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Health Care Is Not Like Car Insurance (Or: Against the Krugman/Clinton Mailer)
The biggest issue with Obama and Hillary's approaches to health care
stem not from the mandate situation, which I am convinced is a red
herring (more on this in a second), but from their non-confrontational
approach to the insurance companies. Hillary claims to have learned
from her 1993 disaster, but the lesson she has learned is to not raise
the ire of the insurance providers (hint: that is the wrong lesson).
Obama talks a better game when it comes to confronting the insurance
companies, but his plan is just as accomodationist as Hillary's. Out of
the three leading Dems, Edwards was the only one spoiling for a fight
with the insurance companies, and that was significant, even if the
differences were mostly rhetorical (he had stated explicitly--where
Obama has just said implicitly--that he viewed his plan as a potential
stepping stone to a single-payer, Medicare-For-All model). If we are
eventually going to get to Medicare-For-All, we are going to have to
bust up the insurance industry.
Unfortunately, looking at all the current proposals, it seems like the
insurance companies have very little to fear from the Dems' plans--
indeed, they'll be making out pretty good under all of them. The
insurance companies want to provide health insurance, not health care,
so they want to attract all the young healthy people to their programs,
the ones who will not use their services and the ones they will
therefore make a big profit off of. Any universal health care plan
worth a damn must pool risk (which will lower everyone's health care
costs), and that means preventing insurance companies from
cherry-picking healthy people and turning away sickies or oldies.
The conventional wisdom is that having a mandate where everyone is
forced to buy health care is the best way to pool risk. But, under the
current proposals, that wouldn't be the case at all. Both Clinton and
Obama would open up the Federal Employees Health Benefit (FEHB) program
to anyone that wants in. That's a good first step, but it has the
potential to promote and accelerate trends toward cherry-picking: the
insurance companies would skim the healthy and the young, and would be
more than happy to leave the higher-risk folks for the FEHB plans.
Mandates would do nothing to stop this cherry-picking and could even
cause it to accelerate further. Unless they are paired with measures
that prevent insurance companies from skimming, mandates are little
more than a cynical rhetorical bludgeon for Clinton and Krugman to use
against Obama. (Let's pause to appreciate what assholes those guys are,
particularly in light of the recent Wisconsin Clinton/Krugman health
care mailer: http://blogs.wispolitics.com/election/2008/02/clinton-kennedy-slam-clinton-mailer.html)
Additionally, let's remember that idea of mandates is a fundamentally conservative one; indeed, the very concept was endorsed by the Heritage Foundation (http://www.boston.com/news/local/massachusetts/articles/2006/04/13/conservatives_split_on_mandate_and_business_fees/). By itself, a mandate takes the principle of universal health care--health care as a right, not a commodity--and then it robs it of all meaning, by devolving responsibility for health care onto the individual. John
Edwards compared health care mandates to Social Security; I think a
better analogy might be to Clinton-style welfare reform, blaming the
victim and not providing the necessary support.
So, let's ask the important question: Who, between Clinton and Obama,
would get us on the path to Medicare-for-all? I am convinced that it is
Obama. For one, Clinton has explicitly ruled out single-payer as a
possibility. She views her rejection of single-payer as somehow a sign
of her political maturity, one of those hard-learned lessons from the
first go 'round. Hillary's plan represents an end-run around Medicare-for all, in that its results intends to
innoculate America against a more comprehensive solution. Obama's plan,
on the other hand, is far more open to expansion. To use a horrible
analogy, the plan is like a piece of software designed to be compatible
with expansion packs in the future.
Obama has embraced single-payer in the past, but now
he is hedging. As politicians will do, Obama is yielding to structural
and institutional pressures. Despite this, Barack Obama's candidacy
offers us an unique opportunity, due in large part to the movement that
has formed around his candidacy. To get single-payer done--to get any
significant change to take place in our political system--you need to
have movements that can apply pressure equal to or greater than the
structural pressures and limitations typically imposed upon
politicians. And Obama has actively encouraged the growth of just such
a movement. No such movement exists around the Clinton campaign, and my
suspicion is that, consciously or not, that is the way they prefer
things. Obama's movement--the millions of newly engaged and newly
idealistic--can help shape his presidency and transform the popular
discourse, provided we don't disband after the election is over.
So, let's get Barack elected, let's hold him accountable, and let's
help him to define a progressive agenda that can succeed nationally in
a way we haven't seen for decades.







