Are Mandates Mandatory?
President Obama didn't think so back in the days when he was running for president and it may be time for progressives to start rethinking the question as well. To be clear, mandates or something very mandate like, are an essential part of a universal health care plan. They are needed for universal coverage, this is largely addressed by insurance reform measures that prohibit discrimination based on pre-existing condition and denial of coverage. With these measures in place, a person can first sign up for insurance after they get sick. It's sort of like buying car insurance after you have been in a wreck, and then having the insurer pick up the tab.
Of course, if everyone waited until they got sick before they bought insurance, then the system does not work. Hence the mandates. But it is important to understand that the mandates are not about extending coverage, they are about preventing free-riding. They are, in effect, a form of taxation, and a a very regressive one.
So, in a context where a public plan looks to be dead in the water -- thank you Kent Conrad -- the question is whether progressives should support a regressive tax, the proceeds of which goes to the insurance industry.
If we get the sort of insurance reform that President Obama has proposed, then mandates, or something very much like them, will be necessary at some point. But they will not be necessary from day 1. After all, not everyone is going to rush out to game the insurance system. It will take some period of time before the number of free riders grows enough to be a real problem.
We know that it will be necessary to revisit health care in the not too future in any case. The lack of mandates will help to ensure that this date comes sooner. Then we can talk about measures that will allow us to control costs, like a robust public plan.
But, if we can't get a public plan in this round, why should progressives be pushing for a regressive tax that will go into the pockets of the insurance companies and their overpaid CEOs? Let the insurance companies try to make a living in the market, when they grow up and feel strong enough to compete with a public plan, then we can have mandates.
And, if it is necessary to agree to mandates to get insurance reform through this round, then we should at least be clear what is going on. The insurance companies' employees in Congress will insist on taxing workers to line their bosses pockets.
The other part of the question is how many of us would be able to afford mandated private insurance? If we know we will be unable to afford it, why support it? Just as a baby step toward eventual, possible further reform? To give the President a bill he can call a victory?
We have heard talk about tax breaks for people with incomes X-times the poverty level. Those computations aren't always curative. The last "stimulus money" never reached the self-employed, who are not an insignifigant part of the economy, though I forget the percentage. 12%?
For me it's just one more in a line of disappointments in this administration.
August 17, 2009 7:11 AM | Reply | Permalink
If we're going with a private-sector solution, then several things will be necessary:
The key in making this work, however, is for the government to require insurance companies to provide an acceptable coverage option at an acceptable price to all customers. Insurance companies can compete by lowering prices or adding benefits, but we must require them to offer a certain basic coverage at an established price to all comers. That's our only hope for controlling costs in a private-sector solution that mandates coverage: force the insurers to offer a reasonable plan at a reasonable price and let them compete by finding ways to provide reasonable coverage for less money or by finding ways to improve coverage at minimal cost.
August 17, 2009 7:50 AM | Reply | Permalink
Thanks for saying it, now I don't have to! Smart comment. Highly recommended.
The key to making this scheme work is draconian enforcement of regulations, sort of like a DEA for health insurance governance laws, and mandated coverage. Along with the actual regulations themselves and the medical best practices boards and support from the grassroots, this plan has a moderate chance at success.
We can always kill the insurance companies in a couple years if they prove unruly and replace them with Medicare if we can figure out a way to fix it, which making it the public option would have done but democrats were too myopic to suggest it.
August 17, 2009 8:21 AM | Reply | Permalink
Enjoy your fantasy world, guys, in which the 'necessary' has the remotest connection with what actually happens.
Progressive politicians need to be prepared to vote against this bill -- not just abstain, vote against.
August 17, 2009 9:16 AM | Reply | Permalink
Whatever it takes. I would rather lose a couple hardcore "liberals" and "conservatives" at the fringes while gaining significant support in the center among all political affiliations.
The key to reform, whether public or private solutions, is regulation and enforcement as well as wide-spread acceptance by a majority of Americans. Without all of those conditions present, any reform package will fail. They are actually doing a decent job of driving a consensus view on a reasonable first step at solving our problems.
If that can't be done for a privately-public hybrid system like we have now then it remains doubly impossible for a government-run one to do so. We have a lot of evidence of government idiocy in the management of large budgets, but many well-regulated industries function quite well, if still imperfectly because we don't vote in primary elections.
The first step of reform, especially medical reform, is to do no harm. We can change the system in small, incremental ways that lead to exponential changes because they are widely supported and Americans are always looking for improvements to the way things run. How about we try and fix the system we have instead of declaring it terminal and starting over?
We can always kill the insurance companies in a couple years if this fails. It also gives Medicare a few years to become stronger and better focused before taking the influx of participants should it become necessary to make that the public option.
Either way, I don't see private insurance companies going away unless they fail to live up their part of the reform bargain.
