowed to charge older people more.
Clinton is determined that they compete "on a level playing field" with the public sector plan. All in all, Hillary's plan makes it virtually impossible to cherry-pick.
Commondreamer-- I respect the fact that you value the "choice of the individual." But Clinton, like
many other progressives, realizes that when it comes to a necessity like healthcare, we have to think collectively. That means we all get into the pool together, and contribute for the welfare of all.
Conservatives always emphasize individual choice. Progressives emphasize equity--everyone having access to healthcare, etc.
As for how Clinton would enforce her mandate--she is not talking about fines. She would enforce it the way we enforce the mandate that everyone contribute to Social Security and that everyone contribute to Medicare.
The least expensive mechanism would be to pay for it out of our paycheck--just as you now pay for Medicare, or pay your share of a private insurance premium if you have employer-sponsored care.
Those who don't have a paycheck (the self-employed) could pay for it on their income taxes--the way they now pay for Medicare. Many of the unemployed would qualify for a full subsidy, so they wouldn't have to pay for it.
Also, if health isurance is mandated, and you sought medical care form a hospital or doctor, you would have to show your insurance card. If you didn't have one, they would automatically enroll you in the public sector plan (using your social security card) and then treat you.
Later, if you wanted to, you could switch to a private plan.
Keep in mind that virtually every other developed country in the world requires that everyone have health insurance --and almost no one objects.
Jon F311--
YOu are right that there is less cherry-picking in the employer-based insurance market.
But, employers often offer a choice of plans, and in those cases as Emma points out, insurers have become pretty good at targeting younger healthier workers--with discounted plans--particularly in places like California.
Also, they charge different small and medium-sized businesses different prices--depending on how healthy their employees are. (In businesses where employee pay is low, employees are likely to be less healthy and premiums are higher--making it less likely that they'll sign up.)
Jhaber --you rightly compare the steep fines Dean Baker describes as equivalent to "the social-security system mandating payments in only when it comes time for payments out. That's a formula for bankrupting either the recipient who needs help or else government and the system itself. Either way, the plan fails and health care loses."
whoffman-- We now spend $2.1 trillion on healthcare--twice as much as the average developed country and in many areas, our health care is not as good (particularly when it comes to preventive care and managing chronic diseases.)
$2.1 trillion is enough to provide high quality care to everyone including the subsidies that lower-middle-class and low-income people will need.
We have more poor people than many nations, so we need to spend more. But we spend 40 percent more than the second highest-spending country--that's enough to take care of the poor if we spend the money wisely.
Yes, there will be complaints when national health insurance refuses to cover every unproven drug that you see advertised on TV. But this isone reason why it is a good idea to have private insurance as well as public sector insurance. When Medicare for all cuts out an ineffective treatment (or will cover it only for the relatively small group of people that it will help) private insuers will follow Medicare's lead--as they do now.
So people won't be able to say "the government is rationing care--or taking away something I need." Everyone will be "rationing care" in the sense of paying only for effective care.
And for-profit insurers will be helping the govt explain why, in fact, this drug or treatment is no better than an older product or procedure--and could be hazardous to your health. More care is not always better care. The newest cutting-edge techniques and products are often not better. All that can be said for sure is that we know less about them. Which is why, three or four years later, so many are withdrawn from the market.
February 6, 2008 5:46 PM | Reply | Permalink
Tom, destor 23, mp,whoffman, jhaber, Emma, Common Dreamer, Jon F311--
It's good to hear from all of you.
Tom--Yes, the question "Why do we have more poor" goes to the heart of the matter. The answer, I'm afraid, is a lack of solidarity. The French feel that nothing is too good for other Frenchmen. We don't feel that way about each other. Instead, we tend to think individually--in terms of what we want for ourselves and our families.
Meanwhile, poverty is the single greatest cause of poor health in America. If we really fought poverty--and brought inner city schools up to the level of the best public schools in the nation--we would do more to improve the health of the nation than any insurance program ever could.
Destor 23-- I think Obama "demonized" the mandate issue with the flyer that looks so much like the "Harry & Louise" ads that the insurance industry used to demonize hillarycare in the early 1990s.
Just as in those ads, Obama's flyer shows a couple sitting at a kitchen table. There's a pile of bills on the table. They're worrying about how they are ever going to be able to afford the
insurance that they are going to be mandated to buy.
Using the "Harry & Louise" ad as a model was
just way over the top. And Obama ignores the fact that Hillary's plan offers subsidies for low-income and lower-middle income people so that they can afford the insurance. Some will get a 100% subsidy. No one will pay more than 5 percent of income. She is very clear on all of that--and Obama knows it.
So, if the poor and lower-middle-class are going to get subsidies, then who would object to
having to buy insurance?
Most people over the age of 35 or so realize that they really need health insurance, as does anyone with a family. They are not likely to object to it--particularly if one of their options is Medicare--for-everyone. Relatively few people object to paying into Medicare--and they really look forward to getting it when they are 65.
The main people who object to mandates forcing them to buy insurance are young, healthy people in their 20s and early 30s who are single or childless and affluent enough that they wouldn't qualify for a subsidy. They feel that they personally don't need health insurance, and many are not particularly interested in contributing to a pool that would help older, sicker, less lucky people (and would also help them when they become older, sicker .)
Who are Obama's most loyal supporters? Young people, under 30, who are well-educated, and elite enough that they are not likely to be eligible for subsidies.
So Obama came out against mandates to pander to his base in a way that seems to me very different from accepting the fact that most people want to keep their employer-based private insurance (if they have it.) I understand why people want to keep what they have and are familiar with.
I'm less sympathetic to young
people you say, "I don't think I need insurance, and I could care less about those who are older and sicker than I am."
Obama is appealing to the resentment that some 20-somethings and 30-somethings feel about baby-boomers--they are concerned that they'll have to support the boomers as they age. (In fact, there is plenty of money in Social Security to take care of the last boomers--the boomers put a huge amount into SS.)
Obama also has had some very unkind things to say about boomers. His message is "unity"--but he seems to want to unite everyone except the young and the old. His casual disdain for the boomers is worrisome. In an interview in the Nation he even referred to the late Senator Paul Wellstone as a "gadfly."
mp--thanks for plugging the blog and the book (For those who are interested, my blog is www.healthbeatblog.org) There I talk about healthcare and health related issues that spill over into poverty, politics, etc. If you're interested in the book, you'll see it on the blog. If you click on the picture, you can buy it, used and in very good condition, on Amazon for a very low price.
whoffmann-- HRC actually has very detailed plans for bringing down the cost of care. See my analysis of her plan here http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
What is very important is that Clinton understands all of the Dartmouth research--which offers a very clear picture of why healthcare in the U.S. is so expensive: one out of three dollars is waste on unncessary tests, unproven procedures, over-priced "cutting-edge" drugs and devices that are not more effective than the older products they have replaced. (See my link to the Dartmouth research in the post on her plan.)
