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December 06, 2007

Ask The Expert

MIT's Jonathan Gruber is among the leading health economists in the country. He's worked extensively with candidates of all stripes, was a prime architect of the Massachusetts plan, and has conducted an unsettling amount of the most used, most respected, current research in the field. He's asked me to post this response to Kit Seelye's atrocious article on the various Democratic health plans, in which he dives into the misuse of the research on auto insurance, explains what's actually going on in Massachusetts, and gives what is the consensus view on mandates and coverage. I'm happy to do so. His full letter is below the fold.

I was surprised and somewhat offended by the lack of balance in the article by Katharine Q. Seelye in today’s Times (“Clinton Attack on Obama Overlooks Some Realities”). The health plans of Hilary Clinton and Barack Obama differ in a number of respects, but most important is the fact that Clinton includes a requirement that individuals purchase insurance. Virtually every health expert in the nation would agree that such a requirement is necessary for universal insurance coverage within our private insurance-based system. As a result, Clinton correctly pointed out that Obama’s plan would leave the nation far short of universal coverage. The 15 million estimate that she used was validated by myself and other experts, as detailed in Jonathan Cohn’s recent post on the New Republic’s web site. In recent days advisors to the Obama campaign have made a series of incorrect attacks on the claim that Clinton’s and John Edwards’ plans would cover more Americans than theirs. Ms. Seelye’s article simply parrots these incorrect attacks.

She first points to the figure from the Insurance Research Council that states that 15% of drivers are uninsured. As detailed in research by J. Daniel Khazzom (paper available at here), this figure clearly overstates the rate of uninsured drivers by computing this rate as the share of accidents in which the driver did not have insurance. But since uninsured drivers are typically from groups that are more accident-prone, the share of accidents involving the uninsured will clearly overstate the share of drivers that are uninsured. Moreover, state reforms to improve compliance with auto insurance requirements have been very successful, with the rate of uninsured drivers (measured appropriately) in Georgia recently falling to 2%.

She then cites the experience of Massachusetts, where I serve on the Connector Board that is implementing our ambitious health reform passed in 2006. She correctly points out that, as part of a compromise last year, we exempted almost 20% of uninsured adults from mandated coverage. But half of these are low income individuals offered employer insurance who can be covered as part of the law, but for whom we have not yet had time to design an appropriate subsidy program. The other half are individuals above three times the poverty line who are excluded from subsidies through a compromise between then Governor Romney and our legislature. If subsidies were extended further, exemptions would have been unnecessary. Candidates Clinton and Edwards have said that under their plans all individuals would be subsidized so that no one has to pay an unaffordable amount for insurance. She has laid out no specific plans for mandate exemptions, and there is no reason why she should be tarred by what we have done under the constraints of our Massachusetts law.

As Ms. Seelye highlights, the 15 million figure is not a precise estimate. But the general point should not be lost in the debate over the numbers: a plan with an individual mandate will cover millions more individuals than a plan without an individual mandate. There can be legitimate debates over whether a mandate is necessary or not. I personally feel that it is necessary to prevent free riding in our health care system, to ensure fluid functioning of insurance markets, and to ensure that all citizens are protected against health risk. At the same time, I can also respect, while disagreeing with, Candidate Obama’s decision to exclude a mandate. But there can be no debate over the fact that a mandate is required to bring us to universal health insurance coverage in the United States, and that a plan without a mandate will leave us far shorter of that goal than any plan with a mandate, proper subsidies, market reforms, and sensible enforcement rules.

December 6, 2007 in Health Care | Permalink


Health care is expensive because the AMA and the government restricts the supply of doctors.

Until the government stops artificially restricting the supply of doctors, all other efforts to control price or demand are pointless.

Posted by: FSK | Dec 6, 2007 12:34:46 AM

The #1 cause of injury, disability, and DEATH in America is, Health Care. More people die now from contact with the American Medical Health Care system than from any other cause of death. More than from Cancer, Heart disease, or Stroke. More than any other country in the world. Many times more than any other people in the world. This fact is a catastrophic indictment of the entire US Health Care System.

Driven by greed. And a rush to profit. Thousands of Americans are killed, and injured daily in America. By compromised health care. Cutting corners. Over, and under treatments. And poisonings with all manor of toxic, poisonous pharmaceuticals. Especially the children. America only makes up 2-4% of the world population. But Americans buy, and consume 50% of all pharmaceuticals world wide.