Comments (24)
Mandatory private insurance is a welfare program for the insurance industry, nothing else.
Perhaps the major mistake of Clinton's 1993 health care debacle was trying to do it all behind the scenes. There were enough other mistakes on her part that it crashed to the ground in a crumpled heap immediately on launch.
And Edwards' proposals, like the rest of his campaign, simply did not resonate with the public. Despite the endless complaints about his lack of coverage, the fact is, a candidate barely polling in double digits is not news, and the lack of coverage was a reflection of that fact, not a cause of it. He meant well.
While Obama's notion of having everything take place in the public eye may not be the ultimate resolution, it is a good first step. And from good first steps comes progress.
Oh yes, and what was that old line about sunlight being the best disinfectant?
I am 100% in favor of single payer/universal Medicare. Ultimately, it will have to happen. There is simply no good reason for the US to be so far out of step with the rest of the modernized world. The fact that it's proven profoundly damaging in our attempts to be economically competitive worldwide makes me wonder where the industrial/corporate folks are hiding. Do they not want to push for something that will restore them an advantage worldwide?
So, we take the "half a loaf" and go forward from there. Always from those further steps forward. That's what progress is.
Incremental progress is frustrating to a lot of immature minds, true, they expect immediate gratification. Life does not work like that. We didn't get into this mess overnight, and we won't emerge from it without some effort and time being involved.
February 18, 2008 12:24 PM | Reply | Permalink
I'm with you! I guess that makes me an "old grouch too."
In my view Obama is more likely to get his measures actually passed. And to mobilize the populace to fight the insurance companies.
Single payor universal care - like Medicare - is the best for citizens and the best for providers. You take out the "middle men" and the "deniers of service" and the "investors seeking a profit."
Let's let the citizens profit - with better health care, no need for authorizations for care, and providers who are paid promptly with no need for worrying about being in a network.
Wherever you'd go, you'd be sure you could get care.
♪♪♪
February 18, 2008 2:31 PM | Reply | Permalink
Well, everyone ought to try being an old grouch for a while, It's kind of fun.
Single payor universal care - like Medicare - is the best for citizens and the best for providers. You take out the "middle men" and the "deniers of service" and the "investors seeking a profit."
Let's let the citizens profit - with better health care, no need for authorizations for care, and providers who are paid promptly with no need for worrying about being in a network.
Wherever you'd go, you'd be sure you could get care.
Well pointed out...
I often wonder why no one on our side challenges the "you won't be able to see the doctor of your choice" lie the Repubs continue to trot out - if every doctor is in the network, you go see whichever doctor you want, or if you're elsewhere, whoever's nearby.
People have trouble enough now seeing doctors they need or want, under "out of network" provisions and the seeming miles of red tape insurers toss around.
If there's only one network, who's outside it?
And frankly, I'd like to see heath care (not health insurance, health care) defined as a basic human right, along with clean air and water, a safe place to live, food, and at least a decent education. When we look at the cost of not doing those things, they seem like very good investments, don't they?
Remember the old movie line: "The strong make many bricks, the weak few, the dead, none!"
February 18, 2008 5:11 PM | Reply | Permalink
Basic Human Right. Amen!
February 18, 2008 9:38 PM | Reply | Permalink
I'm sorry. I missed the part where Health Insurance is not like Auto Insurance, at least as for as mandatory coverage goes.
February 18, 2008 3:40 PM | Reply | Permalink
Try
http://tpmcafe.talkingpointsmemo.com/talk/2008/02/health-insurance-is-like-car-i.php
I'd like to read your reaction.
February 18, 2008 6:59 PM | Reply | Permalink
See your comments.
February 19, 2008 8:54 AM | Reply | Permalink
By itself, a mandate takes the principle of universal health care--health care as a right, not a commodity--and then it robs it of all meaning, by devolving responsibility for health care onto the individual.
That sentence makes no sense at all Does it mean that 'health care as a right has been robbed of it's meaning when pool participants are required to contribute to the pool?'
Any universal health care plan
worth a damn must pool risk (which will lower everyone's health care
costs), and that means preventing insurance companies from
cherry-picking healthy people and turning away sickies or oldies.
I agree with that statement as far as it goes. The plan must also deal with the cherry pickers on the consumer side as well. If you set up a plan that says "If you're young and healthy and don't want to buy health ins now, you can opt in when you get sick," I believe that program is headed for failure.
