An Alternative to the Mandate
When I proposed an alternative to the individual mandate last week in The American Prospect, I mainly thought of it as a means of averting a backlash by conservatives and by people who would be so poorly informed about the subsidies in health-care reform that conservatives could scare them into a revolt. Little did I realize that once the Senate dropped the public option, there would be a revolt against the mandate by some progressives who are doing their best to sound like Tea Party right-wingers.
Let's go over the reasoning behind the mandate. If you eliminate pre-existing condition exclusions but don't have a mandate, the rational thing for healthy people to do is not to pay for insurance until they get sick. But if healthy people don't participate, the whole insurance system breaks down. And this would be true if all insurance was governmental.
Some people on the left are saying, "The individual mandate was a way of getting support from the insurance industry." It is true that insurers are in favor of the mandate. It is also true that if there is no mandate, insurers cannot be asked to eliminate pre-existing condition exclusions. At least, they cannot be asked to eliminate those exclusions without raising rates considerably. And that would be just as true of a government insurance plan as a private one.
The real reason behind the mandate has nothing to do with insurers' profits. They could make money with the mandate or without it. What they cannot do is to hold down insurance rates if they have to cover pre-existing conditions but people can defer buying insurance until they are sick.
Yet there is an alternative to the mandate as it's defined and enforced in the bills before Congress. Remember, the real purpose of the mandate is to prevent people from opportunistically dipping into the insurance funds when they are sick and refusing to contribute when they are healthy. And that can be achieved by allowing people to opt out but not allowing them to opt back in whenever they choose.
So here's the proposal (which is derived from a similar provision in the German health insurance system). If people didn't want to buy insurance, they could take an opt-out by agreeing that they would not be able to come back into the subsidy system for five years. In other words, instead of paying a fine for failing to insure, they would forgo a potential benefit. For five years they would become ineligible for federal subsidies for health insurance and, if they did buy coverage, no insurer would have to cover a pre-existing condition of theirs.
Personally, I would urge people against taking the opt-out. But I believe that given the opposition, this is a reasonable concession to make to political reality. Think of it as a safety-valve and as a means to encourage careful thought about the benefits and costs of insuring.
Under the reforms being proposed in Congress, subsidies would limit how much people would have to pay for both premiums and cost-sharing. For example, under the Senate bill, everyone below 133% of the federal poverty level would be covered by Medicaid. (The federal poverty level for an individual is an income of $10,830; for a family of four, $22,050.) For people with incomes above 133 percent of poverty, there would be a sliding scale for premiums, going from 2.8 percent of income up to 9.8 percent of income at 3-4 times the poverty level. There would also be a sliding scale for cost-sharing. In other words, the government would put a ceiling on your liability for health costs when today there is none.
Under my proposal, you could decide not to pay for insurance and therefore not to receive those subsidies for five years. After that time, you could reconsider and decide whether or not to take another five-year opt out. But what you could not do is go back and forth at will, paying for insurance only when you're sick and then dropping insurance when you're healthy. There is no health-insurance system in the world that allows people to do that. And to think that we could start out that way is just plain silly.
"the rational thing for healthy people to do is not to pay for insurance until they get sick..."
There's no evidence to support this, it's a hypothetical argument. The free rider problem would likely be very small -- people who can afford insurance will want it for the simple reason that you can be very quickly overcome by either sickness or accident. Do you really want to shop for insurance AFTER you break your spine in a skiing accident? That's more than a bit impractical.
Obama had it right the first time -- if the price is proper and the benefits are good, rational people will buy insurance without a mandate (and yes, you can still ban the pre-existing conditions exclusions).
You don't need to forego any benefits or pay any fines to make this work. By the way Massachusetts does have a mandate but it's been criticized over and over for being too weak. But the only people complaining about a free rider problem are profit minded insurance companies. When you peel the onion and look at the data you realize their complaints are puny. So with a weak mandate you get no free rider problem or one that amounts to a rounding error. I suspect it's entirely unnecessary.
Still, the burden of evidence should be on the pro-mandate side. I don't like being bound by laws backed up by hypothetical scenarios concocted by deeply conflicted insurance actuaries.
The mandate, especially attached to the senate bill amounts to a subsidy for the insurance industry that rivals TARP and it's depressing that Democrats are so unashamedly supporting it.
December 18, 2009 10:56 AM | Reply | Permalink
I agree. Rational people will not turn away from purchasing affordable health insurance. Most people are not stupid, it's just that we hear about the few who are.
December 18, 2009 11:15 AM | Reply | Permalink
If one was running low on money, it would make sense to forgo insurance if companies couldn't exclude based on pre-existing conditions. ER treatment does not require insurance, so that takes care of freak injuries. Why pay for insurance while healthy?
December 18, 2009 11:27 AM | Reply | Permalink
I dunno. Why buy a roll of toilet paper before you need it?
December 18, 2009 11:45 AM | Reply | Permalink
For most people, the toilet paper comes with their paycheck every pay period, although it isn't listed as a line item or in any other fashion - it's a hidden part of their compensation.
They don't even see it until they go to take a crap, and lo - there it is! Some folks get Charmin, some folks get 60 grit, depending on the diligence and/or decency of HR and management.
Some folks get their TP via their parents' or spouse/partner's compensation, and as such decline their employers' TP preferring instead to get some of the value of the TP as cash instead.
December 18, 2009 2:24 PM | Reply | Permalink
Paul, this is a very reasonable counter-argument:
http://emptywheel.firedoglake.com/2009/12/15/health-care-on-the-road-to-neo-feudalism/
The bill requires a family at 3x the poverty level to give more money to a for-profit insurance company (who is allowed to turn a 25% profit on the deal) than to the government for the commons.
Legislating a tithe to private enterprise is unprecedented and another (huge) brick in the wall creating a corporatist state.
-- ARG
December 20, 2009 12:02 AM | Reply | Permalink
Re "ER tratment does not require insurance".
This is a serious misunderstanding. If you show up at the door of the ER where I work with a life threatening condition and no insurance, you will be treated enough to stabalize your condition without regard to ability to pay or whether or not you have insurance. But without insurance or ability to pay, you won't get any more than is needed for immediate stabalization. And our business office WILL come after you for the cost of your care. If you have no assets or income, it will likely end up as a written off bill and you won't pay, but if you do have assets or income, we will most certainly go after whatever you have to pay that bill. So counting on ER tratment as part of a plan to remain uninsured until you got sick would not be a smart strategy.
December 20, 2009 4:02 PM | Reply | Permalink
It's crucial to give an incentive of some sort to healthy people to pay for the insurance. The tricky part is designing a golden system with low enough costs to encourage them to pay and at the same provide the Golden Retriever health benefits that are required for the system to be effective at its purpose. Your idea of the five year opt-out would also strengthen the initiative of paying for the insurance, while at the same time retaining the freedom of choice.
March 15, 2011 7:35 PM | Reply | Permalink
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December 20, 2009 10:22 AM | Reply | Permalink
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January 11, 2011 2:48 PM | Reply | Permalink
By the way Massachusetts does have a mandate but it's been criticized over and over for being too weak. But the only people complaining about a free rider problem are profit minded insurance companies. When you peel the onion and look at the data you realize their complaints are puny.