But the tide has turned. I can see it. Hear it. And feel it. The message is getting out. And taking hold about the fact that we have a very serious, and major health care crisis going on in America. Hurting everyone. Especially our precious little children. Rich, and poor alike. And most all Americans seem to understand now that "HR 676 Not For Profit Single Payer Universal National Health Care For All (Medicare For All)" is the way to go. Like all the other developed countries have done. I have seen numbers as high as 90% of Americans want government managed health care Now. Medicare for all. Like other developed countries have. And like older Americans have now.

BRAVO!!! America. YOU GET IT! YOU REALLY GET IT! See sickocure.org.

It's NOW TIME to bring out the BIG GUNS!! The BIG GUNS!! are you. The American people. And anyone else that wants to help. From now until HR 676 is passed into law. I want every person to reach out and touch their fellow Americans every day if you can. I want you to take a phone book. And call at least one of your fellow Americans every day. And ask them to pickup the sword of HR 676 Single Payer Not For Profit Universal Health Care For All (Medicare For All).

Call more than one each day if you can. And ask them to do the same as you are doing if they can. And also to put maximum pressure on their politicians to get HR 676 done. And to make sure their politicians support HR 676. Accept no substitute. HR 676 is a no-brainer. It's the best way to go on health care. It's the only moral, and ethical way to go. That is why every other developed country has done it. Most did it years ago.

I know that many of you have been doing a fabulous job of spreading the word by talking it up with family, friends, and co-workers. And putting pressure on the politicians to get HR 676 done ASAP. The phone calls to your fellow Americans will increase the pressure. And grow the movement at an astonishing, and exponential rate. And I know many of you have been wanting to do something more to help. The phone calls to your fellow Americans is something you can do every day to help.

Trust me. It will be something to see. But you have to keep the focus, and pressure on getting HR 676 passed pronto. They will try to distract you. With all manor of other crises, and catastrophes. And other plans. Don't be distracted. HR 676 Single Payer Not For Profit Universal Health Care is the #1 concern of the American people. Thousands of Americans are dieing daily now. And you or your loved ones could be next.

There is no good reason HR 676 cannot be passed into law well before the coming elections. Do not tolerate delays. If it is not passed before the coming elections. All America will know which politicians are on the side of the American people. And which are not when they vote. Well before the elections.

Everyone can do this. Most of you are well informed about HR 676. This truly is one of those no-brainers. Be considerate of your fellow Americans when you call. But be comfortable about calling. These are your fellow Americans. Some will be receptive. And some will not be. Some maybe rude, and mean. Just thank them, and move on to the next. Most will be with you. And if you get a call from one of your fellow Americans about HR 676. Let them know you are already on board. And thank them for calling. Build them up. And keep them strong. They are fighting for all of us.

I will try to make a second post with just a few of the reasons everyone with 2 working brain cells agrees HR 676 is the best way to go. But you can also look them up for your-self. And read some of the positive informed post on many of the message boards too.

Lastly, I am sick and tired of hearing how the candidates, and politicians health care plans are going to protect, and preserve the private for profit health insurance companies that have been killing, and ripping off the American people. And now the politicians want to mandate (require) that every American has to support the private for profit insurance company's that have been killing, and ripping you off. Or you will be fined, and PENALIZED. Thats right. PENALIZED. Ridiculous! The politicians really think you are all detached idiots. CASH COWS! To lead to the slaughter. Don't put up with that.

So get on it America. Get those phones going. Chat it up! Save some lives. You want all of America talking about HR 676 becoming law, Now! Before more die needlessly. Make it happen. And to my fellow cyber warriors. You have been doing great! I see it! Keep it up. 1 of 2 post...

Below are a few reasons why "HR 676 Single Payer Not For Profit Universal Health Care For All (Medicare For All) is a no-brainer. And some reasons why private for profit health insurance is a stupid idea, and injuring, and killing you and your loved ones.

Medicare cost 2-3% to administer. Private insurance cost 30% to administer.

Under HR 676 everyone would be covered from birth to death. No co-pays. No-deductible. No out of pocket cost. Plus Dental. And Vision. For less cost than we pay now under private health insurance.