From the very outset, there are cuts to be made in what Medicare (and Medicare for all) covers including statins like Lipitor for all women, men over 65, and men who have not had a heart attack.
Last week's Business Week cover story confirmed what many doctors have known for a long time--there is no evidence whatsover that statins help anyone except men under 65 who have already had a heart attack. And we're not sure how statins help them. We do know that the supposed link between high cholesterol and heart disease just doesn't hold up. Meanwhle, the side effects of statins are terrible--particularly for older men. I'll be writing about this on www.healthbeatblog.org in a couple of days.
Yet, we spend a fortune on drugs like Lipitor.
We also spend a fortune on treatments for early-stage prostate cancer--with no evidence that they are any better than no treatment (The New York Times wrote about that today; I have written about it in the past and did an update on healthbeat today.)
Does this mean Medicare and Medicare for all shouldn't cover treatments for early-stage prostate cancer? At the very least, Medicare should insist that patients be involved in "shared decision-making"-- getting full information on the life-changing side effects of all current treatments, plus the lack of any evidence that the treatements "affect the course of the disease" in any way. Here, I'm quoting the National Cancer Institute. The American Cancer Society no longer recommends PSA testing for early-stage prostate cancer. But urologists keep on doing it.
Patients need more information before going ahead with treatment. Most don't know that there is no scientific evidence of effectiveness.
I could go on. But there is a lot of low-hanging fruit where waste could be cut out of the system. Clinton also is committed to negotiating lower prices from drug-makers.
And whatever Medicare and Medicare for all do in refusing to cover unncessary or ineffective treatments, private insurers will follow suit.
No, controlling costs won't be easy. But Hillary already knows a huge amount about this subject. Unfortunately, Obama doesn't. Healthcare just isn't really one of his main interests. (I have interviewed Obama's health care advisor a few times.)
Also, in terms of which plan could get through Congress--many Republicans like mandates. They see mandates as forcing people to take "personality responsibility." As long as we provide subsidies for lower-income people, and guarantee (as Hillary does) that they will have comprehensive coverage and that it won't cost more than 5 percent of income, that's fine with me.
Emma -- You need to read Hillary's plan.
See my description of it here: http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
You are right that insurers know how to target young healthy people. But under Hillary's plan they would not be allowed to sell low-cost
"Swiss cheese" policies filled with holes--policies that don't cover maternity and pregnancy, for instance, or don't cover rehab after surgery, etc. etc.
All private insurers would be required to sell policies that are at least as comprehensive as the public sector "Medicare for all" plan. They could offer more than that--which would make their plans very expensive--but not less.
They also would not be allowed to charge older people more.
Clinton is determined that they compete "on a level playing field" with the public sector plan. All in all, Hillary's plan makes it virtually impossible to cherry-pick.
Commondreamer-- I respect the fact that you value the "choice of the individual." But Clinton, like
many other progressives, realizes that when it comes to a necessity like healthcare, we have to think collectively. That means we all get into the pool together, and contribute for the welfare of all.
Conservatives always emphasize individual choice. Progressives emphasize equity--everyone having access to healthcare, etc.
As for how Clinton would enforce her mandate--she is not talking about fines. She would enforce it the way we enforce the mandate that everyone contribute to Social Security and that everyone contribute to Medicare.
The least expensive mechanism would be to pay for it out of our paycheck--just as you now pay for Medicare, or pay your share of a private insurance premium if you have employer-sponsored care.
Those who don't have a paycheck (the self-employed) could pay for it on their income taxes--the way they now pay for Medicare. Many of the unemployed would qualify for a full subsidy, so they wouldn't have to pay for it.
Also, if health isurance is mandated, and you sought medical care form a hospital or doctor, you would have to show your insurance card. If you didn't have one, they would automatically enroll you in the public sector plan (using your social security card) and then treat you.
Later, if you wanted to, you could switch to a private plan.
Keep in mind that virtually every other developed country in the world requires that everyone have health insurance --and almost no one objects.
Jon F311--
YOu are right that there is less cherry-picking in the employer-based insurance market.
But, employers often offer a choice of plans, and in those cases as Emma points out, insurers have become pretty good at targeting younger healthier workers--with discounted plans--particularly in places like California.
Also, they charge different small and medium-sized businesses different prices--depending on how healthy their employees are. (In businesses where employee pay is low, employees are likely to be less healthy and premiums are higher--making it less likely that they'll sign up.)
Jhaber --you rightly compare the steep fines Dean Baker describes as equivalent to "the social-security system mandating payments in only when it comes time for payments out. That's a formula for bankrupting either the recipient who needs help or else government and the system itself. Either way, the plan fails and health care loses."
whoffman-- We now spend $2.1 trillion on healthcare--twice as much as the average developed country and in many areas, our health care is not as good (particularly when it comes to preventive care and managing chronic diseases.)
$2.1 trillion is enough to provide high quality care to everyone including the subsidies that lower-middle-class and low-income people will need.
We have more poor people than many nations, so we need to spend more. But we spend 40 percent more than the second highest-spending country--that's enough to take care of the poor if we spend the money wisely.
Yes, there will be complaints when national health insurance refuses to cover every unproven drug that you see advertised on TV. But this isone reason why it is a good idea to have private insurance as well as public sector insurance. When Medicare for all cuts out an ineffective treatment (or will cover it only for the relatively small group of people that it will help) private insuers will follow Medicare's lead--as they do now.
So people won't be able to say "the government is rationing care--or taking away something I need." Everyone will be "rationing care" in the sense of paying only for effective care.
And for-profit insurers will be helping the govt explain why, in fact, this drug or treatment is no better than an older product or procedure--and could be hazardous to your health. More care is not always better care. The newest cutting-edge techniques and products are often not better. All that can be said for sure is that we know less about them. Which is why, three or four years later, so many are withdrawn from the market.
February 6, 2008 5:48 PM | Reply | Permalink
Tom, destor 23, mp,whoffman, jhaber, Emma, Common Dreamer, Jon F311--
It's good to hear from all of you.