Criticized by whom? (Just about everybody, that I've heard - I mean whom are -you- referring to?)
I had a housemate get the mailed notice that his fine had been deducted from his state tax return.
(And he worked full-time when this happened.)
He noted that the "low-premium" plans that various insurers had introduced to capture the business of the poor - mandated to buy coverage, penalized if they didn't, and still being too poor to afford a normal plan - offered such poor coverage that he was better off acquiescing to the fine and hitting the ER for care.
So, shit plans, that Gov. Romney (ably assisted by the raging liberal Democratic-controlled State House) instigated by threatening anyone who didn't pony up for a shovelful, take those monies and offer some minimal coverage. I'm not sure what the effect was of capturing their business insofar as risk pools and profit - I am sure that a majority of folks that were affected weren't declining to buy health insurance because of libertarian leanings.
Perhaps I'm overly cynical, but I remain convinced that Gov Romney pressed for universal and mandated coverage in MA strictly to influence any debate or movement on the issue at a national level.
I'm not sure if it's the same free-rider problem you mentioned, but the use of ERs by the un/under-insured for primary(and generally by then it is also, emergency) care in MA has created some serious financial problems for those hospitals that get the bulk of that "business". Which in turn have affected other operations and thus affected accreditation. There is a problem to be addressed, and the mandated universal coverage in MA was and is a means of addressing it. I maintain that it's a poor one, as passed and implemented. Bug? Feature? I suspect former Govs Dukakis and Romney have differing opinions.
December 18, 2009 2:59 PM | Reply | Permalink
Pages 12-13 of this Oliver Wyman report talks about free-riders in Mass.
http://www.bcbs.com/issues/uninsured/background/Oliver-Wyman-Report-Showing-Impact-of-Healthcare-Reform-on-Premiums-pdf.pdf
You can follow their lead to harvard-pilgrim's complaints about the issue as well.
December 18, 2009 3:09 PM | Reply | Permalink
Thanks.
I notice a lot of "should", "could", "may", "will" - and much less "has", "did", "proved", etc. That is, speculative vs concrete - future vs. past. Yes, the report is about a model - though I found it odd that Massachusetts is only mentioned anecdotally(still not data, even if footnoted) rather than as part of the model. Makes me wonder.
And that:
"Oliver Wyman is an international management consulting firm that combines deep industry knowledge with specialized expertise in strategy, operations, risk management, organizational transformation and leadership development"
Which, by the way, I had to transcribe from the image on the website - you can't copy and paste it as text, it's a GIF.
The flash animation is interesting too, I suggest visiting the home page.
Anyway - point is, that is who produced the report. For Blue Cross Blue Shield, presumably.
I'll be they "promote shareholder value", too.
That said - Oliver Wyman, BCBS, Harvard-Pilgrim - they're all barking up the wrong tree. The problem is NOT that people aren't sufficiently punished for being un-covered, that they aren't forced to wait for their coverage to kick in while they are paying for it or that they are jumping into high-coverage/low-deductible plans(that's the subtext in H-P blog that gets danced around) and back out once treated.
There are simply too many pools.
Risk is not sufficiently distributed as a consequence.
Obviously, the best way to manage it and most cost effective to boot, is to have but a single pool containing everyone.
I think we can safely assume none of the above will be able to recognize that, what with that whole livelihood thing.
December 18, 2009 3:57 PM | Reply | Permalink
Well put. This is a transparently silly argument, and yet people like this guy are constantly given a microphone to make it.
December 19, 2009 4:08 PM | Reply | Permalink
While I'm not entirely on the "Kill the Bill" bandwagon, I just don't think being insured is the same as having access çizgi film izle to health care given the past behavior of the insurance companies. If being insured was fal equivalent to access to health care, I doubt we'd be having the current debate.
August 4, 2010 6:05 PM | Reply | Permalink
This makes a lot of sense. Rational people won't just shy away from insurance. It's just that it's too expensive and the few people who do shy away are the only people that make any impact. I'd love to see people consider travel and health insurance too, in the same manner.
October 14, 2010 7:43 AM | Reply | Permalink
There is another alternate to mandates. It is called progressive taxation.
December 18, 2009 11:05 AM | Reply | Permalink
Ding!
December 18, 2009 11:11 AM | Reply | Permalink
needs more CAPS - I almost couldn't hear you, your tone was so matter-of-fact.
December 18, 2009 3:02 PM | Reply | Permalink
Not so many decades ago, the most basic standard for fair public policy was called PROGRESSIVE TAXATION.
December 18, 2009 11:23 PM | Reply | Permalink
My question is why if there is a mandate will insurers still be able to discriminate against people with preexisting conditions by charging them up to 3 times as much as a person without those conditions? With the industry being flush with all kinds of new monies in a mandate scenario...monies of healthy young people who will probably not pose much of a loss risk...why everyone be allowed to purchase insurance at the price that a healthy person in their age group would pay?
I can see maybe charging smokers more. I am a smoker and I realize the risks smoking poses to my health along with the corresponding increase in health care services I will need because of it. And even though I am already being massively taxed for my smoking I would expect to have to pay more for health care. But not for preexisting conditions...and by charging people with preexisting conditions up to 3 times more than people without them it's an onerus financial burden (even with this so-called 'reform') which is being placed on the people who need health care the most...in their very real effort to just remain alive.
December 18, 2009 11:08 AM | Reply | Permalink
It is my understanding that the Senate bill requires insurers to offer a policy to someone with a preexisting condition the same rate as anyone else in that age group.
On the other hand, I think I remember that the max difference in rates that insurance companies can charge for the young and old is 3 to 1. Could it be that this is what you are thinking about?
December 18, 2009 6:21 PM | Reply | Permalink
And thank you for comparing me and the people on the left, who hate this crap bill, to the "teabaggers" because doing so is the newest application of Godwin's Law. We win the argument...
December 18, 2009 11:27 AM | Reply | Permalink
Are you willing to take what the gentleman said into account? Because I'm seeing a lot of left leaning bloggers that don't care to listen. First, the individual mandate was put there for a reason and that reason had nothing to do with making insurance companies profitable.
Second, even with the public option or Medicare buy-in, the bill as it is would have been a dream come true two years ago.
When I look at what this bill does, rather than what it does not, I can't call this a case of "pass anything". It is a good bill.
December 18, 2009 4:29 PM | Reply | Permalink
Please see my comments here, I think it covers this and a few other issues.
December 18, 2009 4:32 PM | Reply | Permalink
Meant "Second, even without the public option or Medicare buy-in, the bill as it is would have been a dream come true two years ago."
December 18, 2009 4:54 PM | Reply | Permalink
Why don't you reconsider what you've written, please? Seems you have taken the same side track members of Congress are on ... the pending bill doesn't acknowledge the public's anxiety over health care nor considers what the people are looking for in reform of the system. After all, it's all being done for their benefit so why aren't their concerns being addressed? The individual mandate is not something the public wants, desires, needs or cares about. Notice the public is completely left out of the discussion, but is told you have to submit. That's why so many view the current legislation as a free-for-all for the industry on the backs of the public, just like the bank bailout was.
December 18, 2009 11:36 AM | Reply | Permalink
The problem is with the word "contribute." A healthy adult in their 20s could very easily go 5+ years without ever having to go to a doctor. I have gone 8 years without seeing a doctor even though I have had insurance for that entire period of time.