August 17, 2009 9:56 AM | Reply | Permalink
. . . you can't have private-sector universal coverage without subsidies for the poor.
And for 95% of everyone not insured through their employers.
August 17, 2009 9:16 AM | Reply | Permalink
...in other words, this would never work.
A free market would demand that health care insurers be allowed to game the system and not follow freedom inhibiting rules and regulations. Like Wall Street.
August 17, 2009 9:16 AM | Reply | Permalink
An arbitrary "Maximum" determined ... how? Seems to me lobbyists would be setting that number, no?
I don't know why everyone's all huffed-out on "universal" ... let's nail affordable and then expand from there. I want to see what they've got, then let's talk about mandates. Look at how well the SEC does at crafting/enforcing systemic industry regulations (or the say - the EPA with coal ash) ... call me crazy but I don't trust a regulation/enforcement-only model for cost containment. There is no historical precedent for anything but crappy results using that model - regardless of how nice it looks on paper.
As far as I'm concerned the government has NO BUSINESS telling me I have to purchase something from the private market. That takes away power as a consumer. If it's mandated - it should be single payer, government administered and paid for with an honest tax. If they don't want to go there, they shouldn't play with mandates. The option to purchase into an honest government plan seems the absolute minimum protection they can provide, and the best chance a "minimum" plan will be offered for less than the "maximum cost allowed".
If you think people are joining militias at a frightening pace now ... wait until they realize the democrats forced them to either give money to the insurance companies or be in violation of the law. One thing for sure, the republicans will be playing Obama's campaign "no mandates" promise on an endless loop next election cycle. If there isn't a SERIOUS equalizer in the bill, the democrats deserve what happens to them.
August 17, 2009 6:25 PM | Reply | Permalink
Like car insurance or homeowners insurance? There are plenty of fundamental services we are required to purchase by the government from private firms. Garbage services in many places is privately run. Electricity and water and gas, while not mandated, might as well be required.
Isn't paying a hefty increase in taxes to the government by weight of law just the same as being required to pay a private company?
So, you don't trust the government to regulate private health insurers but you trust the government to totally run health insurance despite the fact that they have some significant problems doing so?
I am not sure how liberals expect to get anything done until you stop being so bloody paranoid about republicans. It smallest of fringe that belongs to militia groups. They are like the leftie equivalent of crazy hippies who spike trees or chase fishing boats around the Bering Sea. They are hemorrhoids of any political philosophy and general make it impossible for party moderates to get anything done.
Finally, you keep talking about bringing the price down and the only way to do that is to lower demand or make coverage mandated. Mandates also serve another function. In order for private insurance companies to operate in that environment, they have to agree to much stricter regulation. By supplying a mandate, insurers become easier to control.
Sure, they are please as punch that the overall pool of applicants is going up, but they also know they will make much less per person overall. As other reforms start making America healthier and demand goes down, the payouts for insurers will go down and the price will come down as well.
There are some fairly clear analogues from other countries who have done the same with health insurance reform as well as other industries in the US where mandates brought down price, again car and homeowners insurance just to name a few.
August 19, 2009 8:32 AM | Reply | Permalink
The difference vs. home or car insurance is that there are options in both of those cases. If you can't afford home insurance, you can always rent a house. If you can't afford car insurance, use some other means of transportation. How exactly are people supposed to avoid health insurance - die?
August 19, 2009 12:26 PM | Reply | Permalink
That wasn't exactly my point and I am not entirely sure what your point is. I was responding that the mandates for insurance are not unheard of and have been ruled Constitutional in the past.
August 23, 2009 6:12 PM | Reply | Permalink
In Virginia, there is an alternative to buying auto insurance: pay a $500 uninsured motorist fee. This gives the driver no insurance coverage, and he remains liable if he is involved in an accident, but it does allow him to drive legally without insurance coverage.
Hazard insurance on real property is normally required if you have a mortgage, but that requirement is not made by the state but by the lender in order to protect the collateral. I could be wrong, but I don't believe there is any law that requires individual homeowners to carry a hazard insurance policy.
August 19, 2009 3:07 PM | Reply | Permalink
The mortgage laws are where the requirement for homeowners insurance comes in. Additionally, mortgage lenders won't give you a mortgage without it.
August 23, 2009 6:14 PM | Reply | Permalink
No Public Option?
Mandated coverage?
GO POUND SAND!
~OGD~
August 17, 2009 8:39 AM | Reply | Permalink
While the broad market was slammed [today], shares of large health insurers rallied as the Obama administration apparently backed off its plan to give Americans the option of signing up for a government-run health-insurance option.
I wonder why.
August 17, 2009 12:45 PM | Reply | Permalink
I am glad you used the word tax. Mandatory health insurance is, of course, a tax. Even non-mandatory health insurance is a tax. When calculating our national tax take, we should always include the price we pay for health insurance. So instead of 18-21% of GDP it is really a little above 30% of GDP. Has been for years, and getting worse.