Tom--Yes, the question "Why do we have more poor" goes to the heart of the matter. The answer, I'm afraid, is a lack of solidarity. The French feel that nothing is too good for other Frenchmen. We don't feel that way about each other. Instead, we tend to think individually--in terms of what we want for ourselves and our families.
Meanwhile, poverty is the single greatest cause of poor health in America. If we really fought poverty--and brought inner city schools up to the level of the best public schools in the nation--we would do more to improve the health of the nation than any insurance program ever could.
Destor 23-- I think Obama "demonized" the mandate issue with the flyer that looks so much like the "Harry & Louise" ads that the insurance industry used to demonize hillarycare in the early 1990s.
Just as in those ads, Obama's flyer shows a couple sitting at a kitchen table. There's a pile of bills on the table. They're worrying about how they are ever going to be able to afford the
insurance that they are going to be mandated to buy.
Using the "Harry & Louise" ad as a model was
just way over the top. And Obama ignores the fact that Hillary's plan offers subsidies for low-income and lower-middle income people so that they can afford the insurance. Some will get a 100% subsidy. No one will pay more than 5 percent of income. She is very clear on all of that--and Obama knows it.
So, if the poor and lower-middle-class are going to get subsidies, then who would object to
having to buy insurance?
Most people over the age of 35 or so realize that they really need health insurance, as does anyone with a family. They are not likely to object to it--particularly if one of their options is Medicare--for-everyone. Relatively few people object to paying into Medicare--and they really look forward to getting it when they are 65.
The main people who object to mandates forcing them to buy insurance are young, healthy people in their 20s and early 30s who are single or childless and affluent enough that they wouldn't qualify for a subsidy. They feel that they personally don't need health insurance, and many are not particularly interested in contributing to a pool that would help older, sicker, less lucky people (and would also help them when they become older, sicker .)
Who are Obama's most loyal supporters? Young people, under 30, who are well-educated, and elite enough that they are not likely to be eligible for subsidies.
So Obama came out against mandates to pander to his base in a way that seems to me very different from accepting the fact that most people want to keep their employer-based private insurance (if they have it.) I understand why people want to keep what they have and are familiar with.
I'm less sympathetic to young
people you say, "I don't think I need insurance, and I could care less about those who are older and sicker than I am."
Obama is appealing to the resentment that some 20-somethings and 30-somethings feel about baby-boomers--they are concerned that they'll have to support the boomers as they age. (In fact, there is plenty of money in Social Security to take care of the last boomers--the boomers put a huge amount into SS.)
Obama also has had some very unkind things to say about boomers. His message is "unity"--but he seems to want to unite everyone except the young and the old. His casual disdain for the boomers is worrisome. In an interview in the Nation he even referred to the late Senator Paul Wellstone as a "gadfly."
mp--thanks for plugging the blog and the book (For those who are interested, my blog is www.healthbeatblog.org) There I talk about healthcare and health related issues that spill over into poverty, politics, etc. If you're interested in the book, you'll see it on the blog. If you click on the picture, you can buy it, used and in very good condition, on Amazon for a very low price.
whoffmann-- HRC actually has very detailed plans for bringing down the cost of care. See my analysis of her plan here http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
What is very important is that Clinton understands all of the Dartmouth research--which offers a very clear picture of why healthcare in the U.S. is so expensive: one out of three dollars is waste on unncessary tests, unproven procedures, over-priced "cutting-edge" drugs and devices that are not more effective than the older products they have replaced. (See my link to the Dartmouth research in the post on her plan.)
From the very outset, there are cuts to be made in what Medicare (and Medicare for all) covers including statins like Lipitor for all women, men over 65, and men who have not had a heart attack.
Last week's Business Week cover story confirmed what many doctors have known for a long time--there is no evidence whatsover that statins help anyone except men under 65 who have already had a heart attack. And we're not sure how statins help them. We do know that the supposed link between high cholesterol and heart disease just doesn't hold up. Meanwhle, the side effects of statins are terrible--particularly for older men. I'll be writing about this on www.healthbeatblog.org in a couple of days.
Yet, we spend a fortune on drugs like Lipitor.
We also spend a fortune on treatments for early-stage prostate cancer--with no evidence that they are any better than no treatment (The New York Times wrote about that today; I have written about it in the past and did an update on healthbeat today.)
Does this mean Medicare and Medicare for all shouldn't cover treatments for early-stage prostate cancer? At the very least, Medicare should insist that patients be involved in "shared decision-making"-- getting full information on the life-changing side effects of all current treatments, plus the lack of any evidence that the treatements "affect the course of the disease" in any way. Here, I'm quoting the National Cancer Institute. The American Cancer Society no longer recommends PSA testing for early-stage prostate cancer. But urologists keep on doing it.
Patients need more information before going ahead with treatment. Most don't know that there is no scientific evidence of effectiveness.
I could go on. But there is a lot of low-hanging fruit where waste could be cut out of the system. Clinton also is committed to negotiating lower prices from drug-makers.
And whatever Medicare and Medicare for all do in refusing to cover unncessary or ineffective treatments, private insurers will follow suit.
No, controlling costs won't be easy. But Hillary already knows a huge amount about this subject. Unfortunately, Obama doesn't. Healthcare just isn't really one of his main interests. (I have interviewed Obama's health care advisor a few times.)
Also, in terms of which plan could get through Congress--many Republicans like mandates. They see mandates as forcing people to take "personality responsibility." As long as we provide subsidies for lower-income people, and guarantee (as Hillary does) that they will have comprehensive coverage and that it won't cost more than 5 percent of income, that's fine with me.
Emma -- You need to read Hillary's plan.
See my description of it here: http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
You are right that insurers know how to target young healthy people. But under Hillary's plan they would not be allowed to sell low-cost
"Swiss cheese" policies filled with holes--policies that don't cover maternity and pregnancy, for instance, or don't cover rehab after surgery, etc. etc.
All private insurers would be required to sell policies that are at least as comprehensive as the public sector "Medicare for all" plan. They could offer more than that--which would make their plans very expensive--but not less.
They also would not be allowed to charge older people more.
Clinton is determined that they compete "on a level playing field" with the public sector plan. All in all, Hillary's plan makes it virtually impossible to cherry-pick.
Commondreamer-- I respect the fact that you value the "choice of the individual." But Clinton, like
many other progressives, realizes that when it comes to a necessity like healthcare, we have to think collectively. That means we all get into the pool together, and contribute for the welfare of all.
Conservatives always emphasize individual choice. Progressives emphasize equity--everyone having access to healthcare, etc.