If I did not have insurance, I would have a big problem with a mandate. For one, it's unconstitutional for the federal government to force anyone to pay for theoretical services. People will quickly point out the requirement for automobile insurance, but that is a completely different argument. Roads, highways, and freeways are built and preserved by the government with tax dollars. The government, therefore, has a right to require automobile insurance in exchange for access to these roadways.
But what is a healthy person in their mid to late 20s getting in return for their "contribution" in the arena of health care if, like me, they have no reason to visit a doctor over a long period of time?
It's un-American to require someone to pay for something they don't need. In that case, I would agree with the author's 5 year opt out plan.
December 18, 2009 11:49 AM | Reply | Permalink
Yeah Gettysburg, I agree, there are some serious constitutional issues about whether people can be forced by their own government into buying insurance in the marketplace. But with the court's make-up right now, being both very pro-corporate and pro-government, I can see the court saying mandates are ok.
December 18, 2009 12:04 PM | Reply | Permalink
I am afraid that there is a tendency for some people to say "this is unconstitutional" without anything in the constitution to support the claim.
Article 1, Section 8 gives broad authority to the Congress: The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States;
Also of importance here is the 16th Amendment, which gave the Congress the power to "lay and collect" the income tax, essentially without restriction on how it is structured.
The fact that the Constitution doesn't impose any restrictions on how the income tax is imposed means that the Congress has the power to impose a tax on, say, someone who buys a gas guzzling car.
Similarly, it allows the Congress to impose a tax on anyone who doesn't buy health insurance. So technically, this bill doesn't force anyone to buy insurance. It doesn't say "6 months in federal prison for the first infraction".
The legislation just says if you don't buy insurance, you are going to have a higher tax bill. Thanks to Mr. Starr's suggestion, even that may not be necessary to achieve the aim of prohibiting discrimination against people with so called preexisting conditions.
December 18, 2009 12:23 PM | Reply | Permalink
If I did not have insurance, I would have a big problem with a mandate. For one, it's unconstitutional for the federal government to force anyone to pay for theoretical services. People will quickly point out the requirement for automobile insurance, but that is a completely different argument. Roads, highways, and freeways are built and preserved by the government with tax dollars. The government, therefore, has a right to require automobile insurance in exchange for access to these roadways.
Actually, the comparison is not apt, because the federal government does not force anyone to buy automobile insurance. Individual states do this. This does not violate the Federal Constitution for the same reason that the Massachusetts mandate for health insurance doesn't, namely, that the Constitution limits federal powers in thus area, not state powers.
December 18, 2009 3:33 PM | Reply | Permalink
Speaking of state sovereignty, wouldn't health care be best dealt with at the state level? The same goes with education.
One size fits all Federal programs run into trouble because each state faces different challenges. Washington should help subsidize all 50 state governments with their respective health care plans so long as those plans conform to a pre-determined set of guidelines from the Department of Health and Human Services. These guidelines, obviously, must accomplish what everyone wants: access to quality health care for everyone, caps on premium costs (for the sick or those with pre-existing conditions), requirements/incentives for large and small business insurance opportunities, etc. Failure for a state government to comply with the specified guidelines would prevent that state from receiving any Federal subsidies.
It seems to me that a single payer system, like in Great Britain, would only work in the United States at the state level. Although taxation would noticeably increase under this format, at least most of the costs would be paid for in real time by those who will be consuming the health care...as opposed to kicking the funding ball down the road.
I know one thing for sure: Generation X and Generation Y combined probably equals about half the size of the Baby Boom generation. That in and of itself is a huge impending problem; particularly when the Boomers are all retired and not working. Sure that will mean many great job opportunities for younger people, but the math doesn't really add up when talking about the working generation supporting the retired generation. When it comes to health care reform, we can't afford to defer any more costs.
December 18, 2009 10:33 PM | Reply | Permalink
I have gone 8 years without seeing a doctor even though I have had insurance for that entire period of time.
Yeah, about that.
How's your blood pressure? Cholesterol? Blood-sugar? Got any floaters or flashing in your eyes?
You may not have used your insurance in some time, and others without it may not have used any form of care.
That doesn't make it a good idea.
Or a cost-effective one in the long term.
Chronic conditions don't show up like lightning bolts, in most cases. They do, however, tend to be persistent, expensive, and life-altering once they have been contracted.
Like arthritis in joints that were tweaked playing sports of one kind or another. D'oh.
Or repetitive motion injuries that just don't seem important enough to take time to go to the doctor.
December 18, 2009 3:36 PM | Reply | Permalink
And if you don't want to own a car and pay for insurance you can use this public option called a "bus."
December 18, 2009 3:56 PM | Reply | Permalink
And if you are hit by a bus, the hospital doesn't have the option to refuse treatment.
Say, who pays for the uninsured when they get treatment? I do. You mean it isn't optional?
December 18, 2009 4:13 PM | Reply | Permalink
The same thing you get buying homeowners insurance or car insurance or flood insurance -- absolutely nothing unless something goes wrong. The only difference being that in this case something will go wrong eventually and that something will very often be so big that it takes 20 years of contributions to pay for it. And if you haven't been contributing over those 20 years -- if you only get insurance when you get this illness -- you're ripping off those of us who have been contributing because our 20 years of contributions are going to pay for your problem while you've put in almost nothing.
So you'll excuse me if I find your defense of the individual's right to exist as a free-rider on the system hard to swallow.
December 18, 2009 6:24 PM | Reply | Permalink
CommonDreamer,
I understand your point of view, but if everyone my age decided to partake in free-riding, maybe we could implode the entire insurance system. That would be a good place to start if the ultimate goal is to rebuild the United States. The adoption of the concept of insurance has tacitly paved the way for a gross inflation of prices on everything ranging from houses to health care over the past century.
One of my favorite pieces of anecdotal evidence in this regard is Operational Plan III from the government of Kaiser Wilhelm II. As part of Germany's aggressive policy of Weltpolitik in the late 19th century, Wilhelm's military advisers drew up plans for a massive German invasion of New York City and the Eastern Seaboard of the United States. Obviously our nation had virtually no armed forces at this point in time so the Germans knew there could be very little resistance. But the long term prospects for success in such an invasion were thought to be favorable mainly because the United States economy, unlike any other nation on Earth, was overly reliant on credit and insurance.
Such was the German military analysis in 1900. The problem has only been exacerbated exponentially.
December 19, 2009 5:02 AM | Reply | Permalink
Can you please point out the clause in the Constitution that the individual mandate would violate?
December 19, 2009 11:22 PM | Reply | Permalink
El Puerco
Prohibition was the last time the United States government attempted to coerce its populace into conforming to a lifestyle decision. The difference is that Prohibition was enforced through a ratified Constitutional amendment.
Don't bother bringing up Social Security because that's a completely different argument and you know it.
The Constitution allows for the Federal Government to levy taxes, not premiums. From a legal standpoint, an insurance premium differs from taxation.
This will find its way to the Supreme Court guaranteed.
December 20, 2009 1:56 AM | Reply | Permalink
Scrap the mandate and offer a tax credit of say up to $2,000 a head if you buy health insurance. That should be enough to get bare bones coverage for nearly the whole population. The bill could be down to one page, and pass in a flash as there would be no Stupak problems if there is no definition of what that insurance must/must not cover.