When will we reign in those tax-and-spend health insurance companies. Especially since all they spend it on is bureaucracy and perqs of office.
August 17, 2009 9:18 AM | Reply | Permalink
Here is Conrad's webform for email. Let him know what you think about his sell out.
August 17, 2009 9:23 AM | Reply | Permalink
Better yet . . .
Here's the tool's fax number . . .
Conrad's DC FAX: (202) 224-7776
Oh and ... Don't forget Baucus...
DC FAX: 202-224-9412
Make their staff do their job.
~OGD~
August 17, 2009 9:54 AM | Reply | Permalink
Mandates worry me for a couple of reasons. The minor one is that I hate to be told what to do. In this case it doesn't bother me a ton since I'm being told to do something I'm doing anyway.
The regressive tax argument is far more important. We can't force people to buy something they can't afford and Obama had a good quip during the primaries -- what are we going to do, fine them? The answer is to subsidize their purchases of healthcare.
Single payer is one way around this since the government would just sign everyone up and pay for healthcare out of tax revenues. But we can't do that because we live in loony land where it's okay for an insurance company to take premiums out of your paycheck but bad for the government to take taxes in lieu of premiums. Now to me, fifty bucks a week is fifty bucks a week no matter who takes it from me but what do I know?
August 17, 2009 9:28 AM | Reply | Permalink
This is why I really don't understand the folks who are so against the idea of single payer! Fifty dollars is the same no matter who it goes to.
August 17, 2009 9:57 AM | Reply | Permalink
we live in loony land
That really is the crux of the problem, isn't it?
I fear our country is headed for a much-deserved Darwin Award . . .
August 17, 2009 9:59 PM | Reply | Permalink
It's a welfare program for the insurance industry.
August 17, 2009 9:59 AM | Reply | Permalink
dean's really hit the nail on the head - no public option no mandates. progressives who can't bring themselves to vote no on the bill (despite the long list of signers) should make this the bottom line.
the other reforms being proposed into the system are critical and will help some people. but there is no reason to give the insurance companies a captive market if their greed can't be constrained in any meaningful way.
as the business week article on health reform noted, the mandate will make the insurance companies big winners in all of this. don't give it to them.
August 17, 2009 10:49 AM | Reply | Permalink
All the other industrialized democracies provide better health care for all their citizens at lower cost. Mandates are an essential feature of all those systems. Nevertheless, those societies are more egalitarian - i.e., less regressive - than ours. That is because they make sure through subsidies that all citizens can afford their insurance.
This includes the single payer nations (the minority), the nations with public/private hybrid systems (the majority), and the Netherlands, which provides universal coverage for almost all medical services exclusively via highly regulated private insurers.
Currently, we are poised to institute most of the necessary reform provisions, and although a pure government run public plan is unlikely, some public/private competition via non-profit cooperatives is a probable substitute.
We can afford to lose the public option, even though it would be a desirable healthcare component, but I don't believe we could realistically expect to retain the benefits of the other meaningful reforms in the current package if we abandon a mandate.
August 17, 2009 10:49 AM | Reply | Permalink
Unfortunately, a mandate without a public option is nothing but a subsidy.
August 17, 2009 11:38 AM | Reply | Permalink
It's important to remember that this issue is not being decided in a vacuum, but rather that we have the experience of dozens of other nations to guide us. All utilize mandates as an essential feature of their superior systems. Only a minority have established a system in which public and private insurance compete with each other, and one - the Netherlands - achieves universal coverage for most medical services exclusively via private insurers -
http://en.wikipedia.org/wiki/Health_care_in_the_Netherlands
If one considers this issue on the basis of empirical data rather than ideology, I believe it becomes clear that the importance of a public option has been overstated, particularly if a public presence via non-profit cooperatives can be substituted.
To be clear, I favor a public option, and I believe continued pressure on Congress to embrace a public option will be valuable in shaping the outcome. I don't believe that the absence of a public option should be reason for despair. Rather, the proposed reforms, including mandates, will be something to celebrate if we can achieve them.
August 17, 2009 12:01 PM | Reply | Permalink
There you go totally misconstruing how the Netherlands works again. It's apples and oranges and totally misleading in the current debate.
Again. The Netherlands wouldn't work without the Government providing a PUBLIC health plan that covers serious/extended care. They also subsidize the insurance industry: the government pays 62% of ALL health-related costs! They also use claim-based funding to private insurance so they are ASSURED a specific profit margin (and impose strict controls that limit maximum profits). Which proposal on the table mirrors the Netherlands system?
I haven't seen anyone propose to open up wider access to Medicare to remove the burden of high-cost patients from the private market; nor has anyone offered to cover 60% of individual premiums. There doesn't really seem to be much of an analogy between what's on the table and what they do in the Netherlands(a country smaller than New York, BTW). Both of these factors(and the laws/administration) are crucial to the system working.