I believe that you and I have similar desires...ie universal single-payer health care without insurance company involvement?...but, like the candidates, disagree on the best approach to achieving them. Bur goal is the same and if your candidate wins the nomination, as appears likely at this point, I will still jerk that donkey lever in Nov. for Obama.
February 18, 2008 4:25 PM | Reply | Permalink
Hillary hasn't ruled out single-payer. She has made federally-administered insurance an option in a competition with private insurers. The genius part of Edwards/Clinton plan is that the market will decide that private health insurance is a waste of money and it works against improving the development and delivery of health care. People who can't afford the premiums under a mandate would receive subsidies and cherry picking would not be possible, because all providers would have to accept all applicants at the same rates.
I agree that Obama has a better chance of getting a plan passed, but it will be a plan that favors the private providers. He has accepted that they will help design the plan, and that makes it both palatable and useless. Hillary would have a harder row to hoe if she sticks to her guns, but the plan would actually be beneficial to all concerned, except for the insurers. The question is, do we want more of the same, or a shot at a real solution? That's why I hope that she and/or Edwards are at least part of the new administration.
February 18, 2008 4:42 PM | Reply | Permalink
The genius part of Edwards/Clinton plan is that the market will decide that private health insurance is a waste of money and it works against improving the development and delivery of health care. People who can't afford the premiums under a mandate would receive subsidies and cherry picking would not be possible, because all providers would have to accept all applicants at the same rates.
I agree fully. Obama has compromised on the pooling of risk concept coming out of the gate on this issue. Applied to a different insurance market, we shouldn't be mandated to purchase auto insurance until we've had an accident. Conceptually, it's designed to fail.
But I have no doubt the 'no mandate' approach appeals to the younger healthier set which is a large part of Obama's base. Assuming Obama is nominated and elected, I don't think we'll be closer to achieving a single-payer universal system. We could well be farther away.
February 18, 2008 7:14 PM | Reply | Permalink
Don't forget that if you separate Medicare from the other health care, you have already separated out a lot of the risk! Think about it. The elderly and the disabled get Medicare...and the insurance companies get everybody else?
It's like saying the govt will provide mortgages for the indigent, who may default. And the banks can provide them for those who pay!
It's insane! (but then what do I know?)
February 18, 2008 9:41 PM | Reply | Permalink
There's no question that Medicare and Social Security and the VA focus on those most likely to need help. But those programs aren't really insurance. The only reason we are talking about the effects of pooling and the idea of premiums is that the issue has been framed as an insurance matter. The reason it is being framed that way is because in the last forty years private insurance companies have taken over the process of paying for health care. We pay them, they take a taste, and they decide who will be paid for service and how much.
Those without insurance are not in the pool strictly speaking, but people without insurance are still treated, and if they can't pay, where do you think the money comes from? Some indirectly from the companies and some from the tax payers. The whole point is that we are all in the pool. People can't be replaced every hundred and fifty thousand miles, so it's not surprising that the longer you are around the more costly your maintenance becomes.
Back in the sixties, when people were becoming far more mobile and traditional family-based care of the elderly was dying out, elder health care was framed as a moral and ethical issue. Not surprisingly there was a huge amount of resistance. It took the death of JFK, the fresh memory of FDR, and the determination and skill of LBJ and others to make Medicare happen.
February 19, 2008 8:31 AM | Reply | Permalink
One of the funnier ideas Obama has come up with is to hold meetings with the stakeholders on CSPAN. That's an idea that will look good to Obama's upper class base, and I guess things get into your talking points sometimes that are better left out. Truth is, CSPAN isn't even part of basic cable here in Michigan, while CNN is. The people most affected by the outcome of the televised debate will be at work or looking for a job, or watching daytime TV, and they will get their news about who said what about health insurance today from the MSM, just like they get their news about this campaign. The most jarring thing about the Obama campaign to me is how elitist it is. And maybe cynical. Mr. Obama has to know that the people who are most likely to opt out of the system are the people who need health insurance most. We are a society. There is a social fabric. It now includes Social Security, Unemployment Insurance, and Medical Insurance for seniors. It needs to include universal health insurance first, then universal health care.
February 19, 2008 9:08 AM | Reply | Permalink
Finally ... I'm glad someone took the time to explain why mandates are a "political red-herring," and not as exclusionary as Krugman and Clinton would have the public believe. I like Krugman, but he's becoming increasingly indifferent towards Obama, much the same way Frank Rich has openly demonizing Clinton.