I have heard it said that liberals are in favor of anything as long as its mandatory.
December 18, 2009 11:53 AM | Reply | Permalink
Do you mean $2000 a month for family coverage? If health insurance was cheap, I agree the problem could be easily solved.
December 18, 2009 12:26 PM | Reply | Permalink
Annual $2,000 per person. Thats $8,000 for a family of four.
December 18, 2009 7:31 PM | Reply | Permalink
Why do so many folks want to enlarge the IRS and other government tax bureaucracies?
Aren't they big enough already?
Or is it a case of not understanding that the credit will have to be calculated and administered and probably ajudicated here and there as well?
Kinda like the DHS ...
December 18, 2009 4:03 PM | Reply | Permalink
no. the IRS, like most government bureaucracies, are not nearly big enough. they have been gutted and left to wither and now lack the capacity to be sufficinetly effective.
the idea that the federal government is bloated and ineffecient is, like just about every republican talking point, a load of bullshit.
December 18, 2009 8:11 PM | Reply | Permalink
Cap the profit margin. There is no reason that they cannot accept sick patients when they're making 20-30 cents over every dollar.
December 18, 2009 12:08 PM | Reply | Permalink
Its in there. Actually, insurance companies have a profit margin in the single digits. Remember that administrative overhead is not considered "profit".
A more stringent requirement that they spend at least 85% (for group plans) or 80% (individual plans) is in the Senate plan. The House bill establishes a higher bar, but I don't remember what it is.
December 19, 2009 10:46 AM | Reply | Permalink
If you think that the purpose of the health reform bill should be to establish a single payer system, it is easy to see why lossing both the public option and Medicare buy-in -- both of which I have staunchly defended -- as a betrayal.
But for me, this has always been about the 30 million people without insurance, and the 450,000 Americans who will lose their lives in the next decade for lack of insurance.
For those of us who thought that health reform was what we said it was, about giving all Americans some health care security and saving a lot of lives, it is those who want to kill this bill who have broken faith.
I thank the author for pointing out that the individual mandate was put in their by staunch liberals, people I identify with, for the progressive goal of eliminating discrimination based on medical condition or history.
December 18, 2009 12:09 PM | Reply | Permalink
While I'm not entirely on the "Kill the Bill" bandwagon, I just don't think being insured is the same as having access to health care given the past behavior of the insurance companies. If being insured was equivalent to access to health care, I doubt we'd be having the current debate.
While I have no doubt there are significant cost-saving mechanisms in the current proposals (mostly on the government-run side of health care), the argument for the individual mandate bringing down costs seems to rely on the insurance companies behaving rationally and voluntarily reducing premiums, deductibles, and other costs they pass on to their customers (presumably based on some unstated economies of scale?). However, all that government subsidy money to cover the individual mandate reminds me of how all that TARP money was meant to save the banks so that they could voluntarily start lending again. Oops.
So an individual mandate that helps insure 30 million people would be good but only if the health insurance companies actually deliver on affordable health care. Call me doubtful.
December 18, 2009 3:39 PM | Reply | Permalink
I don't see the justification of an individual mandate as being directly cost related. For me, it is more about fixing the preexisting condition problem.
On the other hand, having 30 million fewer uninsured has got to reduce the cost to the uninsured by means of having fewer unpaid cases at your local hospital.
December 18, 2009 5:20 PM | Reply | Permalink
The individual mandate (and the government subsidies to pay for them) is being sold as necessary to defray the cost to the health insurance industry of covering all those additional sick people so cost is directly related to the rationale for the individual mandate.
My point was that without adequate control of how much the health insurance companies can charge, I could be insured but still not be able to afford necessary health care due to high premiums or high cost of drugs or non-allowed (therefore an out-of-pocket expense) procedure, etc. Go bronze plan.
So that 30 million insured sounds good but I question how much it really means in terms of actually helping people.
December 19, 2009 10:49 PM | Reply | Permalink
PS. And thanks for bringing this alternative, opt out if you want to but you can't opt in for 5 years, to the table. I really can't see how anyone can object to this proposal.
December 18, 2009 12:10 PM | Reply | Permalink
Mandates = regressive tax. Barely worthwhile IF it is foot-in-the-door for public sector single payer. Otherwise it is theft.
December 18, 2009 12:23 PM | Reply | Permalink
With respect, did you read the article?
The individual mandate was included to achieve a specific, and laudable goal: the end of discrimination against someone because of their health status or history.
Now, the author has provided a constructive alternative which still achieves this goal. Where's your plan to get rid of "preexsiting conditions"?
Remember, you could have a preexisting condition tomorrow.
December 18, 2009 12:32 PM | Reply | Permalink
The individual mandate was included to achieve a specific, and laudable goal: the end of discrimination against someone because of their health status or history.
Eh? That's not what I got out of it.
The laudable goal you mention is one of the intended consequences of the goal of punishing anyone who does not voluntarily buy insurance.
The mandate is to force(in the sense of coerce) participation.
Ending the discrimination you mention is the favor the Dons will do us in exchange for the small matter of making everyone in the country subject to their slightly-more-closely regulated whim. (So my opinion of the proposed regulation is clear - I believe regulation should be a lot like colonoscopy. I don't think this bill meets that standard.)
December 18, 2009 4:15 PM | Reply | Permalink
Hopefully, you buy insurance for your family now (or accept the insurance your employer purchases from an insurance company). I mean, it is simply irresponsible to go without insurance. What if you, may God forbid, have a stroke tomorrow?
So I would say, a mandate has no effect on those who are responsible enough to buy insurance for their family and can afford it. Without the bill, those without the means to buy health insurance are left out in the cold. With the bill, there is a lot of money to help make it affordable.
Note that the mandate doesn't apply to those for whom buying insurance would trully be a hardship.
December 18, 2009 6:18 PM | Reply | Permalink
If you have followed the thread, you will see that I posted an alternative that is not a regressive tax.
December 18, 2009 11:22 PM | Reply | Permalink
"But if healthy people don't participate, the whole insurance system breaks down."
This pre-supposes that insurance and the insurance industry provide a necessary and beneficial contribution to the health care system. As a supporter of single-payer, I would dispute this assumption.
December 18, 2009 12:26 PM | Reply | Permalink
Indeed, the implied premise -- that the whole insurance system is worth saving -- is false. The vast majority of Americans would be far better off if we had a single payer system.
But the simple fact is that we're not going to have a single payer system anytime soon. We're going to continue to have an insurance system no matter how many times I scream at my representatives to push single payer through reconciliation. We don't, and won't, have 50 votes for single payer. It's just not going to happen -- at least not yet.
I am sadly convinced that the approach being taken by the Dems is the right one. Get rid of pre-existing conditions, get as many people affordably covered as possible. This bill will save many lives -- possibly yours or mine.
December 18, 2009 1:29 PM | Reply | Permalink
Actually trying to have the whole system of health care insurance 'break down' is a noble goal and worth trying to defeat this current bill to see that end result. I agree health insurers bring not one iota of anything worthwhile contribution to the product/service of health care. I have no idea why we are so hell bent on trying to preserve something that provides no benefit and, in fact, has only a negative effect on health care.