As for how Clinton would enforce her mandate--she is not talking about fines. She would enforce it the way we enforce the mandate that everyone contribute to Social Security and that everyone contribute to Medicare.
The least expensive mechanism would be to pay for it out of our paycheck--just as you now pay for Medicare, or pay your share of a private insurance premium if you have employer-sponsored care.
Those who don't have a paycheck (the self-employed) could pay for it on their income taxes--the way they now pay for Medicare. Many of the unemployed would qualify for a full subsidy, so they wouldn't have to pay for it.
Also, if health isurance is mandated, and you sought medical care form a hospital or doctor, you would have to show your insurance card. If you didn't have one, they would automatically enroll you in the public sector plan (using your social security card) and then treat you.
Later, if you wanted to, you could switch to a private plan.
Keep in mind that virtually every other developed country in the world requires that everyone have health insurance --and almost no one objects.
Jon F311--
YOu are right that there is less cherry-picking in the employer-based insurance market.
But, employers often offer a choice of plans, and in those cases as Emma points out, insurers have become pretty good at targeting younger healthier workers--with discounted plans--particularly in places like California.
Also, they charge different small and medium-sized businesses different prices--depending on how healthy their employees are. (In businesses where employee pay is low, employees are likely to be less healthy and premiums are higher--making it less likely that they'll sign up.)
Jhaber --you rightly compare the steep fines Dean Baker describes as equivalent to "the social-security system mandating payments in only when it comes time for payments out. That's a formula for bankrupting either the recipient who needs help or else government and the system itself. Either way, the plan fails and health care loses."
whoffman-- We now spend $2.1 trillion on healthcare--twice as much as the average developed country and in many areas, our health care is not as good (particularly when it comes to preventive care and managing chronic diseases.)
$2.1 trillion is enough to provide high quality care to everyone including the subsidies that lower-middle-class and low-income people will need.
We have more poor people than many nations, so we need to spend more. But we spend 40 percent more than the second highest-spending country--that's enough to take care of the poor if we spend the money wisely.
Yes, there will be complaints when national health insurance refuses to cover every unproven drug that you see advertised on TV. But this isone reason why it is a good idea to have private insurance as well as public sector insurance. When Medicare for all cuts out an ineffective treatment (or will cover it only for the relatively small group of people that it will help) private insuers will follow Medicare's lead--as they do now.
So people won't be able to say "the government is rationing care--or taking away something I need." Everyone will be "rationing care" in the sense of paying only for effective care.
And for-profit insurers will be helping the govt explain why, in fact, this drug or treatment is no better than an older product or procedure--and could be hazardous to your health. More care is not always better care. The newest cutting-edge techniques and products are often not better. All that can be said for sure is that we know less about them. Which is why, three or four years later, so many are withdrawn from the market.
February 6, 2008 5:58 PM | Reply | Permalink
HRC's interview last Sunday on ABC's This Week with George Stephanopoulos has been distorted pretty badly regarding wage garnishing. It's classic work.
The entry page at ABC's site is titled in large letters:
Sen. Clinton Weighs Garnishing Wages to Pay for Universal Health Care.
That is followed by very small type subtitle which says:
Obama's Critique of Clinton's Mandate is "Absolutely Untrue," She Says
The AP version:
Clinton: Garnish wages to pay for health care
Subtitle:
Sen. Hillary Clinton: Force people to pay
The complete transcript of the show.
HRC said that in all cases, the premium would be a small fraction of an individual's total income. She stated that her plan had to be Universal to be doable economically, and that persons found to be in non-compliance would be brought into compliance. She specifically stated that this would not include penalties or fines, and would not rule out garnishing wages absolutely, but it is a non-issue in this case. The vast majority of workers would automatically be in compliance through payroll taxes, and those in non-compliance would be a few self-employed or employees working for small businesses who decided not to go by the rules. How many out of the total work force would this even be germane for if her plan were to be enacted?
Personally, I do not see much difference between forced payroll taxes or wage garnishment, but many workers have a negative reaction to the term "garnishment", while "payroll tax" doesn't affect them the same way. This is an attempt to instill FearHillary.
February 7, 2008 2:35 AM | Reply | Permalink
We keep hearing about "Universal Health Care" and then sit and listen to the candidates (all of them) speak about and describe a universal insurance policy. Listen up folks, there is a difference. Our health care system is stretched to its limits. Fewer and fewer Americans are deciding to enter the health care field and our demand for health care professionals grows every day. Haven't you heard or read about the long delays Americans experience when seeking medical help? If we add 46 million new customers to an already over taxed system these waits will only get longer, complaints will grow, and we will become dillusioned with our system. What these leader "want-to-be's" should be addressing is their plans to bring more of our young into the health field. They (the candidates) don't because they can't. None of them have any vision. One only wants to scare you into voting for him, one has hope (all form and no substance), and the third has a plan (for yesterdays problems). Let's Put America First.
February 7, 2008 12:02 PM | Reply | Permalink
Tom, destor 23, mp,whoffman, jhaber, Emma, Common Dreamer, Jon F311--
It's good to hear from all of you. Sorry I didn't get back to you sooner, but the website wasn't accepting my post.
Tom--Yes, the question "Why do we have more poor" goes to the heart of the matter. The answer, I'm afraid, is a lack of solidarity. The French feel that nothing is too good for other Frenchmen. We don't feel that way about each other. Instead, we tend to think individually--in terms of what we want for ourselves and our families.
Meanwhile, poverty is the single greatest cause of poor health in America. If we really fought poverty--and brought inner city schools up to the level of the best public schools in the nation--we would do more to improve the health of the nation than any insurance program ever could.
Destor 23-- I think Obama "demonized" the mandate issue with the flyer that looks so much like the "Harry & Louise" ads that the insurance industry used to demonize hillarycare in the early 1990s.
Just as in those ads, Obama's flyer shows a couple sitting at a kitchen table. There's a pile of bills on the table. They're worrying about how they are ever going to be able to afford the
insurance that they are going to be mandated to buy.
Using the "Harry & Louise" ad as a model was
just way over the top. And Obama ignores the fact that Hillary's plan offers subsidies for low-income and lower-middle income people so that they can afford the insurance. Some will get a 100% subsidy. No one will pay more than 5 percent of income. She is very clear on all of that--and Obama knows it.
So, if the poor and lower-middle-class are going to get subsidies, then who would object to
having to buy insurance?
