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September 19, 2007

HillaryCare Criticisms

If I were going to not like Hillary Clinton's health care plan, this would be the case I'd make. As it is, I think the areas in which she's vague are not areas in which she'll fail: No politician will create an individual mandate plan and then not offer adequate subsidies. The resulting outrage from families who couldn't afford healthcare but were legally obligated to buy it would destroy their career, doom their reelection, and kill the plan.

September 19, 2007 | Permalink

Comments

I think I read somewhere yesterday that some Clinton advisers in sotto voce said that there was hope there would be no mandate. But it's impossible to find, as the amount of blog noise on HRC is just too high.

Posted by: Nicholas Beaudrot | Sep 19, 2007 2:01:56 PM

No politician will create an individual mandate plan and then not offer adequate subsidies.

Famous last words. Nobody would ever offer inadequate subsidies, right? Just like no one would underfund Medicaid, or make massive cuts to home heating oil programs. Or gut welfare and call it a "reform," for that matter.

It's not enough to present a plan; you have to be willing to stand behind it when it comes to actual money. On the one hand we have Edwards, who's been pretty up-front with the fact that his plan is going to cost quite a bit of money, and on the other hand we have Clinton, who's trying to follow in her husband's "balanced budgets uber alles" footsteps. Edwards, also, actually seems to care about poor people, whereas the Clintons have spent their careers actively trying to give the impression that they aren't bogged down with that touchy-feely poverty crap.

Posted by: Christmas | Sep 19, 2007 2:10:30 PM

"No politician will create an individual mandate plan and then not offer adequate subsidies. The resulting outrage from families who couldn't afford healthcare but were legally obligated to buy it would destroy their career, doom their reelection, and kill the plan."

Here's the problem; by failing to specify this, Senator Clinton's opponents, be they on the right or the left, can simply assume the worst. Thus, "America's Mayor" can assert that (just a hypothetical) this plan will force a family of four, making $65,000 per year, to give insurance companies $2,000 per month. If the family is uninsured now, that's money they don't have, and its going to possibly the most politically unpopular group in the country. She would be toast in Michigan, Ohio, and Wisconsin. Whether she would implement this plan in a less regressive manner after the election won't matter; she won't be elected, and the Democratic party will look feckless and rutterless, just as it did in 1993.

Posted by: Father Figure | Sep 19, 2007 2:18:48 PM

I'm still taking this all in, so I don't really feel strongly in support of any one "plan" - indeed, I think all of this "plan offering" is merely a starting point for expanding the conversation about our healthcare system - we're a good 18 months from any point where one could seriously expect a proposal that would be debated in Congress, for instance, and that's assuming a Democrat wins in November 2008. I think Clinton's proposal raises interesting questions and also offers interesting solutions, but I think with all of them, the details need to be scrutinized, and refined.

Still, Blase finishes by asking "why not just go to single payer and not tie health insurance to employment" which I think is the best general question about what Hillary's proposing - if you agree that the "employer mandate" can't just be erased in one swoop, you have to then do, as she does, a sweries of workarounds, which is what the access to FEHP, the "Medicare-like" provider, and the individual mandates all so. But the question is... why? All of this really adds complication, not reduces it.

However, I think if what we want is to create the room where an alternative, totally single payer model is seriously discussed and debated, we need this proposal. This is, in many ways, the alternative. What I think is entirely likely is that if you were to move to Clinton's plan, two things happen: one is that employers will rush to the exits and move their employees to choose alternatives, and more insurers probably deciding that heavily regulated health insurance plans are less feasible - all of which leads, generally, towards single payer.

I think some conservatives get this (and some conservatives just see "government care" boogeymen in every proposal), but they still don't want to acknowledge that what we have is broken, or offer a credible alternative (look at how Romney, arguably the one who's actually tried a coverage mandate, couldn't offer more than generalized dislike for the plan, and avoided almost any examination of specific aspects). Absent that, we continue to have half a debate, and one where many people still don't understand all of what's being discussed. Is Clinton's plan the best we've got? I don't know; but all I've really wanted to have the actual discussion around healthcare, not the whole "do we like her not" one. What I'd really like to hear, now, is how someone who believes in single payer would handle some of the issues she raises and deals with, especially the political realities around how to end the employer mandate when it's all many people know. Hopefully, as the fall goes on, we will see some of that.

Posted by: weboy | Sep 19, 2007 2:30:15 PM

No politician will create an individual mandate plan and then not offer adequate subsidies. The resulting outrage from families who couldn't afford healthcare but were legally obligated to buy it would destroy their career, doom their reelection, and kill the plan.