December 18, 2009 1:37 PM | Reply | Permalink
I am not at all convinced that the free-rider problem is real. My sense is that if health insurance is affordable, people will buy it. But, since that's just my opinion, I have a proposal taken from the Blue Dogs and supposed centrists -- let's have a trigger.
If after 5 years of no mandates the free-rider problem has caused a verifiable, pre-determined amount of trouble for the system, then we can phase-in mandates. The phase-in would be in triggered stages. In other words, we would start with a very weak mandate and, if that doesn't work, we would move to a slightly stronger mandate and so on, until the proper level of mandate was reached.
This would have the effect of actually getting the mandate right while not gifting the insurance industry billions of dollars.
Who wants to bet that the Blue Dogs/centrists will buy into this? If they don't, then do they really think that the mandate is for anything other than providing a huge gift to the industry? I'm betting that no one wants a trigger that protects the public and not industry.
December 18, 2009 1:40 PM | Reply | Permalink
How about just drop the mandate.
If you want everyone to sign up, make it affordable. That's what Obama championed in the campaign.
December 18, 2009 1:49 PM | Reply | Permalink
Let's all understand that many things of consequence are already mandated, such as an energy source, water source, tax returns, building codes, clothing in public, vaccinations prior to schooling, and so on.
The monopoly as envisioned was not one whose purpose was merely to hand money to the recipient without consequences. That monopoly came with strings, i.e., regulation. Public utilities, until they were "de-regulated" served a vital function, were strictly regulated, relatively stable, made small profits and had to request hearings in order to have a rate increase. I would submit there is no strong evidence that life has been improved by utility deregulation, and if this model were used it would put a screeching halt to runaway pricing increases presently in vogue by large health insurance providers. If the utility model were used, no additional number of participants would be too many, and all would require service per regulated pricing agreements.
The most important aspect if this model were used would be to implement an "improvement mode" wherein as quality improvements were effected variation in processes would result, and the outcome would be reduced cost. This is what is missing in this endless debate over perfection.
There is simply no perfection in any human endeavor, so why act as if there were?
No targets, only improvement over time. Simple and effective. Anyone of the senators interested? Send me an email.
Any comments?
December 18, 2009 2:11 PM | Reply | Permalink
You know, it appears to me that a lot of the objection to much of the HCR centers on the fear that insurance companies will unfairly benefit from the catbird seat the law will place them in. I admit that I hate the idea of giving insurance companies a legal oligopoly position so that they get unearned rent to give to shareholders or executives. It does seem to me to be unjust.
But is avoiding the injustice really worth keeping the people who need to have health care financing from getting it? Once the bill is passed and implemented then the injustice can be reduced later.
This seems to me to be the reverse of the argument conservatives in the Old South use against safety net programs. They vote against such programs because the "shiftless poor" (especially Black) would get a free ride. They are not concerned with the people who really need the program, nor are they concerned with how rare the abuses really are.
Oversight and visibility can minimize the abuses of the system, but the system has to be put into place first.
The mandate is essential to actually getting control of health care costs. First we need the mandate. Which means getting most people into he system. Then after we get a mandate into place, we can make it work properly. Until the mandate is in place, we are stuck with the current lack of system and the predators who prey and get rich on the sick and those afraid of getting sick roam freely. The current lack of system is the true injustice - as well as being way too expensive for the services being paid for.
December 18, 2009 2:31 PM | Reply | Permalink
Insightful post Richard, but I don't agree with the approach.
Considering the effectiveness of our elected officials, we're essentially saying; 'ok, we know you're getting screwed now, and we're working on fixing that, but we're going to have to let them screw MORE of you before we can make it better.' That is a big IF with no guarantees (or triggers or whatever you want to call them) that this does anything to reduce the burden of premiums on Americans now or ever.
Put aside, for a moment, the fact that you follow this debate closely and know vastly more then your average voter. Consider what they are exposed to wrt this healthcare debate. Would you have faith in Democratic leadership to reform the reform?
On an unrelated note:
I'd like to see an HCR amendment to rename and define premiums as taxes. It would put things in perspective for everyone.
December 18, 2009 3:01 PM | Reply | Permalink
I can't find a really strong argument against anything you wrote - except one. I remember the passage of Medicare and I remember 1993. After 1993 nothing happened for sixteen years, and like an infection that is ignored our health care system rapidly became worse. Right now every significant trend that I find says the system as it exist will not only continue to get worse, it is getting worse more rapidly.
As to the decision to change health care, the only Democratic President that has not tried to improve the health care system has been Jimmy Carter. Eisenhower got the Disability program added to Social Security. It got so bad that even Nixon talked about it and Bush 43 had to pass the Part D. of Medicare (incompetently as he did everything - even in comparison with the current bill, Party D was incompetent.) Improving national health care really looks like a political imperative to me.
Then there is the decision process itself. I spent several years studying the process of decision-making in large organizations and political decision-making is similar. The real problem is to get every one to agree on the goals to be achieved. Once that happens, implementation becomes a solvable engineering problem. The trouble with Congress is that the goals to be achieved by each member revolve around election/reelection. The goals of the individual Senators and Reps have to somehow be forced into a joint overall goal to be achieved.
The joint goal here is big and tremendously complex. This bill attempts to restructure the entire health care financing system. All of it. That is goring a lot of oxes. A large number of them prefer the status quo. That makes the overall bill itself is so large that they can almost all act selfishly in anonymity. There really aren't that many desperate enough (like Lincoln) or safe enough (like Nelson and Lieberman) to put themselves on the line in public to kill the total bill. And since the problem to be solved is the entire health care financing system, the individual problems in the system are all over the map. They cannot be individually identified and solved.
But if the system is revamped, all of a sudden many of the individual problems will become separately obvious. They can each be solved individually. That's what revamping the entire system will do. It will allow and require the collection and aggregation of information in new ways, such as comparing larger risk pools, because that data will not be proprietary information held by individual private companies. With the number of uninsured people sharply reduced, the problems in the remaining uninsured pool will also become obvious. The data will be much easier to collect, if nothing else.
I dread the idea of competition nationwide without nationwide regulation, but that will also surface problems that can be solved individually. The problems will be small enough so that the media can get a handle on them, and the atrocities documented. The atrocities are already there right now, but they are lost in the lack of system-wide data that can be compared to other related problems.
Once the problems are surfaced they will be fixed unless they once again require revamping the entire system. That's because the problems will be relatively small non-systematic problems. The current lack of system has been in place long enough so that all the small, identifiable problems that can be fixed have been - several times over. Just the idea of outcomes-based payment will require a lot of improvements to occur. So will community risk pools.
Do I promise all this will happen if the piece of crap the Senate has produced is passed? No. But these are possibilities that will not exist without passing anything. That's what happened after 1993. Nothing. The proposed changes still look a lot better to me than the current system, even though Rube Goldberg would reject it. In fact, I suspect that many of the proposed changes only have a chance to pass because the members of the status quo are too ignorant to recognize the system changes these proposals will cause.
Anyway, that's where I think we are right now.
[And don't look for a well-organized comprehensive essay here. This is a rant. I've been angry at the current piece of crap health care financing system for a long time, for many good reasons.]