Most people over the age of 35 or so realize that they really need health insurance, as does anyone with a family. They are not likely to object to it--particularly if one of their options is Medicare--for-everyone. Relatively few people object to paying into Medicare--and they really look forward to getting it when they are 65.
The main people who object to mandates forcing them to buy insurance are young, healthy people in their 20s and early 30s who are single or childless and affluent enough that they wouldn't qualify for a subsidy. They feel that they personally don't need health insurance, and many are not particularly interested in contributing to a pool that would help older, sicker, less lucky people (and would also help them when they become older, sicker .)
Who are Obama's most loyal supporters? Young people, under 30, who are well-educated, and elite enough that they are not likely to be eligible for subsidies.
So Obama came out against mandates to pander to his base in a way that seems to me very different from accepting the fact that most people want to keep their employer-based private insurance (if they have it.) I understand why people want to keep what they have and are familiar with.
I'm less sympathetic to young
people you say, "I don't think I need insurance, and I could care less about those who are older and sicker than I am."
Obama is appealing to the resentment that some 20-somethings and 30-somethings feel about baby-boomers--they are concerned that they'll have to support the boomers as they age. (In fact, there is plenty of money in Social Security to take care of the last boomers--the boomers put a huge amount into SS.)
Obama also has had some very unkind things to say about boomers. His message is "unity"--but he seems to want to unite everyone except the young and the old. His casual disdain for the boomers is worrisome. In an interview in the Nation he even referred to the late Senator Paul Wellstone as a "gadfly."
mp--thanks for plugging the blog and the book (For those who are interested, my blog is www.healthbeatblog.org) There I talk about healthcare and health related issues that spill over into poverty, politics, etc. If you're interested in the book, you'll see it on the blog. If you click on the picture, you can buy it, used and in very good condition, on Amazon for a very low price.
whoffmann-- HRC actually has very detailed plans for bringing down the cost of care. See my analysis of her plan here http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
What is very important is that Clinton understands all of the Dartmouth research--which offers a very clear picture of why healthcare in the U.S. is so expensive: one out of three dollars is waste on unncessary tests, unproven procedures, over-priced "cutting-edge" drugs and devices that are not more effective than the older products they have replaced. (See my link to the Dartmouth research in the post on her plan.)
From the very outset, there are cuts to be made in what Medicare (and Medicare for all) covers including statins like Lipitor for all women, men over 65, and men who have not had a heart attack.
Last week's Business Week cover story confirmed what many doctors have known for a long time--there is no evidence whatsover that statins help anyone except men under 65 who have already had a heart attack. And we're not sure how statins help them. We do know that the supposed link between high cholesterol and heart disease just doesn't hold up. Meanwhle, the side effects of statins are terrible--particularly for older men. I'll be writing about this on www.healthbeatblog.org in a couple of days.
Yet, we spend a fortune on drugs like Lipitor.
We also spend a fortune on treatments for early-stage prostate cancer--with no evidence that they are any better than no treatment (The New York Times wrote about that today; I have written about it in the past and did an update on healthbeat today.)
Does this mean Medicare and Medicare for all shouldn't cover treatments for early-stage prostate cancer? At the very least, Medicare should insist that patients be involved in "shared decision-making"-- getting full information on the life-changing side effects of all current treatments, plus the lack of any evidence that the treatements "affect the course of the disease" in any way. Here, I'm quoting the National Cancer Institute. The American Cancer Society no longer recommends PSA testing for early-stage prostate cancer. But urologists keep on doing it.
Patients need more information before going ahead with treatment. Most don't know that there is no scientific evidence of effectiveness.
I could go on. But there is a lot of low-hanging fruit where waste could be cut out of the system. Clinton also is committed to negotiating lower prices from drug-makers.
And whatever Medicare and Medicare for all do in refusing to cover unncessary or ineffective treatments, private insurers will follow suit.
No, controlling costs won't be easy. But Hillary already knows a huge amount about this subject. Unfortunately, Obama doesn't. Healthcare just isn't really one of his main interests. (I have interviewed Obama's health care advisor a few times.)
Also, in terms of which plan could get through Congress--many Republicans like mandates. They see mandates as forcing people to take "personality responsibility." As long as we provide subsidies for lower-income people, and guarantee (as Hillary does) that they will have comprehensive coverage and that it won't cost more than 5 percent of income, that's fine with me.
Emma -- You need to read Hillary's plan.
See my description of it here: http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
You are right that insurers know how to target young healthy people. But under Hillary's plan they would not be allowed to sell low-cost
"Swiss cheese" policies filled with holes--policies that don't cover maternity and pregnancy, for instance, or don't cover rehab after surgery, etc. etc.
All private insurers would be required to sell policies that are at least as comprehensive as the public sector "Medicare for all" plan. They could offer more than that--which would make their plans very expensive--but not less.
They also would not be allowed to charge older people more.
Clinton is determined that they compete "on a level playing field" with the public sector plan. All in all, Hillary's plan makes it virtually impossible to cherry-pick.
Commondreamer-- I respect the fact that you value the "choice of the individual." But Clinton, like
many other progressives, realizes that when it comes to a necessity like healthcare, we have to think collectively. That means we all get into the pool together, and contribute for the welfare of all.
Conservatives always emphasize individual choice. Progressives emphasize equity--everyone having access to healthcare, etc.
As for how Clinton would enforce her mandate--she is not talking about fines. She would enforce it the way we enforce the mandate that everyone contribute to Social Security and that everyone contribute to Medicare.
The least expensive mechanism would be to pay for it out of our paycheck--just as you now pay for Medicare, or pay your share of a private insurance premium if you have employer-sponsored care.
Those who don't have a paycheck (the self-employed) could pay for it on their income taxes--the way they now pay for Medicare. Many of the unemployed would qualify for a full subsidy, so they wouldn't have to pay for it.
Also, if health isurance is mandated, and you sought medical care form a hospital or doctor, you would have to show your insurance card. If you didn't have one, they would automatically enroll you in the public sector plan (using your social security card) and then treat you.
Later, if you wanted to, you could switch to a private plan.
Keep in mind that virtually every other developed country in the world requires that everyone have health insurance --and almost no one objects.
Jon F311--
YOu are right that there is less cherry-picking in the employer-based insurance market.
But, employers often offer a choice of plans, and in those cases as Emma points out, insurers have become pretty good at targeting younger healthier workers--with discounted plans--particularly in places like California.
Also, they charge different small and medium-sized businesses different prices--depending on how healthy their employees are. (In businesses where employee pay is low, employees are likely to be less healthy and premiums are higher--making it less likely that they'll sign up.)
