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November 30, 2007
Man Date and Sub Sud Eyes
by Nicholas Beaudrot of Electoral Math
In all this discussion about the enforcement of an individual mandate to purchase health insurance, we seem to have lost sight of the fact that the Clinton, Obama, and especially Edwards plans all provide generous subsidies. Poor, working-class, middle-class, an barely-middle-class-in-NYC-and-SF Americans will only pay part of the cost of health insurance, with the government picking up the rest. It's bad politics to make the middle class pay too much for health care; thus, the President (and Congress!) will have huge incentive to make sure it doesn't cost too much. Thus, in practice, the number of people who would actually see their wages garnished or get taken to collections would be relatively low. And if there are huge complaints about affordability, that will create the political will to increase the subsidies. Is this all a little bit backwards? Shouldn't we just pay for health insurance directly out of the general fund, or just build some state-run hospitals? Maybe. But if the goal is to get a system that's truly universal with one swing of the bat, it's probably the only way to get from here to there given the country's current political dynamics.
Update: Touche.
November 30, 2007 | Permalink
Comments
I'm sorry, but both Hillary and Edward's plans for health care are disasters waiting to happen. The problem is that people WILL see their wages garnished, and those that do will likely end up being unable to pay rent or afford food when they do. That is going to create hundreds, or even thousands, of horror stories about 'universal healthcare' that are going to rattle around the countries collective brain for decades.
There's also the fact that legislation can take years to work its way through congress ass corrupt Republicans and Democrats alike attempt to block every reform that comes along. It's entirely possible that nothing would ever be fixed, and the public will end up going extremely sour on the idea of universal health care extremely quickly. I don't doubt for a moment that HMOs and the insurance industry will do everything in their power to make sure people have as hard a time with this as possible.
Both Hillary and Edwards have essentially the same plan, and they are both much too flawed to be successful over the long term. I've seen too much of the elite simply defying public opinion to trust that political expediency will ever actually force congress to do anything that would hurt their corporate pay masters. I understand what the candidates are trying to do here, and I appreciate why it seems like such a good strategy. However, I think they are making a very big mistake.
Posted by: soullite | Nov 30, 2007 12:46:37 PM
It doesn't matter whether or not people actually will see their wages garnished, etc. As we all know nowadays, politics is about perceptions not reality. If people perceive it possible that a system will result in wage garnishment or what not it won't fly ... and the "anti-gummint" backlash will be globally disastrous for Democrats and progressive programs.
Posted by: DAS | Nov 30, 2007 12:52:47 PM
In all this discussion about the enforcement of an individual mandate to purchase health insurance, we seem to have lost sight of the fact that the Clinton, Obama, and especially Edwards plans all provide generous subsidies.
How generous, and to whom? I haven't seen any numbers on this. How much money is going to people under the poverty line? 200% of the poverty line? 300% and 400% of the poverty line? Because the "poverty line" is pretty fucking far below where actually it actually starts getting hard to properly care for your family.
And these subsidies aren't exactly going to be set in stone, are they? Like every entitlement program in U.S. history, they'll be up for review by every Congress - and right-wing Congresses will be very eager to trim those subsidies. Only instead of having to go without healthcare, the poor will have to go without health care and into eternal debt while being hounded by collection agencies. This is one of those times when I really, really resent the fact that the overwhelming majority of people who make and comment on policy and well-off and white, because you really don't know how incredibly fucking miserable a collection agency can make your life until you've had one breathing down your neck.
This is a deal-breaker for me. If this is what mandates look like, I'll go with Obama.
Posted by: Christmas | Nov 30, 2007 1:01:42 PM
And I've said this before over at Matt Yglesias's place, but it's pretty obvious to me that the top Democrats - along with pundits like Ezra Klein - have really learned the wrong lesson from '94. Clinton's plan didn't just fail because it would've changed people's coverage; it failed because it was very complex and hard to explain, and was easily portrayed as dangerously impenetrable and convoluted. The current plans have so gone out of their way to preserve the patchwork system of employer-based insurance we've got now that they're inordinately convoluted themselves and remarkably difficult to explain.
Single-payer, on the other hand, is as simple as it gets: we sign everyone up for health insurance, and it can never be taken away. I really don't understand why this isn't considered a sellable message, except for the fact that no one is trying to sell it.
Posted by: Christmas | Nov 30, 2007 1:14:11 PM
Pretty much, ditto on the above posts. Krugman does a smear job on Obama in today's Times on this issue.