December 18, 2009 4:17 PM | Reply | Permalink
Well, as rants go this is a very good one. I agree very strongly that finally enacting a systemic overhaul now will be a precondition for future change and piecemeal adjustment. And it's not as if the current bill doesn't have any value in and of itself.
December 18, 2009 10:17 PM | Reply | Permalink
Here's to hoping you're right. Unfortunately I'm a bit more pessimistic overall. Thank you for your response. It was concise and clear.
December 21, 2009 6:26 PM | Reply | Permalink
"The mandate is essential to actually getting control of health care costs."
Only within the universe that decreed that we HAD to maintain a system wherein what we pay is double the rest of the world.
December 18, 2009 11:22 PM | Reply | Permalink
A big reason why the U.S. pays so much for health care is that there is an extortion premium.
Since one in sixteen people are not covered, and that group includes a lot of people who used to have insurance but got sick, lost their job and then their insurance, the remaining people are willing to overpay for what they have. Particularly since that is coming from a third party payer. The payment decision is made during the employment process, not when someone is actually ill.
That extortion premium exists because there is such a large pool of uninsured and because most of us know someone it happened to. Reduce that pool to a minimum and a lot of the fear will go out of the planning process. That means somehow covering everyone or nearly everyone. Single payer would be best, but without that a mandate is required. The healthy have to pay into the insurance to cover the sick, or there is no insurance process. That requires community insurance pools to which everyone belongs and in which everyone pays or is paid for whether they are sick or healthy.
Once that happens the cost of health care will fall. The cost of health care is an outcome of the lack of system we live in, not a cause.
December 19, 2009 4:34 PM | Reply | Permalink
"The real reason behind the mandate has nothing to do with insurers' profits. They could make money with the mandate or without it. What they cannot do is to hold down insurance rates if they have to cover pre-existing conditions but people can defer buying insurance until they are sick."
What you fail to understand is that although insurance companies can make money without the mandate, they can make more money with it. The only objective of the health insurance industry is to maximize profits at all cost. What the health insurance companies won't do, unless forced to by legislation, is lower health insurance premiums. There is no reason to think that health insurance premiums will go down just because the companies get relatively healthy insureds in the risk pool as a result of the mandate.
"Tort reform" has also been touted as a means of reducing health insurance premiums on the theory that doctors won't have to practice "defensive medicine". However, in Florida where tort reform has been in effect for quite a few years, statistics from the State's insurance department show: the number of malpractice insurers in the market has increased, the malpractice premiums have decreased, & amount paid out for malpractice claims have decreased. But over the same period of time, health insurance premiums have continued to skyrocket. Cost savings have not been passed on to the health insurance consumer in the form of lower premiums,& instead are being used to further increase the profit margin of the health insurers.
There is no good reason to think that increasing the risk pool by mandating the purchase of coverage will result in lower health insurance premiums unless there is also a corresponding legislative mandate that premiums be reduced.
December 18, 2009 2:34 PM | Reply | Permalink
1. Are firms obligated to pay whatever price for insurance that the insurance companies demand? Do any large companies in America self-insure? Is there any rule against large companies joining together to self-insure? Do the current bills permit self-insurance?
2. Do any companies trying to increase profit margins by lowering their costs instead of increasing their prices? What happened to health insurance costs (public and private) during the mid to late 1990's?
3. Why does the cost of Medicare and Medicaid continue to climb at rates similar to private insurance? Is the government also trying to maximize profits?
4. If the cost of public and private insurance is increasing at roughly the same rate, is the most likely explanation for why (a) because of the profit motives of the private insurers (b) because of the increasing cost of health care that both private and public insurers have to pay for?
5. "Tort reform" reduced the cost of being sued and subsequently insurance premiums went down. reducing the cost of being sued did not change the cost of health insurance. Is this because (a) health insurers are truly immoral but malpractice insurers are nice guys, (b) malpractice insurers costs went down and got passed on as lower premiums, but malpractice awards have little to do with the cost of health care so the costs of health insurers was not affected at all?
6. If the price of insurance has little to do with the size of the risk pool, or the average risk of payout per insured, then why do insurance companies try to exclude the most expensive customers? Why does my car insurance rate go down if I get a car with lots of air bags or a fancy alarm system?
December 18, 2009 5:02 PM | Reply | Permalink
I agree with you Sir. lucy
April 26, 2010 5:15 AM | Reply | Permalink
"there would be a revolt against the mandate by some progressives who are doing their best to sound like Tea Party right-wingers."
Haha. good one. zing. Those silly progressives-- no as wise and logical as you are huh. yeah.
The bill is a pile of crap for many many many reasons. You've latched onto the mandate and ignored the rest. Try to take the bill in total-- see whats gained and whats given up, then see if you should be leveling insults at progressives, because a lot of people are thinking it makes you look pretty dumb. And this is supposed to be your job. You should have more respect for yourself in the way you do your job, author. Save the weak insults, and you are saving yourself.
The insurance industry isn't going by "has tos" or "cants" or "musts", its going by what would make them the most money. Period.... That's it. One could argue that they should have accepted the public option as well, because they could jetissonned the riskiest cases, and could compete well with a government agency. But they didn't.
Let me repeat again: they care only about the bottom line. They dont care about you, or me, or doing the "right" thing. Its money. They make money in a system in which congress sets up and controls the environment. We control the goal posts here to their little dirty money game, and we are pretending we need their buy in. Its the same with the banks. We control the rules of the game, but we act like we need the players' consent to make or change the rules. We don't. We shouldn't, and we *Can't* if we are going to run the games well. Capitalists don't understand that they shouldn't be allowed to define the rules of the game, or they will always absolutely wreck the game. If they were more long sighted, they would not push against the rules so hard. If they were really long sighted, they would cooperate with the public, instead of being predatory for an extra few cents of profits. But they aren't long sighted.
Back to health care-- Some things just flatly don't belong in the profit motive sphere. Health care is clearly one of those things. I'm not concerned with protecting the profit motive of people whose primary goal is to make a buck, whether it kills people or not. Health insurance doesn't belong in the private sphere, unless they can compete reliably with a government run option. And for all that industry likes to push the myth that private industry can do a better job running things than public industry can, its just not true a lot of the time. Every utility that used to be public and was turned private to compete and lower prices has backfired, and people have been screwed. Why is that, if government is so bad at running things?
And yet the press for more privatizing continues, and the myth goes unchallenged. Its like trickle down-- totally disproven, and yet still popular.
December 18, 2009 2:46 PM | Reply | Permalink
When you take the position that it doesn't matter if the law prohibits onerous industry practices, that pretty much defeats the purpose of any reform.
It sounds a lot like the "government can't ever do anything right" cynicism that the Teabaggers specialize in.
December 18, 2009 5:43 PM | Reply | Permalink
There's no reason why they can't ban onerous insurance practices, right now. This giant structure isn't necessary to ban rescission or refusal to insure for whatever reason. I'm not saying that's all that needs addressed, but a lot of people are saying that we need to support whatever form the bill takes purely to accomplish an end to a small number of key abuses. If abuse were banned tomorrow, don't you think the discussion would change? It would start to be about what it really IS about which is how can insurance companies continue to extort as much money as they can while simultaneously making it affordable to the point that Americans don't simply refuse to buy it, DEMAND a switch to single payer, or riot in the streets.