Jhaber --you rightly compare the steep fines Dean Baker describes as equivalent to "the social-security system mandating payments in only when it comes time for payments out. That's a formula for bankrupting either the recipient who needs help or else government and the system itself. Either way, the plan fails and health care loses."
whoffman-- We now spend $2.1 trillion on healthcare--twice as much as the average developed country and in many areas, our health care is not as good (particularly when it comes to preventive care and managing chronic diseases.)
$2.1 trillion is enough to provide high quality care to everyone including the subsidies that lower-middle-class and low-income people will need.
We have more poor people than many nations, so we need to spend more. But we spend 40 percent more than the second highest-spending country--that's enough to take care of the poor if we spend the money wisely.
Yes, there will be complaints when national health insurance refuses to cover every unproven drug that you see advertised on TV. But this isone reason why it is a good idea to have private insurance as well as public sector insurance. When Medicare for all cuts out an ineffective treatment (or will cover it only for the relatively small group of people that it will help) private insuers will follow Medicare's lead--as they do now.
So people won't be able to say "the government is rationing care--or taking away something I need." Everyone will be "rationing care" in the sense of paying only for effective care.
And for-profit insurers will be helping the govt explain why, in fact, this drug or treatment is no better than an older product or procedure--and could be hazardous to your health. More care is not always better care. The newest cutting-edge techniques and products are often not better. All that can be said for sure is that we know less about them. Which is why, three or four years later, so many are withdrawn from the market.
February 7, 2008 2:48 PM | Reply | Permalink
Tom, destor 23, mp,whoffman, jhaber, Emma, Common Dreamer, Jon F311--
It's good to hear from all of you. Sorry I didn't reply sooner, but I couldn't get the website to accept my response. . .
Tom--Yes, the question "Why do we have more poor" goes to the heart of the matter. The answer, I'm afraid, is a lack of solidarity. The French feel that nothing is too good for other Frenchmen. We don't feel that way about each other. Instead, we tend to think individually--in terms of what we want for ourselves and our families.
Meanwhile, poverty is the single greatest cause of poor health in America. If we really fought poverty--and brought inner city schools up to the level of the best public schools in the nation--we would do more to improve the health of the nation than any insurance program ever could.
Destor 23-- I think Obama "demonized" the mandate issue with the flyer that looks so much like the "Harry & Louise" ads that the insurance industry used to demonize hillarycare in the early 1990s.
Just as in those ads, Obama's flyer shows a couple sitting at a kitchen table. There's a pile of bills on the table. They're worrying about how they are ever going to be able to afford the
insurance that they are going to be mandated to buy.
Using the "Harry & Louise" ad as a model was
just way over the top. And Obama ignores the fact that Hillary's plan offers subsidies for low-income and lower-middle income people so that they can afford the insurance. Some will get a 100% subsidy. No one will pay more than 5 percent of income. She is very clear on all of that--and Obama knows it.
So, if the poor and lower-middle-class are going to get subsidies, then who would object to
having to buy insurance?
Most people over the age of 35 or so realize that they really need health insurance, as does anyone with a family. They are not likely to object to it--particularly if one of their options is Medicare--for-everyone. Relatively few people object to paying into Medicare--and they really look forward to getting it when they are 65.
The main people who object to mandates forcing them to buy insurance are young, healthy people in their 20s and early 30s who are single or childless and affluent enough that they wouldn't qualify for a subsidy. They feel that they personally don't need health insurance, and many are not particularly interested in contributing to a pool that would help older, sicker, less lucky people (and would also help them when they become older, sicker .)
Who are Obama's most loyal supporters? Young people, under 30, who are well-educated, and elite enough that they are not likely to be eligible for subsidies.
So Obama came out against mandates to pander to his base in a way that seems to me very different from accepting the fact that most people want to keep their employer-based private insurance (if they have it.) I understand why people want to keep what they have and are familiar with.
I'm less sympathetic to young
people you say, "I don't think I need insurance, and I could care less about those who are older and sicker than I am."
Obama is appealing to the resentment that some 20-somethings and 30-somethings feel about baby-boomers--they are concerned that they'll have to support the boomers as they age. (In fact, there is plenty of money in Social Security to take care of the last boomers--the boomers put a huge amount into SS.)
Obama also has had some very unkind things to say about boomers. His message is "unity"--but he seems to want to unite everyone except the young and the old. His casual disdain for the boomers is worrisome. In an interview in the Nation he even referred to the late Senator Paul Wellstone as a "gadfly."
mp--thanks for plugging the blog and the book (For those who are interested, my blog is www.healthbeatblog.org) There I talk about healthcare and health related issues that spill over into poverty, politics, etc. If you're interested in the book, you'll see it on the blog. If you click on the picture, you can buy it, used and in very good condition, on Amazon for a very low price.
whoffmann-- HRC actually has very detailed plans for bringing down the cost of care. See my analysis of her plan here http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
What is very important is that Clinton understands all of the Dartmouth research--which offers a very clear picture of why healthcare in the U.S. is so expensive: one out of three dollars is waste on unncessary tests, unproven procedures, over-priced "cutting-edge" drugs and devices that are not more effective than the older products they have replaced. (See my link to the Dartmouth research in the post on her plan.)
From the very outset, there are cuts to be made in what Medicare (and Medicare for all) covers including statins like Lipitor for all women, men over 65, and men who have not had a heart attack.
Last week's Business Week cover story confirmed what many doctors have known for a long time--there is no evidence whatsover that statins help anyone except men under 65 who have already had a heart attack. And we're not sure how statins help them. We do know that the supposed link between high cholesterol and heart disease just doesn't hold up. Meanwhle, the side effects of statins are terrible--particularly for older men. I'll be writing about this on www.healthbeatblog.org in a couple of days.
Yet, we spend a fortune on drugs like Lipitor.
We also spend a fortune on treatments for early-stage prostate cancer--with no evidence that they are any better than no treatment (The New York Times wrote about that today; I have written about it in the past and did an update on healthbeat today.)
Does this mean Medicare and Medicare for all shouldn't cover treatments for early-stage prostate cancer? At the very least, Medicare should insist that patients be involved in "shared decision-making"-- getting full information on the life-changing side effects of all current treatments, plus the lack of any evidence that the treatements "affect the course of the disease" in any way. Here, I'm quoting the National Cancer Institute. The American Cancer Society no longer recommends PSA testing for early-stage prostate cancer. But urologists keep on doing it.