If you think most uninsured Americans do not buy insurance because they don't think they'll get sick, then mandates are the way to go. If you think, instead (and the evidence backs this), that most don't get ins. because they cannot afford it, then mandates are just mean. There an accounting gimmick to make the proposed reforms appear cheaper.
Sure, some wealthier people decide that they would rather pay out of pocket rather than buy expensive ins., but they still pay into the system when they do get sick and at higher rates than those w/ ins. do. If ins. was cheaper, they would buy in and that has nohing to do with mandates because most people want health ins. anyway. Just how much loss is there from the percentage of the 16% uninsured who could afford to buy ins. now but do not buy it? Let's be clear. The money from premiums does not go straight to hospitals, doctors, and nurses. It sits in ins. co. coffers until one of *their* beneficiaries gets sick. Mandates insure that insurance companies get paid, not that people get healthcare, especially if co-pays are too high for lower premium plans.
Posted by: c.l. ball | Nov 30, 2007 1:38:28 PM
Clinton's plan didn't just fail because it would've changed people's coverage; it failed because it was very complex and hard to explain, and was easily portrayed as dangerously impenetrable and convoluted.
One more piling on, here--when I was an undergrad, my old man bitched up a storm about our having to submit what felt like his complete financial history to the university to qualify us kids for financial aid. Of course, when my older sister graduated a year later, said university decided that financial aid was no longer required for me--never mind that my sister funded a huge chunk of her tuition on her own.
I wouldn't be surprised if the Nixon administration's cutting of school funding might have actually been the real reason, but the underlying point remains: putting people through paperwork (even on-line paperwork) aggravation, to maybe qualify for help with something that most people feel that everyone should have anyway, is just handing the beat-it-to-death-in-the-bathtub types a ready-made bludgeon.
With single-payer, the RW's will scream "socialism!!" but if your cousin with a pre-existing condition can finally get treatment without a hassle, it ain't gonna get much traction. With what Hil is proposing, they'll scream "socialism!!" anyway, and if your cousin says he had to jump thru 13 hoops to get that treatment, you might be a little more likely to say, "gee, maybe those Republicans might have a better idea how to do this!!"--which impressions they will gleefully take advantage of, to poison the sorry thing beond recognition.
I agree with everybody above: big mistake.
Posted by: Captain Goto | Nov 30, 2007 1:46:49 PM
I have yet to see a subsidy that arrived as fast as a fee, reliably and without a lot of hassle. I'm willing to believe that a government program could provide the subsidies ahead of the fees - it's not a law of nature that it works this way, it's just that doing it the other way requires a really massive sustained effort to change administrative practice. And in the meantime, those most in need will already have learned that they must always ask themselves "What if the help is ever delayed?" The only way they can relax from doing that is if in fact the fee that will ever be charged them is down low where it must be for them.
Posted by: Bruce Baugh | Nov 30, 2007 1:48:46 PM
...the problem is that people WILL see their wages garnished, and those that do will likely end up being unable to pay rent or afford food when they do. That is going to create hundreds, or even thousands, of horror stories about 'universal healthcare'...
Soullite: the very "horror factor" you bring up here is the reason it is unlikely that the political process would ever let such a situation get too widespread. Voters wouldn't tolerate it. I say, if lots of "horror stories" are starting to happen after that "one swing of the bat" -- and we've arrived at truly universal healthcare, we'll be in a good situation to raise taxes or do whatever it takes to minimize those horror stories. Perhaps at such a juncture it might even be politically feasible to open up Medicare to those who want to join. The only other possibility is that the hue and cry forces us to retreat from making healthcare access truly universal. But I think this is exceedingly unlikely. I'm not aware of a single Western country whose politics have permitted jettisoning universal healthcare once it's been obtained. I doubt our politics would permit this either.
Beaudrot: I think your analysis is 100% correct here.
Posted by: Jasper | Nov 30, 2007 2:43:41 PM
Jasper, voters tolerate a lot of horror when it comes to the poorest members of society. Voters as a whole are wealthier on average than the population, and representatives are more responsive to wealthy constituents than poor ones. It's not that I think most Americans are callous monsters, at all. But many are ill-informed about the situations of the poor or the impact of policies upon them.
Posted by: Bruce Baugh | Nov 30, 2007 3:22:48 PM
so wrong.
look, instead of an automatic government signup for an insurance program if you can't prove you have one already, why not the other way around? everyone is signed up, but if you have your own plan, you can opt out. everyone pays taxes for the default plan, but if you are paying for your own insurance, you can get a credit for that, directly in each paycheck.
i will be damned if i can understand why it's a great idea to make the STARTING POINT of this fight be subsidizing insurance companies who will be doing their best to kill and pervert anything we attempt to do.