Again, slowly. The Netherlands provides "Social Insurance" (a Public option) for everything but basic acute/preventitive care - open to anyone of any age who needs it. Full Stop. To call it a private insurance only system. Is. A. Lie. Full Stop. To imply that the bullshit system Kent Conrad hopes to see would be it's equivalent - Is. A. Lie.
If you look at it empirically - you are intentionally slinging bullshit. And FYI, CBO reports indicate co-ops don't control prices worth a crap.
August 17, 2009 5:47 PM | Reply | Permalink
. . . you are intentionally slinging bullshit.
Could it be that Fred Moolten is a concern troll -- that visiting liberal blogs is his day job paid for by a public relations and/or direct lobbying firm?
Who has the time to type as much as he does about health care "reform"? Who regularly argues that everything the Democrats give up is understandable and explainable and in the long run, a good deal because we liberals are getting more than we could hope for? Who argues that the health insurance industry -- after accepting a few tweaks -- constitutes a perfectly reasonable solution to the health care crisis?
If he's not a concern troll, he might as well be.
August 17, 2009 8:57 PM | Reply | Permalink
Totally agree, Ellen!
August 17, 2009 11:04 PM | Reply | Permalink
Could be.
August 17, 2009 11:46 PM | Reply | Permalink
Having been accused of the same crime, partisan paranoia is a far more likely explanation than paid provocateur. I thought you were fan of Occom's Razor politics, Gasket.
August 18, 2009 12:37 PM | Reply | Permalink
Hmmmm, could be
=D
December 5, 2009 10:08 PM | Reply | Permalink
Missed this one. Ellen strikes again. But sadly it is looking like freds team might have won the war.
December 6, 2009 2:20 AM | Reply | Permalink
It's not a matter of ideology for me to say that a mandate with only private health insurers is an industry subsidy. If the government required all citizens to purchases 15 pounds of broccoli a year you'd rightly call that a subsidy for the broccoli industry, wouldn't you?
August 17, 2009 6:19 PM | Reply | Permalink
Well, you can protest you're not an ideologue all you want, but I know you're living in a "vacuum" and are refusing to "consider" the "empirical data" -- just like the rest of those despicable liberal ideologues.
I know because Fred Moolten told me so.
August 17, 2009 9:09 PM | Reply | Permalink
LOL!!!
August 18, 2009 12:56 PM | Reply | Permalink
If the benefits are mandated at a set amount based on a defined package of services, what does it matter who provides the services? As a matter of fact, as the largest single client of the private insurers, they are going to have even more power to negotiate. Same way the Medicare Part D thing would have gone under a smarter group of legislators.
I think many here are drastically underestimating the good that proper regulatory frameworks and enforcement of those rules via a national mandate for coverage can have on the current environment. Even absent a public option of any kind, let alone the Sallie Mae style coops, this will be a huge win for democrats because it will be moderate enough to force many republicans to vote for it.
The public opinion for health care reform of some kind being passed this year is pretty clear. The on-going need for reforms is a given. I think over four years progressives can get everything they desire by way of a series of smart fixes of our existing system vice tossing the baby out with the bathwater.
Like it or not, this country has long taken its change in gradual, moderated steps over a number of years that were widely supported by the majority of voters. This is just the goal-line push on the opening drive of the game. Walking away with a field-goal is always the wisest strategic move at that point in the game, even if the touch down would feel better.
August 18, 2009 12:44 PM | Reply | Permalink
I think many here are drastically underestimating the good that proper regulatory frameworks and enforcement of those rules via a national mandate for coverage can have on the current environment.
Sorry, the Bush Administration amply demonstrated the folly of putting too much faith in the efficacy of regulatory frameworks.
August 19, 2009 3:27 PM | Reply | Permalink
So, the government is unable to regulate properly but they can run a medical insurance system for 320 million? They are having a hard time making it work for a third that many people right now, let alone the billions upon billions that is wasted in every other executive department. Partisan talking point from either camp won't get this done.
August 23, 2009 6:17 PM | Reply | Permalink
Fred-you conveniently forgot to mention that in countries such as France that have a sort of "public/private" hybrid, the private companies are NON PROFIT! In the Netherlands, the government sets the rates that the companies can charge for the basic service, as well as setting what the basic service entails.
My problem with your views has always been about the morality of mandating profit for a class of companies! I do not believe that is the right thing for the government to do.
And all the folks who are crying "socialism" somehow think that it is perfectly fine to mandate increased profits for the "free-market" (ha!) insurance industry. Not!
August 17, 2009 6:21 PM | Reply | Permalink
Your statements about both France and the Netherlands are incorrect. Both for-profit and non-profit private insurers operate in France, and the Netherlands does not set rates for premiums, but rather requires insurers to offer the same rate to all subscribers regardless of health status. In fact, those private insurers compete with each other to offer the lowest rates.