Patients need more information before going ahead with treatment. Most don't know that there is no scientific evidence of effectiveness.
I could go on. But there is a lot of low-hanging fruit where waste could be cut out of the system. Clinton also is committed to negotiating lower prices from drug-makers.
And whatever Medicare and Medicare for all do in refusing to cover unncessary or ineffective treatments, private insurers will follow suit.
No, controlling costs won't be easy. But Hillary already knows a huge amount about this subject. Unfortunately, Obama doesn't. Healthcare just isn't really one of his main interests. (I have interviewed Obama's health care advisor a few times.)
Also, in terms of which plan could get through Congress--many Republicans like mandates. They see mandates as forcing people to take "personality responsibility." As long as we provide subsidies for lower-income people, and guarantee (as Hillary does) that they will have comprehensive coverage and that it won't cost more than 5 percent of income, that's fine with me.
Emma -- You need to read Hillary's plan.
See my description of it here: http://tpmcafe.talkingpointsmemo.com/2007/09/17/update_hillarys_plan/
You are right that insurers know how to target young healthy people. But under Hillary's plan they would not be allowed to sell low-cost
"Swiss cheese" policies filled with holes--policies that don't cover maternity and pregnancy, for instance, or don't cover rehab after surgery, etc. etc.
All private insurers would be required to sell policies that are at least as comprehensive as the public sector "Medicare for all" plan. They could offer more than that--which would make their plans very expensive--but not less.
They also would not be allowed to charge older people more.
Clinton is determined that they compete "on a level playing field" with the public sector plan. All in all, Hillary's plan makes it virtually impossible to cherry-pick.
Commondreamer-- I respect the fact that you value the "choice of the individual." But Clinton, like
many other progressives, realizes that when it comes to a necessity like healthcare, we have to think collectively. That means we all get into the pool together, and contribute for the welfare of all.
Conservatives always emphasize individual choice. Progressives emphasize equity--everyone having access to healthcare, etc.
As for how Clinton would enforce her mandate--she is not talking about fines. She would enforce it the way we enforce the mandate that everyone contribute to Social Security and that everyone contribute to Medicare.
The least expensive mechanism would be to pay for it out of our paycheck--just as you now pay for Medicare, or pay your share of a private insurance premium if you have employer-sponsored care.
Those who don't have a paycheck (the self-employed) could pay for it on their income taxes--the way they now pay for Medicare. Many of the unemployed would qualify for a full subsidy, so they wouldn't have to pay for it.
Also, if health isurance is mandated, and you sought medical care form a hospital or doctor, you would have to show your insurance card. If you didn't have one, they would automatically enroll you in the public sector plan (using your social security card) and then treat you.
Later, if you wanted to, you could switch to a private plan.
Keep in mind that virtually every other developed country in the world requires that everyone have health insurance --and almost no one objects.
Jon F311--
YOu are right that there is less cherry-picking in the employer-based insurance market.
But, employers often offer a choice of plans, and in those cases as Emma points out, insurers have become pretty good at targeting younger healthier workers--with discounted plans--particularly in places like California.
Also, they charge different small and medium-sized businesses different prices--depending on how healthy their employees are. (In businesses where employee pay is low, employees are likely to be less healthy and premiums are higher--making it less likely that they'll sign up.)
Jhaber --you rightly compare the steep fines Dean Baker describes as equivalent to "the social-security system mandating payments in only when it comes time for payments out. That's a formula for bankrupting either the recipient who needs help or else government and the system itself. Either way, the plan fails and health care loses."
whoffman-- We now spend $2.1 trillion on healthcare--twice as much as the average developed country and in many areas, our health care is not as good (particularly when it comes to preventive care and managing chronic diseases.)
$2.1 trillion is enough to provide high quality care to everyone including the subsidies that lower-middle-class and low-income people will need.
We have more poor people than many nations, so we need to spend more. But we spend 40 percent more than the second highest-spending country--that's enough to take care of the poor if we spend the money wisely.
Yes, there will be complaints when national health insurance refuses to cover every unproven drug that you see advertised on TV. But this isone reason why it is a good idea to have private insurance as well as public sector insurance. When Medicare for all cuts out an ineffective treatment (or will cover it only for the relatively small group of people that it will help) private insuers will follow Medicare's lead--as they do now.
So people won't be able to say "the government is rationing care--or taking away something I need." Everyone will be "rationing care" in the sense of paying only for effective care.
And for-profit insurers will be helping the govt explain why, in fact, this drug or treatment is no better than an older product or procedure--and could be hazardous to your health. More care is not always better care. The newest cutting-edge techniques and products are often not better. All that can be said for sure is that we know less about them. Which is why, three or four years later, so many are withdrawn from the market.
February 7, 2008 4:37 PM | Reply | Permalink
The conversation you linked to is very hard to follow but I do admire your willingness to engage your oppostion. I remain in opposition but will retire for now to order my thoughts for another tilt another day.
February 7, 2008 6:20 PM | Reply | Permalink
Re: We have more poor people than many nations, so we need to spend more.
I'm not sure the poor are the problem, as they usually receive healthcare through Medicaid, albeit of an often inferior sort. The real problem is with working people and the self-employed for whom insurance (even when offered through employers) is simply priced out of reach.
Re: Fewer and fewer Americans are deciding to enter the health care field
Can you document this? It's my understanding that healthcare employment is steadily increasing. Given that it often pays modestly well (with exceptions, like nursing home workers)
and is very nearly recession-proof I would be surprised if people were passing up on this field.
Re: If we add 46 million new customers to an already over taxed system these waits will only get longer...
We aren't adding anyone. They're already here and they are already getting healthcare though in very inefficient and costly ways (and may end up in bankruptcy if their problems are serious).
February 7, 2008 7:26 PM | Reply | Permalink
Maggie, I still think you are missing the problem with this plan. If you are an upscale worker with a nice corporate or government job, you've got health insurance which may well be quite nicely subsidized and quite a bargain particularly if you are a higher income employee who could afford to pay substantially more. The working class guy or working class gal probably already resents your good fortune. So who do these "mandates" punish? Not the upscale folks who get to keep what they already like but the downscale folks who are coerced into buying what they can't afford or perceive they can't afford for a promise of a subsidy later (which the Republicans will relentlessly attempt to undermine as they already do with programs like SCHIP). Medicare and Social security work at least in terms of being popular because people perceive they are being treated equally. The mandates do not fall on everyone equally.
February 7, 2008 8:03 PM | Reply | Permalink
Bluebell, Jon F311 and Emma
Hello again!