Preach it, Ezra. Getting overly specific in 1994 didn't exactly work wonders. Why anybody would want a repeat of that fiasco is beyond me. I don't know why nobody mentions congress in all this, either. I mean, it's not as if it's against the constitution for our elected legislators (especially Democratic ones) to, you know, work with the new Clinton administration on some of these concerns. It's hard to imagine that any legislation that has a prayer of reaching Hillary's desk will force people of moderate means to, say, rack up several tens of thousands of dollars in credit card debt in the eventuality that they'll get reimbursed via a check from the IRS. Let's all just chill, people, and get a Democrat elected, and let that Democrat propose a bill that represents the most optimal possible blending of political feasibility and social justice.

Posted by: Jasper | Sep 19, 2007 2:32:19 PM

still no answer of the basic question. starting think sirota maybe right.

Posted by: akaison | Sep 19, 2007 2:33:44 PM

This is an honest question. Getting rid of private insurers seems to be something people are always looking for out of the next Greatest Health Care Plan Evah, but what does this exactly mean? I don't think a plan that leaves thousands upon thousands of people unemployed would be easily sold. So, I presume I am missing something.

Posted by: IllusiveTruth | Sep 19, 2007 2:35:10 PM

No politician will create an individual mandate plan and then not offer adequate subsidies. The resulting outrage from families who couldn't afford healthcare but were legally obligated to buy it would destroy their career, doom their reelection, and kill the plan.

I guess it all depends on the definition of "adequate."

Massachusetts Democrats lost in a stand-off with Romney on this very issue, but still pushed the legislation through. The uproar was minimal, you need to be really wonkish to start wading through sliding scale subsidies based on various multiples of the poverty level.

Its not hard to imagine a similar situation at the federal level.

Posted by: wisewon | Sep 19, 2007 2:37:02 PM

Most of these critisms are just double standards driven by dislike for Hillary. To ask a politician to complete specficy every part of their policy proposal during the campaign is ludacris. It would be one thing if her plan was just a general idea like "we should insure everyone" then it'd be fair to argue vageness. But to demand a thousand page document explaining every nitpick aspect of her bill is an unfair standard not being applied to any other candidates.

Posted by: Phil | Sep 19, 2007 2:40:30 PM

please spar us the talking points. answer the questions and criticisms.

Posted by: akaison | Sep 19, 2007 2:55:23 PM

Most of these critisms are just double standards driven by dislike for Hillary. To ask a politician to complete specficy every part of their policy proposal during the campaign is ludacris.

I'm not asking for "completely specify everything". I'm saying, this provides Cadillac-quality health insurance for everyone, and funds it via an extremely regressive tax. That's a very bad combination.

Posted by: SamChevre | Sep 19, 2007 3:10:49 PM

The subsidies in Massachusetts are insufficient. Why should I believe that anything will be different on the Federal level?

I do not understand why health care wonks love these plans so much: its as if they don't have any idea abut the economics of normal families. I know thats not the case, so what gives? These plans depend on very generous subsidies to make sure that people can afford decent care, and there is nothing in our country's recent history to suggest those subsidies will be given. They do nothing to limit the power of the worst actors in public health, the private insurance companies, they do nothing to limit the growth of costs, and they do nothing to guarantee that people will have access to good health care.

So what is the attraction?

Posted by: Kevin | Sep 19, 2007 3:14:47 PM

because our side creates them

Posted by: akaison | Sep 19, 2007 3:34:42 PM

Oh my, Ezra, you really blew this one. I completely agree with Kevin's comment: The subsidies in Massachusetts are not really generous enough for those who get them; and they don't reach a number of moderate-income folks who really do need them. The premiums and cost-sharing for someone who makes just $37,000/year will not keep people out of the poorhouse. See this poll for how people in MA feel about it; interestingly, the most popular part of the law is the most "socialistic"; and people tend not to like the unsubsidized part.

That's my guess for how this will turn out - much like Massachusetts, with *exactly* the flaw you mention. You are whistling in the dark.

Posted by: Charley on the MTA | Sep 19, 2007 3:51:04 PM

No one cares about the subtleties. What people will hopefully latch on to is that the very name of the program appears to contain a lie.

Posted by: TLB | Sep 19, 2007 4:11:19 PM

I do not understand why health care wonks love these plans so much: its as if they don't have any idea abut the economics of normal families.

Sorry to pile on, but I think this is the crux of this issue. Wonks also tend to work for institutions that have at least fair health care plans so they have no idea what it's like for those of us who are truly out in the market. Also, everyone loves unfunded or underfunded mandates because it pushes the issue off onto others in a diffuse fashion. I don't mean to be unpleasant, but I do think this post reflects a signficant disconnect.

Posted by: sparky | Sep 19, 2007 4:35:53 PM

I do not understand why health care wonks love these plans so much: its as if they don't have any idea abut the economics of normal families.