In any case, I don't suggest we can emulate the Netherlands, and while the French system would be a welcome goal, it's not where we have been headed with the public options that have been proposed.
Remember though that this thread is about mandates, and all the nations with good healthcare mandate coverage. It is not a government run public option per se, but the combination of mandates and competition that is a common feature.
It seems to me that challenging mandates is therefore a step in the wrong direction. We should insist on mandates, and also insist that insurers must compete to offer a specified package of essential services, with no cherry picking and no discriminatory rates based on health status.
How best to do this? Well, I have consistently supported a public option as the best approach, and I hope we all press our legislators to support that option. We should also recognize that there is no magic in a public option that will erase the much larger problem of excessive facilities, tests, and procedures within health care itself; that must still be addressed. Neither should we ignore the fact that while a public option may be the best way to control costs, other measures have already shown themselves capable of doing some of the same things.
August 17, 2009 10:15 PM | Reply | Permalink
No Fred, YOU are wrong.
August 17, 2009 11:02 PM | Reply | Permalink
Hmmm - Would you care to specify?
Here are my main points:
1. We must push hard for a public option as the most effective means of controlling insurance costs. Is that wrong?
2. Mandates are part of the universal healthcare systems in all the other nations that do better than we do. Is that wrong?
3. Mandates are necessary, because in their absence, healthy, low risk, or rich individuals will often not participate, leaving insurance to cover the poor and the sick. This would make premiums unaffordable. Is that wrong?
4. In the Netherlands, most medical services are covered by private insurers. The government does not set the rate for insurance premiums. Rather, insurers compete among themselves to offer subscribers lower rates. Is that wrong? (provide documentation if you think so, since my earlier link substantiates this point).
5. In France, most individuals purchase private insurance to cover expenses not covered by the government. These insurers include both for-profit groups and non-profit (generally mutual type) organizations. Is that wrong?
6. We would not be able to emulate the Netherlands, and although the French system might be something we would one day wish to emulate, our current proposals differ substantially from the French system. In France, there are no parallel private insurers and public options offering the same benefits and competing with each other. Rather, the public insurance dominates, and private insurers occupy a separate niche. Is that wrong?
7. The evidence I've cited merely documents the fact that competition between a public insurance plan and private insurance is not the only mechanism by which a successful health care system can operate. No claim was made that competition exclusively among private insurers is as effective as would be the presence of a public option. In fact, I stated the opposite. Is that wrong?
My point in this entire discussion is that there is empirical evidence we must review in assessing what works and what doesn't. That doesn't necessarily require us to change our mind about what would be ideal, but should give us pause before damning anything less than ideal as worthless.
August 18, 2009 11:44 AM | Reply | Permalink
Seriously, dude, stop being a troll.
August 18, 2009 12:49 PM | Reply | Permalink
et tu Brute?
Seriously, thanks, Jason.
But being a troll is so much fun!
I was accused of being a "concern troll", though. What does that mean?
To answer the accusers. I'm not a troll, but a believer in facing reality. The irony of that accusation is that I agree with most participants here in the necessity for healthcare reform and the desirability of a public option. I'm merely hoping to stimulate enough thought about the details so that various elements of healthcare reform can be put seen in proportion.
Oh well, as the saying goes, "No good deed goes unpunished."
August 18, 2009 1:33 PM | Reply | Permalink
Just curious Fred, how you square your statement, "Well, I have consistently supported a public option as the best approach", with a blog you wrote not that long ago which you wrote with the sole intention of down playing the importance of the public option?
It is these uncertainties that make it difficult to judge the eventual importance of a public option independent of its short term ability to achieve minor cost reductions beyond those achievable by a robust reform program lacking a public option.
December 5, 2009 10:23 PM | Reply | Permalink
As BHO said:
In some cases, there are people who are paying fines and still can’t afford it, so now they’re worse off than they were. They don’t have health insurance and they’re paying a fine.
BTW, who was it first that said, "Liberals are in favor of anything as long as its mandatory?"
August 17, 2009 11:47 AM | Reply | Permalink
Thanks for this. IMO, even with "free riding" ... a system that handles the sick through a negotiated set of costs will be a considerable cost savings than the "emergency room plan" we have currently where top dollar is charged to the "payer of last resort".
IMO, the whole "free ride" argument is a bit of a red herring. We should accumulate some data once health care actually comes into the range of affordability before we demand everyone buy in to a system that might not change anything. This just seems like turning us in to slaves to the insurance industry.