Posted by: tatere | Nov 30, 2007 3:23:08 PM
Voters as a whole are wealthier on average than the population, and representatives are more responsive to wealthy constituents than poor ones.
Bruce Baugh: I think it is overwhelmingly likely that the bulk of any "horror stories" that materialize will not involve poor people (many of whom, after all, are eligible for Medicaid) but rather middle class folks who vote. Indeed most of the 40-50 million Americans who lack health insurance are not poor. Rather, they have jobs. They have middle class incomes. And they vote. Besides, the possibility of "horror stories" can be dealt with in the initial legislation, if all progressives get together and really hold the feet of our political leaders to the fire, so that the legislation that emerges really improves things, and includes features like low premium/income ratio caps, truly generous subsidies, etc.
Posted by: Jasper | Nov 30, 2007 3:44:59 PM
With single-payer, the RW's will scream "socialism!!" but if your cousin with a pre-existing condition can finally get treatment without a hassle, it ain't gonna get much traction.
But your cousin with a pre-existing condition won't be able to get treatment, because single payer can't be passed in the first place. Millions of Americans like their private sector health insurance arrangements. Why is this so hard to understand?
Posted by: Jasper | Nov 30, 2007 3:51:25 PM
Thus, in practice, the number of people who would actually see their wages garnished or get taken to collections would be relatively low.
So it's OK to criminalize SOME poverty, as long as you don't make criminals of ALL poor people?
Individual mandates are MORALLY wrong, whether they affect one person or one million. They turn the victims into criminals.
Posted by: Dilan Esper | Nov 30, 2007 4:07:23 PM
Millions of Americans like their private sector health insurance arrangements. Why is this so hard to understand?
And they will be able to keep them, just as Medicare doesn't prevent seniors from purchasing insurance from insurance companies.
Single payer sets a floor, not a ceiling.
Posted by: Dilan Esper | Nov 30, 2007 4:08:45 PM
Individual mandates are MORALLY wrong, whether they affect one person or one million. They turn the victims into criminals.
Dilan: I must say that's one of the crazier opinions you've uttered. Why is mandating that a person pay health insurance premiums any less moral than requiring him to pay taxes?
And they will be able to keep them, just as Medicare doesn't prevent seniors from purchasing insurance from insurance companies. Single payer sets a floor, not a ceiling.
Well, then you're not talking about single payer. You're talking multi-payer -- with private sector insurers still doing the heavy lifting on paying medical bills -- but allowing Medicare for all who want it. I don't see why you can't combine this idea with personal mandates: you know, "Everybody will be insured, everybody will contribute to the system, and, oh, by the way, if you prefer to join Medicare instead of a private health insurer, that's on option, too."
I think this is an approach worth trying. Again, achieving universality through mandates is not incompatible with "Medicare for all who want it" and I encourage people to see if such a provision could be adopted. I also think the health insurance companies will fight it tooth and nail and it therefore has little chance of passage, but I could be (and I hope I am) wrong.
Posted by: Jasper | Nov 30, 2007 4:21:34 PM
If there is a mandate can I buy Medicare? I am not sure if this is what Jasper is suggesting. I do not want to be forced to pay some inefficient company's CEO big bucks. If private industry is so efficient make them compete against Medicare.
Posted by: cheflovesbeer | Nov 30, 2007 5:04:58 PM
if the health insurance companies will fight it tooth and nail equals little chance of passage we might as well give up before we start.
Posted by: tatere | Nov 30, 2007 5:05:20 PM
Christmas,
Because the "poverty line" is pretty fucking far below where actually it actually starts getting hard to properly care for your family.
You have got to be kidding. Did the typical middle-class American family of the 1950s and 1960s have a standard of living "far below where it actually starts getting hard to properly care for your family," in your opinion? Because most Americans classified as living in "poverty" by the federal government today enjoy a standard of living superior to that of middle-class Americans of just a generation or two ago. "Poor" Americans are the richest poor people in the world.
Posted by: JasonR | Nov 30, 2007 5:17:21 PM
Krugman does a smear job on Obama in today's Times on this issue.
Doesn't he, though. Krugman's recent writings on health care have been an exercise in dishonesty and spin, but he really outdoes himself in today's hatchet job on Obama.
Posted by: JasonR | Nov 30, 2007 5:21:42 PM
If there is a mandate can I buy Medicare? I am not sure if this is what Jasper is suggesting.
That is what I'm suggesting. Again, I think it would be difficult to get such a bill out of Congress, but it's certainly worth a try at some point in the sausage-making process called legislation.