Although I'm not such a creature, and although I don't pretend to speak for Ezra or any other "health care wonk," I do think it's a wild exaggeration to claim such folks "love" these plans. I think rather, that there is support for a large-scale sea change in the way Americans get healthcare, and getting millions more people -- hopefully everybody -- covered. I believe there is also genuine reason for hope and optimism about the fact that we may finally be on our way to substantive reform that eventually gives the country national health care.

These plans depend on very generous subsidies to make sure that people can afford decent care, and there is nothing in our country's recent history to suggest those subsidies will be given.

Maybe so, but America's healthcare system is currently characterized by massive cross subsidization of one form or another -- so at least there's some precedent. But there's very little precedent indeed -- not to mention almost nothing in the way of credible political support -- for single payer here in 2007. I mean, for starters, there's that little detail of how to pay for it. The price tag would surely dwarf by several degrees the $110 billion price tag mentioned by the Clinton campaign. How exactly is the country going to pay for it? And please don't answer: by diverting money that under the status goes to private insurance companies -- because to attempt to force that on American is essentially synonymous with legislating out of existence (or pretty near to it) a $600 billion business. Ain't gonna happen. Far better to set up a structure that at least gets people covered, and then, in the fullness of time, let the government pick up the pieces as private insurers go out of business, or as employers dump them as vendors. And hopefully people of good will will work together to insure that the eventual plan includes subsidies large enough to minimize the pain of ordinary folks who will be facing monthly premiums.

The benefit of doing it this way, of course, is that, by making insurance coverage truly universal, it will being to more closely resemble, well, social insurance. And as people get used to the idea that coverage is a right, it will set the stage for deeper reform. And if, as I suspect, the business model of for profit insurers begins to wilt, then the accompanying pain will itself provide the political pressure forcing more radical reform. The unfortunate reality for people who know the US could be enjoying a much saner and just system is we simply haven't made our case yet with sufficient credibility to a sufficient number of Americans. Too many Americans are happy with their personal health insurance situations to swing for the fences with a French-style reform. That's changing, mind you -- enough so that a modest expansion of the status quo's coverage opportunities to get all citizens covered is no longer political dead duck. We need look no further than the states to see the evidence for this. But a radical overhaul -- not yet. But hopefully soon.

As I've written before, I suspect the pressures on the healthcare system will intensify to the point that some sort of national healthcare system will be forced on the country -- even if many of its residents are dragged kicking and screaming every step of the way. But we're simply not quite there yet. The best evidence of this is the poll numbers of the candidates who are proposing the most comprehensive health care reforms, like Dennis Kucinich.

Posted by: Jasper | Sep 19, 2007 6:20:32 PM

Although I'm not such a creature, and although I don't pretend to speak for Ezra or any other "health care wonk," I do think it's a wild exaggeration to claim such folks "love" these plans. I think rather, that there is support for a large-scale sea change in the way Americans get healthcare, and getting millions more people -- hopefully everybody -- covered. I believe there is also genuine reason for hope and optimism about the fact that we may finally be on our way to substantive reform that eventually gives the country national health care.

Love may be too strong, but they certainly seem to be in deep, deep like. Ezra has called these plans "very good" on more than one occasions, and it seems to be the consensus among the health care wonks I have access to that these are good plans. What I have not seen is reasoned argument as to why these plans will lead to the desired outcomes despite the flaws that I and others have pointed out.

I suspect, though will be happy to be corrected on this -- mind reading is bad form -- that the main reaosn is summed up in your comment here:
Maybe so, but America's healthcare system is currently characterized by massive cross subsidization of one form or another -- so at least there's some precedent. But there's very little precedent indeed -- not to mention almost nothing in the way of credible political support -- for single payer here in 2007. I mean, for starters, there's that little detail of how to pay for it. The price tag would surely dwarf by several degrees the $110 billion price tag mentioned by the Clinton campaign. How exactly is the country going to pay for it? And please don't answer: by diverting money that under the status goes to private insurance companies -- because to attempt to force that on American is essentially synonymous with legislating out of existence (or pretty near to it) a $600 billion business. Ain't gonna happen. Far better to set up a structure that at least gets people covered, and then, in the fullness of time, let the government pick up the pieces as private insurers go out of business, or as employers dump them as vendors. And hopefully people of good will will work together to insure that the eventual plan includes subsidies large enough to minimize the pain of ordinary folks who will be facing monthly premiums.