August 17, 2009 5:06 PM | Reply | Permalink
Now that we have discovered who ultimately runs the America of 2009 -- the managers, and perhaps, up to a point, the stockholders (‘owners’) of large insurance corporations [1] -- there is no point in good guys forgetting this unpleasant fact as quick as possible merely because it is so exceptionally unpleasant. Maybe facing it can wait until after Labor Day, because it really is difficult to think in a straight line during heat waves, whether literal and meteorological or figurative and Foxogenic. But that is the limit. Staring 0900 on 8 September, then, let us have no ostrich impersonations, O good guys, but noses held stoutly to the grindstone of "at least be clear what is going on."
Clear at least about the overlap between what Dr. Baker thinks is going on and what one thinks oneself, for I fear I do not see eye-to-eye with him 100%.
The word ‘tax’ ("regressive tax" elsewhere) may have been intended to jolt us into seeing what we would otherwise miss. But it could also be an economist talking funny and in a pro jargon that tends to cover up the political aspect of things. That lemonade won't do anybody any harm, I don't think, but the patient might supplement it with a shot of the hard stuff like "Health insurance mandates involve handing over sovereign prerogatives of the State to secret- or private-sector cabals and conventicles." [2]
That, it seems to me, is what "Let's have UnitedHealth and WellPoint collect taxes for Uncle Sam, shall we?" really means. Dr. Baker may not disagree with my meaning in the slightest, but he did not express it. The meaning he did express struck me as tame. Also a little unfair to "the best politicians money can buy."
Mais que sçay-je?
Happy days.
___
[1] In this connection, allow me to celebrate the extreme disinterestedness and moral grandeur of our kiddie conservatives: not many liberals and democrats and Democrats would so much as dream of preferring the commercial freedom and dividends of strangers to medical security for friends and family and self. Scarcely one wingnut in ten thousand can be personally dependent on the flourishin’ of Big Insurance for her self-esteem, or for her self-freedom, or for her retirement portfolio. Or even just for a 9-5 job. And yet here we are, O Homelanders! "Never ... so many ... so few," like Winston Smith used to say.
It's really very odd, is it not? Who would have expected "Ail for Aetna" to have so much more market appeal than "Die for Danzig"?
[2] Know the foe! There is a handy list of cabals and conventicles at
http://tinyurl.com/ocqttb.
The top two must have conglomerated themselves recently, because both names are of the nerdish DoubleWord type. For literary and alliterative purposes, I believe I'll stick with Aetna.
August 17, 2009 6:25 PM | Reply | Permalink
The single reason the insurance companies are "cooperating" with Obama is the promise that they will no longer have to sell insurance, but just collect their fees. They will all have guaranteed profits, guaranteed customers, and no restrictions. We simply can't let that go through. The only way there can be a mandatory insurance requirement is if there is also a government run option to private insurance. Then the mandate is similar to any other government fee, like taxes, permits, etc.
Democrats obviously need to let the blue dogs know that there will be no mandate unless there is a real public option. And, none of this BS about cooperatives - that already exists as Blue Cross/Blue Shield. When do we give up playing ping pong while the Repubs play hockey, and expecting to win anything?
August 17, 2009 7:19 PM | Reply | Permalink
But, without a public option, are mandates constitutional? Clearly, Congress can under its general taxing and spending power require people to pay taxes for something like Medicare. But, can Congress require people to pay premiums to private insurers? I do not think that the commerce clause is sufficiently broad to justify this. Sure, we could require that all employers to engage in interstate commerce or manufacture goods which are reasonably likely to be traded across state boundaries to do so, but what about the the regular John Garcia whose company does not have to provide health care? How can Congress require him to give money to Kaiser or Cigna? Public option would eliminate this constitutional problem.
August 18, 2009 2:48 AM | Reply | Permalink
If mandates are constitutional, when they are mandates to buy something from a for-profit, private business, then a mandate requiring everyone to replace their computer every 3 years is also constitutional. Or, a mandate to replace their automobile. Or, a mandate to see a dentist every 6 months, etc. I think the hypotheses that such a mandate could be constitutional fails the reductio ad absurdum test.
And, of course, we all believe that Obama believes in following the Constitution, right? Hmmm. Right? Speak up!
August 18, 2009 11:41 AM | Reply | Permalink
Most or all states mandate automobile insurance, without a public option. The insurers typically compete with each other - I get bombarded regularly by messages from insurers claiming to offer me better service at lower rates. I tend not to pay much attention, but if it were my health care that was being insured, at current health insurance rates, I would pay considerable attention.
I expect a public option for automobile insurance would drive rates even lower, although I don't wish to stretch the analogy between the two types of insurance - my point rather is that constitutionality is not an issue. There is actually one connection between them, however. Mandatory automobile insurance spares the government (state or federal) from being stuck with the medical bills incurred in cases when neither of the parties involved can afford to pay them.