My own view is that opening Medicare to all is the logical second step on the road to robust (i.e, French-style) UHC. First, get everybody covered with individual mandates, guaranteed issue, and community rating (hopefully combined with meaningful subsidies and true affordability). And then if, as I think is likley -- a much more heavily regulated private health insurance industry begins to flag, it will be politically feasible to open up Medicare for all -- as a means of providing coverage to people whose private health insurance plans are going belly up. Once we reach this stage, it will be only a short while before employers begin dropping coverage en masse, and we see a huge migration to Medicare.
So, I do think "Medicare for all" is likely (not to mention desirable) I just don't see how we get it as the first stage of UHC. I think more likely it's third or fourth stage.
Posted by: Jasper | Nov 30, 2007 6:31:08 PM
c.l. ball do you have anything to back up your claim that most people without insurance can’t afford it?
These stats directly contradict your assumption.
http://www.speroforum.com/site/article.asp?id=10869&t=America's+uninsured
Of the 2.2 million people who became uninsured in 2006, 1.4 million had a household income of $75,000 or higher. About 1.2 million of the newly uninsured worked full time.”
But the Census data also show that 9.5 million of the uninsured listed themselves as “not a citizen”:
there are 8.3 million uninsured people who make between $50,000 and $74,999 per year and 8.74 million who make more than $75,000 a year.
according to the Congressional Budget Office, 45 percent of uninsured people will be uninsured for less than four months.
http://www.ncpa.org/pub/ba/ba484/
• An additional 10 million to 14 million adults and children qualify for government programs (Medicaid and CHIP) but have not enrolled.
Posted by: Nate O | Nov 30, 2007 6:45:49 PM
The federal poverty line is useless when the rent or price for a home - not to mention food and other necessities - fluctuates by more than 2x, and doesn't decline when less people are added to it.
Just because there are only two people in my household doesn't mean that we don't pay the same rent as the family for eight next door. And that isn't a family of eight wage-earners, that a family with two or three earning wages; though usually in a group that like one is out of work at any average time.
Gas costs over $3 here - it costs just over a $1 where my spouse's parents live. Their house cost 90K for nine acres - house here lists 750K for 1500 sq ft. And we're not talking the jazziest neighborhood, either.
Posted by: Crissa | Nov 30, 2007 10:31:25 PM
The following are facts about persons defined as "poor" by the Census Bureau, taken from various government reports:
Forty-six percent of all poor households actually own their own homes. The average home owned by persons classified as poor by the Census Bureau is a three-bedroom house with one-and-a-half baths, a garage, and a porch or patio.
Seventy-six percent of poor households have air conditioning. By contrast, 30 years ago, only 36 percent of the entire U.S. population enjoyed air conditioning.
Only 6 percent of poor households are overcrowded. More than two-thirds have more than two rooms per person.
The average poor American has more living space than the average individual living in Paris, London, Vienna, Athens, and other cities throughout Europe. (These comparisons are to the average citizens in foreign countries, not to those classified as poor.)
Nearly three-quarters of poor households own a car; 30 percent own two or more cars.
Ninety-seven percent of poor households have a color television; over half own two or more color televisions.
Seventy-eight percent have a VCR or DVD player; 62 percent have cable or satellite TV reception.
Seventy-three percent own microwave ovens, more than half have a stereo, and a third have an automatic dishwasher.
As a group, America's poor are far from being chronically undernourished. The average consumption of protein, vitamins, and minerals is virtually the same for poor and middle-class children and, in most cases, is well above recommended norms. Poor children actually consume more meat than do higher-income children and have average protein intakes 100 percent above recommended levels. Most poor children today are, in fact, supernourished and grow up to be, on average, one inch taller and 10 pounds heavier that the GIs who stormed the beaches of Normandy in World War II.
Posted by: JasonR | Nov 30, 2007 10:41:00 PM
Dilan: I must say that's one of the crazier opinions you've uttered. Why is mandating that a person pay health insurance premiums any less moral than requiring him to pay taxes?
Mandating that a poor person pay taxes he can't afford is not less moral-- and we don't do that. We exempt the poor from the income tax.
Mandating that people who can't afford health insurance purchase it anyway is blaming the victim. We might as well solve the homelessness problem by mandating that the homeless buy housing.
Posted by: Dilan Esper | Nov 30, 2007 11:39:13 PM
Dilan that's just cruel, if they can show a rent receipt that should be accepted to.
Posted by: Nate O | Dec 1, 2007 9:07:39 AM
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