With private insurance. You have 47 million Americans with no insurance.

And 89 million Americans that had no insurance part of the time from 2006-2007.

And over a 100 million that are under insured.

18-30 thousand Americans that die each year from lack of health care.

Health Care bills as the #1 cause of personal bankruptcy. And loss of homes.

Under HR 676 health care is moral, and ethical.

Private for profit insurance is immoral. And unethical.

Profit is the primary motive of the private insurance companies.

They make profit by charging needy, vulnerable, sick Americans as much as they can charge them.

Then they make more profit by denying them care when they most need it. And are most vulnerable and unable to fight back. When they are sick. Or trying to recover from major illness.

Yep! I know you are getting angry. I'm sorry. But I have to continue.

Under HR 676: we will save 300 billion dollars in administrative cost each year.

With private insurance: we spent more per capita on health care than any other country in the world. Over twice as much as most other developed country's. Yet we have 47 million with no health care.

We rank at the bottom in quality of health care #37.

Americans have a shorter life expectancy than people from all other developed countries. We rank # 42 in life expectancy. Down from #1.

For the first time in American history. The life expectancy of American children is less than that of their parents. American children are dieing at a record rate. And are in terrible health generally.

People from other country's enjoy a much higher level of general health than the best privately insured Americans.

Americans are also shrinking. We used to be the tallest people in the world. Now we are down to # 10.

People from other country's never have to worry about going bankrupt, or loosing their homes over medical bills if they get sick.

Maybe you should go take a break for a while before I go on. I know this must be upsetting. But this is just a small part of the sad truth about private health insurance that HR 676 can fix.

Under HR 676: Health care will be based on need. Not on profit. And high standards, and quality will be enforced, and patients protected by the Government through a dedicated civil service. With the power, and resources to rain in abuses of patient care. Like they do with Medicare now.

With private insurance: Medical care is base on ability to pay. And profit. Tens of thousands of patient are killed, and millions are injure, crippled, and mutilated each year under private for profit health care, and insurance.

By insurance companies denying needed care to increase their profits.

By hospitals cutting corners. And using the cheapest least experienced personnel, equipment, and standards they can get away with.

By doctors that over treat, and under treat. Who injure, mutilate, and kill patients with unnecessary test, procedures, surgery, and invasive diagnostic test for profit. Who poison, kill, and injure millions of Americans with all manor of unnecessary pharmaceuticals for profit. Men, Women, Children, and babies.

Americans makeup 2-4 % of the world population. But Americans buy, and consume 50% of all pharmaceuticals world wide. This is a monstrous evil. And immorality.

And lastly, by politicians that take blood money from all these despicable groups and turn blind eye's to this slaughter of the American people. And the slaughter of their own loved ones. And them-self.

Well I could go on. And on. But I think this is enough to get you started making your daily phone calls to your fellow Americans to support HR 676. And to help them understand how important it is that each of them join the fight. And bring the MAXIMUM pressure to bear on all individuals, parties, and especially your politicians, and Representatives. To get HR 676 passed into law immediately.

This is an emergency. America is in a crisis. More Americans have died from this health care crisis than have died in all the wars in US history. Do your best. Millions of Americans lives are counting on each of you. Including your own life. Remember, you are Americans. You know how to fight for your country when you have too. The whole world is in your blood. I'm with you.

All the best... 2 of 2

Posted by: jacksmith | Dec 6, 2007 1:30:38 AM


Here's a revised version of the entry I posted over on the Plank on TNR's website.

I think that you're off the mark on the mandate issue. (Full Disclosure: I'm an Obama supporter and a resident of MA, the only state with a mandate.) A few points:

1. Mandates are fiscally regressive.

Progressives can make a good case that we shouldn't support them for the same reason that we don't supprot regressive taxation. For example MA caps its subsidies at 300% of the federal poverty line. That means that a family earning about $62,000 would have to may at least $8000 a year for bare bones, high-deductible coverage (according to the MA health connector website, probably closer to $12,000) or a $4000 penalty. That's unconscionable. Alternatively, you can exempt people who can't pay. MA has done precisely this, exempting some 20% of its uninsured population. If you project that percentage nationally, that's about 9.4 million people. The point is that there is an anguishing choice here -- and you can't just wish it away. You also shouldn't give Hillary a free pass on her plan, which would almost certain leave people uninsured -- possibly 10 million, but we won't know exactly until she tells us how she'll enforce the mandate and how many she'll exempt. The salient point is that an unenforced mandate means that her plan is non-universal.