August 18, 2009 11:58 AM | Reply | Permalink
Sorry, Fred, that is a very poor analogy. The states do not mandate purchase of automobile insurance. No citizen of any state is required to buy automobile insurance. What the states do is condition your license to drive an automobile on having insurance for that automobile. If you chose not to play that game, and not purchase the insurance, you just don't get a license to drive a car.
Health care is nothing like that. Of course you could chose to commit suicide and not be required to purchase insurance, but beyond that you would be required to purchase it. Big difference, huh?
August 18, 2009 12:53 PM | Reply | Permalink
Another point: California, at least, requires you to pay a private business for a smog inspection of your automobile or other vehicle about every other year, but no one is forced to buy a smog inspection. Instead, part of the automobile registration process is getting a smog inspection, when required, just as part of it is to demonstrate financial responsibility by proving that you have automobile insurance. Again, if you chose not to participate, that's fine. You just can't use a vehicle in that case.
August 18, 2009 1:02 PM | Reply | Permalink
The issue is constitutionality, not whether automobile insurance is strictly analogous to health insurance, since no-one would claim the latter. States mandate automobile insurance if you own an automobile, and that to my mind, signifies that the claim that mandatory insurance would be unconstitutional is without foundation.
In fact, the current proposals all grant exemptions from mandatory health insurance in certain circumstances (e.g., religious beliefs), where there might be a clash of constitutional rights.
The government also mandates income tax payments, which it then uses to pay small businesses for a variety of services, without a public option.
It seems to me that the constitutionality of government-mandated fees, taxes, or other forms of payment that is then directed in part to the private sector has been settled for close to a century. Mandated health insurance may be a variation on the theme, but the theme itself is well established.
August 18, 2009 1:51 PM | Reply | Permalink
Or, a mandate to replace their automobile
Incidentally, your statement above was the analogy you yourself used, Hoppy, and was part of the reason I brought up the subject of automobile insurance, which you then decided was irrelevant because not everyone is compelled to own an automobile.
August 18, 2009 2:00 PM | Reply | Permalink
There is no law requiring you to own a car. The insurance (and emissions) requirements are not an individually mandated tax; but a specific use requirement. Since individual ownership and operation of an automobile is not mandated by law, there is no analogy between that situation and an individual requirement to purchase insurance from a private company.
If the government mandated tax payments that then were used to pay small businesses for Health Services, that would of course be constitutional. And also it is the definition of SINGLE PAYER.
The government isn't talking about taxing us and buying health services on our behalf - which as you observe is of established legality. They are talking about requiring Americans to enter in to an individual private contract by law completely outside the constitutional system of legal taxation.
August 18, 2009 3:39 PM | Reply | Permalink
I believe you should abandon the constitutionality issue as a dead end, KGB, although you are welcome to consult a law professor with constitutional expertise if you still want to push it. I doubt that it would get very far in the courts, for reasons I've already enumerated. As I mentioned before, mandated premiums are a new variant but on an established principle - the government can ask you to pay money that will then be directed to private enterprises for services for which there is no public competitor. In my view, the difference between paying the government, which then pays the private sector service of their choice, and paying the private service directly is not a constitutional issue disfavoring the latter. Perhaps we can move on to other things.
August 18, 2009 4:22 PM | Reply | Permalink
If I were as wrong headed about a subject as you are on this one I would want the discussion to move on too. Nothing in the Constitution allows the government to force people to pay a private business for something they haven't decided they want. The sole exception is if the government licenses use of guns for example, they could mandate you showing a certification of completion of a gun safety course. That means, of course, that you don't have to pay someone for that course if you chose not to use a gun. The analogous argument with health insurance is that you don't have to buy it if you just kill yourself - an absurdity.
August 18, 2009 8:50 PM | Reply | Permalink
Why don't you report back to us, Hoppy, after you have consulted a law professor who's a constitutional expert, quoting his or her opinion?
I do think you're spinning your wheels on this one, but when you report to us, we'll be able to decide. At that point, you can notify Congress and the White House to alert them too.
August 18, 2009 9:22 PM | Reply | Permalink
What you are saying is not the case in Virginia. Insurance has nothing whatsoever to do with your license to drive a car. It is, however, connected to the registration of your automobile. You can opt out of carrying insurance if you pay a $500 uninsured motorist fee in addition to your registration fee.
August 19, 2009 3:36 PM | Reply | Permalink
This is one of the things that most turned me off to Hillary's campaign (among the policy planks that is). Not that mandates might not be necessary -- that's a fair thing to at least prepare us for (and in that sense, Obama perhaps in a way free-rode on Hillary's openness on the question) -- but that we were somehow supposed to get all jazzed up about them. To lose the freedom not to buy health insurance from a company looking to profit from your fear of getting ill is nothing to expect people to be thrilled about. It seemed to invite those with coverage to see people who have difficulty getting coverage as more part the problem than as in need of assistance.