I don't think I can disagree with this attitude more strongly. "Medicare for everyone" is a simple, easy to understand plan that could be sold in this country, at this time. But whether I am right or wrong, starting with these plans is pre-emptive compromise and that is the worst kind of bargaining. Nothing we do will prevent the insurance industries and the GOP from trying to kill anything that resembles health reform in this country. Starting out with a compromise just gives away what we could win through public relations/negotiations right at the start. It is bad politics and if this is the driving force behind these plans, it is bad politics that is leading to bad policy.

And I know that people of good will will work to make the subsidies acceptable. ut people of goodwill did that in Massachusetts and failed. And people of goodwill tried to make welfare reform and actual path out of poverty and they were defeated by those who just wanted o dump people off the roles. People of good will tired to make NCLB about educating children instead of punishing public schools and they failed their, too. A plan that results in most people paying more for less coverage -- which appears to be beginning to happen in Massachusetts -- is going to kill health care reform in my lifetime.

And, yes, Clinton or Edwards or Obama would pass such a plan, because it would be good for them politically. It gives them a big win to trumpet in the press and then they can just blame the problems on the GOP.

The best evidence of this is the poll numbers of the candidates who are proposing the most comprehensive health care reforms, like Dennis Kucinich.

I don't think this is fair. Kucinich combines the worst aspects of the "humorless gnome" and "lunatic stoner" personality types. Bet you 50 dollars to your favorite charity that if Edwards, Obama, or Richardson proposed Medicare for all, Clinton would no longer be the prohibitive favorite.

Posted by: Kevin | Sep 19, 2007 7:03:02 PM

Ezra says he would ideally put doctors "on salary". Doctors are actually trained (unlike self professed "educated" opinionators and wordsters) through long years of expensive, arduous study. For a pipsqueak like you to blithely consign them to a salary (undoubtedly of your determining) is just too much. The (undeserved) arrogance of it!

Posted by: Klein's normal nut | Sep 19, 2007 8:31:41 PM

"Ain't gonna happen."

The political climate in this country is fertile for single payer health care. It's like the neoliberals don't understand. When Democrats offer unpopular plans that exacerbate every negative aspect of the health care system, they ruin their credibility, especially when they appear to be trying to trick the public through incrementalism. Better to just stand up for what we believe in, and leave the technocrats and economists at home.

Posted by: Father Figure | Sep 19, 2007 8:56:52 PM

Each federal entitlement program is in deep financial trouble. Social Security is insolvent and the only argument is when it will fail. Even more so with Medicare.

Why would anyone believe that the federal government will be able to afford this aggressive plan to insure everyone? Has anyone addressed the fact that all these plans are doomed to financial failure, or does it really matter to them?

Posted by: El Viajero | Sep 20, 2007 10:20:43 AM

The political climate in this country is fertile for single payer health care. It's like the neoliberals don't understand.

Look, I'm willing to listen to arguments that the major candidates are underestimating the appetite of the American people for single payer, but it would be nice to hear actual, you know, arguments, rather than mere assertions. The evidence mostly says otherwise, which is likely why the skilled politicians with an actual chance of taking the nomination (C/O/E) aren't proposing it yet. Who knows, maybe after one of them takes the oath, the push from the left will be so strong that the eventual Democratic president and congress will be forced to pass something more radical. I hope this comes to pass. Indeed, now that I think of it, that may well be the strategy with the greatest possibility for success: keep your powder dry, elect a Democrat, and then hold their feet to the fire to get the best possible legislation. We all seem to be wasting a lot of keystrokes arguing about it at present (admittedly I'm the biggest offender here), but Clinton, Obama and Edwards don't seem to be listening.

Posted by: Jasper | Sep 20, 2007 11:59:09 AM

Chiming in to support Jasper: I thought that most of the leftish pundits in favor of unicersal health care thought that single payer (Canada, Great Britain) was a poorer model than mixed (France, Germany).

Posted by: SamChevre | Sep 20, 2007 12:12:05 PM

Viajero is right. Also, is anyone even attempting to follow out the establishment of these plans for unintended consequences, which are an invariable part of social engineering? To just name the obvious, if doctors are not allowed to make lots of money, who the hell would want the risk, tension, and hard work of being one? So much harder than pontificating on hardball, for instance.

Posted by: Klein's normal nut | Sep 20, 2007 1:01:00 PM

(Let me get this straight.)

Our big hero Dems got licked last time out (1993) by the Republicans calling PRIVATE based health coverage "socialism".

But this time out our Dem heroes are afraid to propose PUBLIC based Medicare-for-all -- which ironically is the only plan Repubs CANNOT GET AWAY WITH calling "socialism" because everybody knows what Medicare is -- because our Dem heros are now afraid of a political fight with the "very industry" that (together with Repubs) knocked out private-based universal care the last time.

(Am I making any sense?)

Posted by: Denis Drew | Sep 21, 2007 10:04:03 PM

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