This is straight off the Obama campaign's talking points. But let's take it a step further. Let's say that low-income Americans who don't qualify for a subsidy have to purchase insurance and this drives them into an even more financialy precarious situation. There's a lot of social science and public health data that suggests that socioeconomic status is a more powerful determinant of health outcomes than access to medical care. This is debatable, but you should at least consider this. So a mandate could leave low income Americans far worse off.

To take this even further -- the real problem with any plan that lacks a mandate is that if you don't force everyone to play some healthy people will game the system. This is what Krugman argues -- that some people will forgo insurance while they're healthy and then buy it when they need a bone marrow transplant. Obama's plan deals with this by capping risk for insurers through federal reinsurance, a provision that the Clinton plan lacks (even though several of her advisors were strongly in favor of such a provision when they were working for Kerry in 2004.) The Obama plan allows the federal government to shoulder the cost of paying for the sick until we can lower the price of insurance for everyone. After lowering costs, he's open to mandate to cover whoever's left.

Bottom line: Obama's argument against mandates is neither calculating nor conservative -- it's progressive. It shares nothing in common with the argument against mandates made by the AEI, even though that's who the NYT decided to quote (oddly, I agree.)

2. Obama isn't opposed to a mandate in the long run.

Both the Clinton and Edwards plans are non-universal in that they leave out a few important details. Clinton says that she'll negotiate the enforcement provision of her mandate with Congress after she's elected. She doesn't say where she'll draw the line on subsidies. This really isn't any different from Obama saying, as he has, that he's willing to consider a mandate after his plan has lowered the cost of health insurance to reasonable level. It's intellectually dishonest to call her plan universal and chastize Obama for introducing a non-universal plan and setting back the cause of universal healthcare.

As a subpoint, I've always understood you to be in favor of a single payer system. I certainly am. I don't understand how you can charge that the Obama plan sets back the cause of universal healthcare, but then pull your punches when it comes to the Edwards or Clinton plans. If we're going to measure all plans by the same ideal standard of single payer, and if we're going to be textualists, then we should acknowledge all of them as non-universal. If we're going to look at intent, then all three candidates are committed to universal health care. In fact, only Obama and Edwards are commited to doing it in their first term. The Hillary campaign says that it could take eight years. That's not setting back the cause of universal healthcare?

3. You and Paul Krugman are giving Hillary a free ride.

Lastly, and most importantly, can you and Paul Krugman honestly claim that the Obama plan's lack of a mandate, despite his stated committment to achieving universal health care in his first term, will do more to set back the cause of universal health care than Hillary's turning the mandate into a litmus test issue for progressives?

You guys are shredding the progressive coalition on this issue.

Every prior attempt to enact universal health care has failed because we haven't been able to hold the coalition together. Individual mandates for insurance have never been a cornerstone of progressivism. In fact, Krugman himself was lukewarm about Arnold Schwarzenegger's mandate-based plan when he wrote about it last January: select.nytimes.com/.../12krugman.html. When did the individual mandate suddenly become the best idea in health policy?

My point is that you, Hillary and Paul Krugman are turning on a fellow ally in the fight for universal healthcare -- and this is doing more to destroy the progressive front on this issue than any specific aspect of Obama's plan.

Don't give Hillary a free pass on this!

Progressives should be making the moral case for universal health care. That's what Obama is trying to do. You and I could undoubtedly come up with 10 different ways of reach universal healthcare if someone were to lock us in a room for an hour. It's not for lack of ideas or policy wonks that we don't have universal health insurance in this country.

Give me a call or drop me a line if you want to chat about this some more!

Posted by: John Rawls | Dec 6, 2007 6:54:46 AM


Nice catch. Gruber's response has a few misstatements as well key omissions. Thoughts:

1) Virtually every health expert in the nation would agree that such a requirement is necessary for universal insurance coverage within our private insurance-based system.

No, if universal means 100% coverage. A fully-funded single-payer system gets you that, not an individual mandate. The latter, as he suggests, is widely seen as the best approach to achieving near universal coverage outside of a single-payer option.