August 18, 2009 4:55 AM | Reply | Permalink
I really don't give a %@&@$ if there are mandates. The free rider problem is not MY problem. It is the insurance industry's problem.
At this point, I don't care about being "fair" to the insurance industry. Obviously, they can take care of themselves.
I want more regulation of the insurance industry. They should not be allowed to discriminate against sick people (i.e. those with "pre-existing conditions.") Our current plan healthcare system is one where only the healthy can get health insurance. But the current health care system does not provide healthcare to the sick -- those who need it. Some system!
We fix this insane system by prohibiting discrimination against the sick. Require insurance companies to treat the sick like everyone else. No individual insurer is at a competative disadvantage because they all have to play by the same rules.
And since the insurers no longer have to spend $$$$ sorting out the sick from the healthy, we should see a significant decrease in administrative costs -- maybe we can even get them to Canadian levels...
Requiring insurance for the sick already is being done with respect to employer provided health care. Employers have a hard time refusing employement to sick people -- most likely, such discrimination would violate the Americans with Disabilities Act. (For example, they cannot require a physical exam until a job offer has been extended.) Plus, many of the sick are older employees, and firing, refusing to hire or otherwise discriminating against them them would be violative of the ADEA.
August 18, 2009 8:10 AM | Reply | Permalink
Exactly right. Proper regulation and enforcement can stop the bleeding on the major problems with the current system. Tackle Medicare next while we implement. Rinse and repeat. This isn't rocket science but it does take a longer view than many around these parts seem to possess.
August 18, 2009 12:50 PM | Reply | Permalink
I agree we should take a long-term view. Let's start by bringing down costs. THEN let's look at making it mandatory.
Simply eliminating the preexisting condition and letting it go at that will change absolutely nothing. And putting individual mandates into a half-assed solution will be worse for consumers than the red-herring of "free riding". Seriously, in a game where profits are maximized by denying million-dollar treatments - how much "administrative savings" are they going to see by eliminating the department that denies claims ... that assertion is ABSURD on it's face.
As long as competitive profits are driven by pools of shareholders, there is a financial incentive to get rid of sick people. Ultimately a regulatory structure will always be gamed and will always be subject to well-placed individuals undermining regulation (think Gramm-Leach-Bliley applied to health insurance).
By simply creating a system where shareholder return isn't the incentive and allowing it to compete on the open market, the market is forced to respond based on the true laws of competition and customer demand. To me that is far more American (and conservative) than arbitrary price controls that would be required to prevent insurance companies from passing profit reductions caused by new preexisting condition requirements on to the customer.
There is nothing in this hyperincrementalist view that achieves the objective of cost containment - no matter how many decades you extend it while Americans wait for some movement in a fundamentally flawed market. Unless we're fixing Medicare to let all Americans purchase into the system as the next step - which I haven't heard anyone propose.
August 18, 2009 3:23 PM | Reply | Permalink
Of course the most direct approach to the health care problem would be make Medicare apply to everyone. Part A would be in effect for everyone, and those who pay a monthly fee would get Part B, just as it is with us seniors.
After the general public experiences Medicare they would very soon want it modified to cover the true cost of their care, and then they would be supportive of doing so. That is the type of incrementalism that would be effective. All of the nonsense being spouted in the Senate now is not the answer to anything other than keeping Senators at the teat of the insurance industry.
August 18, 2009 8:58 PM | Reply | Permalink
Except Medicare requires private insurance to make it work in even the half-ass fashion it does today. Even then, the program is unsustainable and unstable as currently run. It would need a massive overhaul to function as a single payer system.
August 19, 2009 8:13 AM | Reply | Permalink
You are debating this as if your every objection isn't being solved by the legislation that is likely to come out of conference committee.
Treatment norms will be established by a combination of medical best practice boards and the nonprofit coop and HHS. Insurance companies will be required to operate under those norms, which include required services. The consumer will all sorts of protections and options that they don't currently have if an insurance company steps out of line.
Setting this baseline will level the playing field and cure the current system's worst abuses, which appear to be the basis for all your criticism.
What we need to do is stop scrapping regulatory structures that work. Consistent, even application of objective standards leads to stable and sustainable growth. You can sell that shit all day to conservatives and the president would have 75 or 80% approval on this right now.
I couldn't disagree more with your underlying assumptions about what is taking shape in Congress. As far as I can tell, except for those who only favor single payer as a solution, most who favor reform agree that this package is much, much better than nothing while being far from perfect.
Not sure how you expected more than that.
August 19, 2009 8:40 AM | Reply | Permalink
The bottom line seems to be this: An effective plan with no public option means more regulation, more actual monitoring and enforcement than would be the case if we were to build a system with one. (Of course, we all know how dedicated past administrations have been to enforcement of regulations.)
August 19, 2009 12:46 PM | Reply | Permalink
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January 12, 2010 6:15 AM | Reply | Permalink