But the real question isn't allowed to be stated, because if it was, people would quite sensibly decide that there are much better, simpler and cheaper ways to actually provide healthcare to the nation, and it wouldn't be anything like this bill.
December 18, 2009 11:37 PM | Reply | Permalink
If you can't afford insurance you get fined. If you can't pay the fine you go to jail. And by the way, you can afford the insurance if we say you can.
What's not to love?
How can anyone on the left be so out of touch with the streets as to not smell the stink of this?
December 18, 2009 2:48 PM | Reply | Permalink
On the plus side, you'd be able to get free healthcare in jail!
December 18, 2009 3:02 PM | Reply | Permalink
Thats a good point. I wonder if they have projected the number of people who will be jailed for not being able to pay, and accounted for them in the "30 million".
December 18, 2009 5:19 PM | Reply | Permalink
No, no, no.
First, if you can't afford insurance, there is a federal subsidy to help you out.
How much this is (and how much you can make and still qualify) is far from settled.
Second, there is a hardship clause to give an out to those who can't afford insurance despite the subsidy.
December 18, 2009 6:27 PM | Reply | Permalink
As he said, based on whether the government thinks its a hardship for you. 9.8% of a 67K income for a family of four is a hardship.
December 19, 2009 1:39 AM | Reply | Permalink
Five years is too long. Six months would be sufficient.
Keep in mind that a "public option" of sorts already exists in 29 states. These states have high risk pools which provide coverage to those who cannot get it in the private market place.
By definition, all of these people have pre-existing conditions -- that is why they cannot obtain private insurance.
The premiums charged by the high risk pools are reasonable. In fact, they are less than the amount to be paid under the proposed expansion of Medicare. Subsidies are available to the poor, but I believe that most of these programs are paid out of the premiums they receive. However, they are non-profit programs.
Most of these plans do have an exclusionary period, typically six months to one year. This appears to be sufficient to prevent people from gaming the system.
I just wonder why so many liberals who claim to have the best interests of the uninsured at heart, seem to eager to enage in punitive measures. So many liberals seem to be unusally eager to fine people for being poor.
December 18, 2009 3:10 PM | Reply | Permalink
Back in the early 70's Congress did away with aid to the aged, blind and disabled as federally financed but state operated programs and gave them to the Social Security Administration as Supplemental Security Income. Each state had its own system for administering the programs, some state-wide and others at the county level.
Congress gave Social Security eleven months from the passage of the bill to the date the first checks had to be in the mail.
Creating a new nation-wide computer system, finding out who was getting how much at what address and mailing out the first checks took the entire eleven months, and the computer system had no way of handling changes.
That's no changes in benefit amounts, names, addresses, anything. We didn't get those capabilities for months. And then they didn't work well for a long time.
This will be much larger and a lot more complicated. Ask the FBI which has scrapped at least three efforts that I know of simply to upgrade their (much smaller) computer system. I'd bet on congress giving them about four or five years and it will still be a real mess when it starts.
When the IRS first computerized back in the middle 60's they were still having problems with the system over a decade later. I heard they were still using that same COBOL-based system prior to the year 2000 problem because of the difficulties involved in just changing the system that large. Or look into the difficulties the FAA has been having upgrading their system. Last I heard they were still using antiques.
The size and complexity of the systems involved present unique problems.
December 18, 2009 4:40 PM | Reply | Permalink
I was thinking "1 year is too short", but then the author said 5 years. If you could opt back in in 6 months, a lot of people would be willing to take the chance.
If you look at the state chartered "high risk pools", they usually will not allow coverage on your preexisting condition for a year. People still join these programs and pay out of pocket for their own treatment for a year.
That has to lead to people opting for the minimum treatment for that first year. If people can make it through a 1 year lockout, getting through 6 months has got to be that much easier.
December 18, 2009 6:34 PM | Reply | Permalink
One thing I don't understand about the clause making it illegal to deny insurance to anyone for a pre-existing condition is whether there is some sort of cost limitation on such insurance. It seems to me that a company can say, "Bob, we see you have end-stage heart failure, and the law says we cannot deny you coverage for a pre-existing condition, so we are going to offer you health insurance for $20,000 a month." No subsidy is going to come close to covering that.
December 18, 2009 3:53 PM | Reply | Permalink
It is my understanding that the Senate bill requires the insurance company to charge the same for someone with a preexisting condition as everyone else in the same age group.
It might be better if the bill imposed a strict community rating rule (everyone pays the same), but this would have the effect of lowering premiums for older participants (good) at the expense of increasing premiums for younger participants(bad).
December 18, 2009 6:10 PM | Reply | Permalink
The Senate bill allows three risk pools, older people (I can't seem to unwind at what age "older" starts), smokers and everyone else. The "older" risk pool cannot charge more than three times what they charge the "everyone else" pool.
December 18, 2009 10:25 PM | Reply | Permalink
Which, of course, means that the insurance companies WILL charge those in the older person pool three times the premium of the younger people.
December 19, 2009 4:37 PM | Reply | Permalink
It is quite possible that nothing that can realistically be passed through the Congress will ever satisfy the netroot types.
Is it possible the Republicans really do have our number? Is it possible that we are incapable of handling success (winning house, senate and Whitehouse) without going into a self-destructive spiral?
I challenge the Dean for America believers here: Look at what this bill accomplishes for one minute. Do you think we could ever get hundreds of billions in dollars for health insurance subsidies with a Democratic Congress and a Republican Whitehouse?
Do you think we could ever get a law that prohibits discrimination against preexisting conditions, in a hundred years, with a Democratic House and Republican Senate?
Do you think we could ever get a law that prohibits cancelling someone's insurance after they get sick with a Democratic Senate and Republican House?
Vent your energy toward sufficient subsidies to make insurance affordable and a rule requiring insurance companies to spend at least 85% of the premiums on health care.
December 18, 2009 5:07 PM | Reply | Permalink
Seems to me almost everyone in the "netroots" was willing to accept the PO - even the watered down PO - instead of single payer. Most were even willing to accept the Medicare buy-in instead of the compromise of the PO. You're right. We're just being unreasonable because we won't accept something we see as a windfall for the insurance companies that will hand the republicans a huge issue in the next few election cycles.
December 19, 2009 1:45 AM | Reply | Permalink
I'm not opposed to the individual mandate on general principle. I think the mandate is better than the alternative described here, but I see it as a reasonable alternative if the mandate turns into a huge albatross.
December 18, 2009 7:41 PM | Reply | Permalink
You know, center-left liberals wouldn't be having so much problem getting this mandate to go down with their friends to the left if they had done their duty and taken on the health lobby with something approaching vigor. People are willing to chip in and do their part for the common good if the sacrifice is equitable. But when the call that goes out is not balanced, you get trouble.
The mandate is designed to redistribute wealth from the young and healthy to the old and sick, and thus to socialize the costs of health care. Good. I favor that. I like socialistic solutions. Some of the people on whom the mandate falls would turn into free riders without the mandate. But some wouldn't. That's not the point. The point is to keep America from being a socially Darwinist society, where the young, strong and healthy tell the old, infirm or sick that they are on their own. Even people who don't have children, and don't have a direct personal about educating them, are asked to contribute a substantial amount to the social task of educating them. In the same way, we need to ask everyone to contribute to the common social task of keeping our fellow-Americans healthy.