I can't wait till the primaries are over, and we can start working on fixing this country. Health care or not, it won't matter without jobs.
February 18, 2008 5:05 PM | Reply | Permalink
Krugman is not indifferent to Obama, he is overtly hostile towards his candidacy.
February 18, 2008 6:20 PM | Reply | Permalink
Finally ... I'm glad someone took the time to explain why mandates are a "political red-herring,"
I guess I missed that 'explanation'. Where is it?
February 18, 2008 7:15 PM | Reply | Permalink
Bill Clinton's leadership of the Democratic Leadership Council had, as its major strategy the tactic of "triangulating" issues.
This translated to "sounding" progressive while simultaneously incorporating Heritage Foundation and American Enterprise Institute "values" into proposed legislation.
The real point has never been GOOD legislative proposals or consensus building. The point is the game called:
"Don't-give-the-radical-right-any-ammunition-that-could be-used-in-a-soundbyte-that-might-lose-us-the-next- election."
They call the approach "incremental."
In truth, it was gutless.
And, ineffective.
It lost more elections than it won.
But, it was GREAT for fundraising.
And for perpetuating the dialog of the deaf that has been politics since...oh...the mid-eighties, when Tip O'Neill retired from the house and the DLC took over the party.
Hillary AND John Edwards have been dedicated DLC stalwarts. (Hence the opportunistic votes FOR the Iraq war--and SO much more.)
"Mandates" are a capitulation to the AEI/Heritage Foundation narrative that the DLC is trying to appropriate while also keeping their traditional but shrinking base somewhat satisfied.
That narrative has as its main tenet the idea that poor people are poor because they don't take "personal responsibility" for things like chronic illnesses, unplanned pregnancies, bad schools, hopeless neighborhoods with crumbling infrastructure and non-existent policing, asthmatic children, maternal and infant mortality rates that should be the shame of the developed world ...in short, anyone who has not managed to reach the economic middle-class deserves any bad thing that happens to her. (I say "her" because most of the poor and uninsured in this country are female. White females, more specifically, but that's not part of the narrative.)
The sheer fact that "mandates" and "penalties" became part of this conversation BEFORE solid proposals for regulation of the health care industry did tells me that neither Clinton or Edwards has any real clue about how broken the "system" is and how much health care actually costs anyone who is not under 25, male and in the pink of health. (females of childbearing age pay more in an open insurance market where "pregnancy" is defined as an illness.)
It's not about "taking on" the insurance companies. It's about taking on our own legislators. They need to LEGISLATE regulation of the industry. But neither Clinton or Edwards would dare to say that in an era when the AEI has made the problem not an industry run amok but people who want "too much" health care and "frivolous law suits" and the dems have let them get away with it.
February 18, 2008 7:17 PM | Reply | Permalink
Thanks for the comments and the constructive criticism. As a result of this discussion thread, I have been looking more closely at the plans' provisions for limiting private insurers' abilities to turn away applicants, and I am actually finding myself heartened by both Hillary's and Obama's plans. They each have a little more teeth to them than I had previously suggested (that is, if they make it into law unscathed-- which is anything but a sure bet).
It is anybody's guess as to which candidate will kowtow more to the insurers. They've both taken a hell of a lot of money from insurance and pharma folks (although Clinton has Obama beat here, both in terms of quantity, and in the fact that only she takes $$ from lobbyists, while Obama's insurance and pharma money comes from individual execs). At times both candidates have talked tough about taking on the insurance companies, and at other times they have each sounded conciliatory. It is sort of a wash.
Mandates are sort of a wash as well, mostly on the basis of enforcement:
Obama has stated that, if necessary, he would consider imposing mandates. More significantly, he has said that he would consider an "automatic enrollment" system in government plans for the uninsured as plan of his proposal. Clinton, for her part, has avoided the question of exactly how she would enforce her mandate. And enforcement is an awfully big question. If she won't come straight out and say that she will fine the un-enrolled, then it is possible that, to her, a "mandate" just is a tougher-sounding name for automatic enrollment. So unless she is explicit about the implementation and enforcement of mandates, the differences between the two health plans become moot.
What's most important is that we get started on the long road to single-payer. And Obama has a history of supporting Medicare-for-all (while Clinton, as shown during the S.C. debate, appears downright hostile to the idea). And, like many of you, I think Obama can inspire America to rally around the cause universal health care. Whereas for Hillary, it remains a partisan battle.