Bluebell: YOu are right the people who have relatively generous employer plans that they like tend to be people on the upper end of the middle class ladder, upper middle class people and the wealthy.
But mandates won't "punish" downscale people. As the American Prospect's Paul Starr has pointed out, it would be politically impossible to mandate that everyone buy insurance without providing adequate subsidies that will make it possible.
IF you believe otherwise it's because you have been listening to the scare campaigns,launched by Obama as well as the conservatives, warning that the government will force low-income families to buy insurance they cannot afford. No one can or will do that.
That's why Massachusetts has had to exempt 20 percent of its population from the requirement ot buy insurance. The state cannot come up with enough money to cover subsidies (in part because it doesn't have a mandate with teeth, many affluent people aren't contributing to the state fund that would provide subsidies) and so it had to drop the mandate for one-fifth of its population.
Less affluent people won't be punished by a mandate ; they'll have something they never had before: enough money to buy really good insurance.
Every other developed country in the world does this: requiring insurance and making it affordable.
And by the way, Republicans won't be able to underfund the subsidies the way they have underfunded SCHIP because SCHIP is a state plan. The states decide how much to spend, and what to do with the federal money they get. The Republicans made sure of that when SCHIP was first passed. And it is possible for the federal govt to give states an "unfunded mandate"--requiring something without giving the states enough money to pay for it. It is not possible, however, for the Federal govt to give American citizens an unfunded mandate--the promise of subsidies will have to be fulfilled.
The people who will be unhappy about mandates are the very affluent people who self-insure using a health savings account. For the very wealth, HSAs are the best tax loophole ever. You just have to
have enough discretionary income to fund one every year, and then use other savings for your routine
health care needs. Meanwhile your HSA compounds, tax-free, for 30 or 40 or 50 years. A nice windfall to hand down to your children, insuring that wealth in the U.S. continues to be consolidated in the hands of a small percentage of
families.
These wealthy families also buy a low-cost, high-deductible catastrophic policy to cover any huge health bills, but if there is no mandate, they don't have to buy a comprehensive insurance package, and pay full-price into the national insurance fund that will provide subsidies for the less wealthy.
(Under all of the Democratic plans private insurers will only be able only sell comprehensive plans that are at least as comprehensive as the Medicare for all public sector plan--no how-deductible plans low cost plans filled with holes)
The other group that dislikes mandates are the young, affluent peopole who support Obama. This is why he has said no to mandates--he is trying to appeal to his base. This 20-somethings and some 30-somethings are young enough and healthy enough that they feel they don't need insurance. Or at most, they'll buy a low-cost catastrophic plan. They do not particularly want to have to contribute their full fair share to a national fund that will help people who are poorer, sicker, and older than they are. (Even though, when they are older and sicker, they will expect society to care for them.)
Recently, here on TPM Jim Sleeper gave what I am afraid is a pretty accurate description of many people in his group. Keep in mind, they are Sleeper's friends. (Although he is older, he watched Super Tuesday with a group of younger friends. And he supports Obama and voted for him. Nevertheless, Sleeper has concerns about Obama's supporters. He writes that he
"fears that too many young whites with bright prospects have no really serious intention of redressing the growing inequities which the neoliberal world that employs them is spawning, not just between themselves and poor blacks on the Southside but, these days, between blacks and blacks, and women and women, let alone between cool young whites like themselves and the declasse, lumpy white and Latino workers all around them.
"Not that my young friends defend wholeheartedly the system in which they're prospering. To their credit, it makes them uncomfortable. But they grasp at mostly symbolic gestures of a politics of moral posturing that relieves racial and class guilt and steadies their moral self-regard with smallish contributions to Obama, an Ivy alum whom they trust to help those people on the Southside without dragging them too deeply into it; without reconfiguring how we charter our corporations and re-construe the private and public investments that employ upscale young whites and well-behaved non-whites; and certainly without redistributing their own bright prospects and future prerogatives and second homes."
These are the people who don't want mandates.
Jon F311--
Healthcare for the poor is very expensive precisely because the care they get on Medicaid (if they qualify for Medicaid) is inferior. So they get sicker.
Problems that could have been treated in a doctor's office are treated in a hospitals. Diabetics undergo amputations because no one was managing their disease.
And often, the poor get no care at all. IN New York City, it is very difficult to find a specialist who will take a Medicaid patient. At academic medical centers there are separate clinics for people on Medicaid and they are seen by medical students (resident) not their professors.
In many states, a very poor adult does not qualify for Medicaid unless he has children. (Somewhere along the line, someone decided that the only "deserving poor" are people who marry and have families. Tough luck for Gays.
The poor also are sicker because air quality in areas where they live (like the Bronx) is much poorer. Lots of asbestos. Lots of respiratory diseases. Obesity is a bigger problem cause many of the cheapest foods are high-carb. And in ghetto neighborhoods, if you can find fresh fruits and vegetables they are very expensive. Poor people don't belong to gyms. They don't come home and jog because it's too dangerous in their neighborhood.
In NYC public schools in poor neighborhoods don't have gyms and they don't have playgrounds.
This is why the poor are sick.
I'm not sure who said fewer Americans are entering the heatlhcare field--it wasn't me.
But it is true that fewer Americans are willing to become nurses and work in our hospitals becuase our hospitals are so chaotic and so many errors are made. Nursing pay has gone up substantially, but many nurses say "I won't do it for any amoutn of money. It's just too stressful--i'm constantly afraid that I'm going to make a mistake--or someone is going to give met the wrong medication--and I'll kill someone.
That's why the average hospital in the U.
S. is able to fill only 92% of its nursing slots. That's why, when a patient rings, no one may have time to respond.
Emma-- Here's a link to something else I wrote about the Hillary plan that you may find clearer:
http://www.thehealthcareblog.com/the_health_
care_blog/2007/09/policy-clinton-.html
February 9, 2008 2:16 PM | Reply | Permalink
- Massachusetts plan has left 20% (maybe more) uninsured. If we apply that to the nation, we're talking at least 8 million uninsured.
- Clinton's enforcement mechanism versus Obama's encouragement mechanism will have very similar results. The difference is political feasibility.
- Both will offer subsidies for those who cannot afford it. My understanding is that Obama's are better funded.
- But, the real problem is that you have to cut costs before you can do a full mandate. This is what Obama plan does. Yes, Hillary has plans here too, but she is putting the cart in front of the horse.
February 9, 2008 3:39 PM | Reply | Permalink