The problem is that while many people who would prefer not to purchase health care at all are being asked to pony up for this cause, those who should have been asked to do the most are getting away with doing the least. Not only has the health-industrial complex not been asked to sacrifice anything substantial, they are going to reap enormous benefits from this bill. And that industry is filled with extravagantly wealthy individuals, monsters of social waste, inefficiency and imbalance whose criminal avariciousness is treated as normal and untouchable by the timid center.
December 18, 2009 8:10 PM | Reply | Permalink
There's nothing new about that. That's what all insurance does. It's especially what Medicare does.
In 1965 when Medicare passed I was surprised to find that even employer insurance cut off at age 65. Three months before your 65th birthday you got a notice that as of age 65 you had no more health insurance. Everywhere. There were no major insurance companies who insured the elderly.
Why? They said that it was because they had no history of the costs and so they couldn't predict the expense they would be charging for. That's the problem Medicare was passed to solve. And it did.
The insurance companies were willing even then to sell insurance to the health risk pools and avoid the unhealthy risk pools (like the elderly.) Skim the cream and let the rest go hang. That is the essential nature of private insurance.
Public insurance is different. It can simply put everyone into one risk pool, charge the premium ("tax" is the label) from everyone and provide insurance at reasonable and predictable costs.
But the mixed public/private system means the private insurers find the low-risk pools, charge them, kick out the sick and force them into the public insurance which becomes nothing but the high risk expensive individuals. That's Medicaid.
That's what California Blue Cross Blue Shield is doing when they raise the premiums and kick out some 6 million or so policy holders next year. (or was it 600,000? I can't find the article. I saw it three or four days ago. Hell. It's only a decimal point. Physicists don't worry about decimal points. It's definitely one or the other though.) The insurance companies keep the cream and make their profit by managing their risk pool by shifting the expensive cases to the government. That's called "Business Efficiency."
Every insurance plan is designed to redistribute the wealth from the healthy to the sick. That's the nature of insurance.
Because of the statistical law of large numbers insurance allows everyone to predict and pay for the unexpected in advance and not have to worry about getting sick, losing the job and being unable to pay for needed health care at the time it is delivered.
December 19, 2009 5:13 PM | Reply | Permalink
Hello, I know you are not listening, but that doesn't change the fact that public policy can be paid for with TAXES. It is the normal way. Mandates are effectively a REGRESSIVE TAX. Not so many decades ago, the most basic standard of fairness in public policy was PROGRESSIVE TAXATION. Pay for it with PROGRESSIVE TAXES, you know, the beneficiaries of the George W. Bush Tax Cuts could pay for this thing and still keep some of their ill gotten gains.
December 18, 2009 11:27 PM | Reply | Permalink
you got that right
December 18, 2009 11:28 PM | Reply | Permalink
Damn straight !!!
C
December 18, 2009 11:33 PM | Reply | Permalink
YES! Simplicity itself. And it would free up time otherwise spent debating the merits of Exchanges, triggers, etc.
December 19, 2009 10:22 AM | Reply | Permalink
It's too late. Our senators already lined their pockets with insurance money. They don't want to have to pay higher taxes now.
December 20, 2009 10:50 AM | Reply | Permalink
What doesn't make sense to me is the cost structure. If, on the one hand, the premiums would go up without the mandate, why won't the premiums come down *with* the mandate?
The estimates I've seen all show the premiums staying at or above current levels. If you suddenly add 30 million people to the risk pool, that should lower the overall premium costs.
And if we're borrowing your idea from the German system, let's borrow one of their other ideas - the public option. Germans have a wide range of plans to choose from, both public and private. Not only would the public option put downward pressure on the for-profit company pricing, it would provide an option to those of us who would rather not waste 25% of our premium dollars on the overhead, bonuses, advertising, and stock dividends paid out by the profiteers.
December 19, 2009 1:41 AM | Reply | Permalink
Yes, the mandate lowers the average COST to insure. No one questions that. The problem is that there is nothing that forces the insurance companies to lower the PRICE commensurately. The cost ot the insurer does not equal the cost to the insured.
December 19, 2009 1:51 AM | Reply | Permalink
That's because of the nature of making the estimates. The only source of data for costs is the current costs. So all current estimates will be based on current costs that can be collected from the insurance industry. There are no good estimates for the changes in costs that will occur when everyone is in the same risk pool.
An economist might tell us which direction the costs are likely to go with everyone in the same risk pool, but he won't be able to say how much. The CBO is staffed by accountants or people using accounting numbers, and they don't trade in estimates unsupported by data.
That's why the conservatives used to complain that CBO estimates never took into account the fact that tax cuts would increase government revenues. You can't get estimates when there is no historical data from the same kind of situation.
December 19, 2009 5:24 PM | Reply | Permalink
The problem as I see it with this opt-in/ opt-out idea is this. If someone has decided to opt-out and then gets sick, they will STILL show up at the ER and WE will still pay that much higher cost for treatment. Also, they will probably be foregoing preventive and on-going care as it will cost them out of pocket, same as now. So that they will end up sick or sicker than if they'd been insured.
December 19, 2009 2:11 PM | Reply | Permalink
One thing to notice is that ERs are usually paid for first out of local property taxes. Medicaid (federal and state funds) supplements that. That seems likely to me to throw greater cost on local property tax payers if the state opts out.
It looks to me like the conservatives thought that opt-out business might work, but the county supervisors are going to scream to high heaven if the state tries to opt out of the system. I'll sure be complaining to my county commissioner about the misuse of my property taxes.
It should set up an interesting dynamic the next couple of times the state legislatures meet.
December 19, 2009 5:33 PM | Reply | Permalink
get lost you shill.
all this nonsense coul d easily have been avoided if obama was not a paid employee of the insurance industry.
everyone pays into and gets medicare.
cutthe war budget and presto!
December 21, 2009 8:17 AM | Reply | Permalink
What would happen if after opting out, people got sick and couldn't pay their bills? In that case, by their own choice, they'd be back in the world that exists today. They could still try to buy insurance without a subsidy; they just wouldn't be guaranteed any insurer would take them.
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I like your proposal, but the problem is if you are poor and you choose to opt out, then what are you going to do when you get sick? That's right, emergency room. What are you going to do with your ER bill? That's right, ignore it. If you don't speak English, you will have access to free translation services. So we are back to square one, to the situation we are in right now.
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I can see maybe charging smokers more. I am a smoker and I realize the risks smoking poses to my health along with the corresponding increase in health care services I will need because of it. And even though I am already being massively taxed for my smoking I would expect to have to pay more for health care. But not for preexisting conditions...and by charging people with preexisting conditions up to 3 times more than people without them it's an onerus financial burden (even with this so-called 'reform') which is being placed on the people who need health care the most...in their very real effort to just remain alive.
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September 2, 2010 11:49 PM | Reply | Permalink
So here's the proposal (which is derived from a similar provision in the German health insurance system). If people didn't want to buy insurance, they could take an opt-out by agreeing that they would not be able to come back into the subsidy system for five years. In other words, instead of paying a fine for failing to insure, they would forgo a potential benefit. For five years they would become ineligible for federal subsidies for health insurance and, if they did buy coverage, no insurer would have to cover a pre-existing condition of theirs.
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