February 18, 2008 8:59 PM | Reply | Permalink
Your last paragraph bears rereading. Folks, please reread the last paragraph of the post above.
♪♪♪
February 18, 2008 9:44 PM | Reply | Permalink
Excellent discussion. I don't know why I haven't wandered over to TPM Cafe before; but I have greatly enjoyed the cogent, careful conversations I have read here.
Thanks.
February 18, 2008 10:32 PM | Reply | Permalink
Obama has stated that, if necessary, he would consider imposing mandates.
He already is; (from BarackObama.com)
Mandatory Coverage of Children: Obama will require that all children have health care coverage.
Sounds like a mandate to me. Anybody know how he intends to enforce this mandate? Thanks in advance.
Employer Contribution: Employers that do not offer or make a meaningful contribution to the cost of quality health coverage for their employees will be required to contribute a percentage of payroll toward the costs of the national plan.
Another mandate?
National Health Insurance Exchange: The Obama plan will create a National Health Insurance Exchange... The Exchange will require that all the plans offered are at least as generous as the new public plan and have the same standards for quality and efficiency. The Exchange would evaluate plans and make the differences among the plans, including cost of services, public.
Mandates Lite, maybe?
Because the word "mandate" doesn't poll well, the Obama campaign made a decision early on trying to finesse the Libertarian-leaners on the center-right to vote for him. It's nothing more than a political calculation on the campaign's part.
February 18, 2008 10:36 PM | Reply | Permalink
While not for certain, though highly likely, the target demographic group of this mailer tells more than the message itself. If you translate the barcode on the mailing label (easy cryptography) you get the 3200 Block of Mary Street in Stevens Point, Wisconsin. This neighborhood is a low income, marginalized area near the railroad tracks. We can actually pinpoint it further (but that is uncool).
Bottom line here is: Hillary Clinton is mailing healthcare scare letters to poor people.
http://www.wispolitics.com/1006/080217ClintonMailer.pdf
February 19, 2008 7:03 AM | Reply | Permalink
Thanks for the link. Which part of the mailer is untrue?
February 19, 2008 8:59 AM | Reply | Permalink
"Which part of the mailer is untrue?"
Um, where do you want to begin? Remember Al Franken's "weasel words"? Things that are not technically "lies" but are clearly intended to mislead? Or, put another way, Everything that's come out of Karl Rove's mouth ever? This flyer is sick with them. So let's begin:
"Which of these people do not deserve health care?" The insinuation here is that the difference between Obama's plan and Hillary's is that people would be turned away from getting health care under Obama's plan. False.
And this line of attack gets more explicit and scare-monger-y on Page 2:
"Will it be YOU?"
(Here, a more honest mailer would say "Turn over for answer!" and then would have the word "NO" written in 128-point font.)
The mailer uses contested claims that 15 mil would not have health insurance to suggest that those people would be denied or left without access because... of what? their income level? pre-existing conditions? The mailer doesn't say (and even the study that came up with the number of 15 mil never charged that anyone would be "left out"-- the number is just an estimate of the healthy young folks it thinks would choose to opt out of the system). Why? Because it would be a flat-out lie to say any of these things. Instead, the piece just implies these things by declaring that Hillary's plan would "end discrimination against people with existing conditions." By contrasting this statement with the bulletpoints underneath Obama's plan (wasteful, demagogue, hates universal care), the mailer suggests, in a none-too-subtle way, that Obama's plan would not do the exact same thing with regard to preexisting conditions. Which is BS, and very, very Rovian.
Indeed, every feature of Hillary's health care plan that she talks up in her bulletpoints is shared in its entirety by the Obama plan (keeping your current plan, making care affordable for all, ending discrimination against pre-existing conditions). The only difference between the plans (a difference without a distinction, as I hope I've shown in my past posts) is that her plan involves some vague notion of mandates (a word, unsurprisingly, nowhere to be found in the piece). But the average reader would wouldn't know that. Which is the point.
On the last page of the mailer, the Clinton stoops to perhaps its lowest level yet, by taking advantage of a man who with obvious psychological problems. For a campaign that claims to be concerned with health care, you'd think Hillary would show more concern for the clearly troubled Paul Krugman, instead of choosing to display his logorrhea and angry derangement on the back of the mailer for the world to see. For shame, Hillary, for shame.
February 19, 2008 10:26 AM | Reply | Permalink
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