2) I am amazed that he refutes an estimate from Obama's campaign, but still does not present an estimate himself. Why is it that only Obama's campagn has an estimate of 15 million uninsured for his plan? How is this an intellectually honest debate? We know that the mandates plans will not achieve 100%. He already cites Georgia, with 98% compliance with car insurance (which is presumably the best compliance rate in the country)-- which extrapolated would already mean mandate plans would have 6 million uninsured. If Obama's plan leaves 15 million uninsured, that equates to 95% coverage. In refuting the analogy of car insurance-- is Gruber suggesting that the average insured rate for cars is greater than 95% across the US?

3) If getting to 2% uninsured in Georgia took a series of reforms on top of the mandate itself-- how is that materially better than a proposal of universal access with a willingness to come back to mandates down the road? How long did those additional reforms take?

PS If Gruber reads this-- I'm not a single-payer advocate and I'm not an Obama supporter. I am concerned with the lack of balance in this debate. It is right to point out that Obama's plan is estimated to leave 15 million Americans uninsured. It is wrong to not provide a similar estimate for mandate plans. For folks concerned about the details here, they should be able to compare both plans fairly and similarly.

Posted by: wisewon | Dec 6, 2007 7:40:19 AM

Note: Typo on #2-- I meant to say why Obama's plan has an estimate of 15 million uninsured but no estimates for the others. I'm well aware his campaign did not offer that up voluntarily.

Posted by: wisewon | Dec 6, 2007 7:43:01 AM

O C Doctors Stop Accepting Health Insurance

[If it doesn't address the central problem of insurers denying claims and care, then doctors will simply stop accepting insurance and demand payment in cash, as this Irvine clinic has already done. ]

Look for this trend to spread across the country. Most doctors offices and clinics have between two and six employees who spend the majority of their time dealing with insurance companies, paperwork and their bureaucracies. I know that hospitals around the country are headed in the same direction, and I have knowledge of one in particular Broward General Medical Center , a public hospital in Broward County Florida, one of the best trauma centers in the country, which has constructed an entire new wing that is specifically reserved for cash customers only. I'm told by reliable sources within the hospital that no insurance whatsoever is excepted as payment for patients in this huge new wing. I can only assume that they have chosen this route in hopes of offsetting the cost of all the uninsured patients they treat in Broward County. But that is only charitable supposition.
(In the interests of full disclosure, I will say that I was once indebted to Broward General for a sum in excess of $1.7 million.)

Medicare is a prime example of what were headed for, since the vast majority of private physicians, or at least quality private physicians, don't except Medicare. And why should they, when private physicians have the option of cherry picking patients who have premium health insurance or pay cash. Why would any doctor want to treat 40 or 50 patients a day, when they can make the same money treating 15 to 25 a day. As a result many private physicians and their employees look upon Medicare patients with disdain.

People on Medicare are relegated to clinics and doctors who largely constitute the bottom of the barrel in the health-care spectrum. Many doctors would actually prefer to provide their services pro bono, rather then deal with Medicare, since they take so long to pay and are such a hassle to deal with, apparently. Just ask Ron Paul, he was refusing to take Medicare and Medicaid long before it was fashionable, opting to treat his patients free of charge, or set up a payment schedule. Though I believe in his case his refusal is on ethical grounds.

And Clinton wants to mandate/force Americans to pay these insurance companies, who will surely relegate their clients (they don't call them patients, because it makes it easier to screw them using this designation) to the lowest-cost health-care providers i.e. the worst, lowest level of care, or they won't be able to find health care at all, which has become commonplace for people on Medicare who live in locations where there are few choices, like rural areas, or urban inner-city areas, as more and more doctors refuse Medicare.

None of the presidential candidates will come out and talk about what really needs to be done to fix healthcare in this country. If it were up to me, I would grab the insurance companies by the throat, Medicare and Medicaid included, and throttle them into submission. Wrap the yoke of regulation around their necks and squeeze the money out of them, until the two-bit-shysters and profiteers begin dying off in droves. Mandate coverage for every American , and put the health insurers back in their place, a position where profits are only marginal, which will squeeze the criminally predatory unethical element out of the business.

Posted by: Aaron | Dec 6, 2007 8:39:44 AM

These are all stopgap measures, we need to go to single payer, universal healthcare - just like all the other industrialized nations. And we already have a model that works very well, called Medicare. The fix for healthcare is astoundingly simple - just drop the age requirement for Medicare, end of story.

Posted by: craigdp | Dec 6, 2007 11:48:14 AM

I constantly marvel at this argument that because mandates will result in violators of the law, those violators therefore can and should be equated to a plan without mandates which by definition provides for legal exemptions.

The extension of the logic would seem to lead to an argument such as; proposal 1) each individual will be allowed to commit 1 murder in their lifetime without punishment; proposal 2) all murders will be subject to punishment, thereby mandating no murders. Since we know that proposal 2 will not eliminate all murders, the argument goes that we should mitigate proposal 2 with an estimate of how many murders will be committed by each individual so that we can better determine the viability of proposal 1. An extreme, absurd analogy, I realize, but it seems to me logically consistent with the Obama protesters.

In evaluating alternative proposals it would seem that you have to presume that a rational man would not violate the law, even though we know that not to be entirely true. You have to assume certain givens and if one alternative exempts one of those givens, it must be comparable against the other on its face.

The other premise by the Obama folks is that once we get insurance costs under control we will move to mandates, conceivably achievable by the end of his first term. This embodies so many uncertainties it's almost laughable. Getting any quasi-universal system passed through Congress will be extremely difficult. Expecting to come back, especially within 4 years, and alter that system in a significant way could create exponential problems with a very low probability of success without even considering a political party change to the Congress.

It would seem that we should attempt to get the basic structures in place in the first place. Changes to exemptions and subsidies would be far less likely to be major obstacles than trying to, after the fact, impose mandates which would then create significant compliance problems and trackable methodologies.

I like Obama and Hillary and Edwards and though Obama's concerns are reasonable I believe his approach is naive and we would be much better served getting the hard parts handled first.

The fallacy, as I see it, for all of them, is trying to create a hybrid system bound to be full of cost redundancies, confusion and more opting out than a single payer system. I know that their plans are predicated on what's doable but the issue is important enough to try and get it right once because a piecemeal approach will possibly leave us with an even worse situation than we have today and altering or undoing it could take decades.

Posted by: Art A Layman | Dec 6, 2007 12:25:25 PM

Aaron: "Medicare is a prime example of what were headed for, since the vast majority of private physicians, or at least quality private physicians, don't except Medicare."

This may be the case where Aaron lives, but it definitely isn't true in Austin or Santa Fe. My wife and I have had excellent docs and hospital care in both cities while covered by Medicare (6 years for her, 3 for me). And we kept the same docs when we went from private insurance to Medicare. I assisted my mother with her Medicare coverage in Dallas for 24 years, and I never had any problem finding good docs for her.

Medicare's customer service is mediocre (obviously it's underfunded for the level of demand and the potential for confusion among its older clients), but then my private insurance customer service has also often been awful.

I've always thought single-payer made good sense, but my experience with Medicare has convinced me that it is a no-brainer.

Posted by: Bob Gaines | Dec 6, 2007 12:41:03 PM


Absolutely, but putting health insurance companies out of business would cause a lot of disruption, don't you think? The plan that Edwards, and now Clinton, propose would require all to be covered, allow Medicare to compete with private insurers for the business and subsidize those who can't afford the premiums.

Since Medicare is more efficient than private plans, it is reasonable to expect that many private insurers will leave the business on their own, and some might become more efficient. I would guess that pressures from the medical/pharmaceutical community for more generous coverage will increase the cost of Medicare, but it seems unlikely that private insurers, with profit, lobbying and marketing as part of their cost, will be able to bring their price point down enough to wipe out the single-payer advantage.

This seems to be a classic example of how government can actually be more effective than the market in providing a service, and the beauty of the mandate/Medicare/subsidies solution is that it will provide a clear demonstration of that fact -- a terrifying prospect for right wing ideologues.

Posted by: vdomeras | Dec 6, 2007 12:47:49 PM

Key phrase: "within our private insurance-based system". Yes, if you want to put the magic label "universal" on a health care plan and do it without upsetting an industry awash with money, you would push a mandate that everyone buy private coverage. That way, it's "universal", which means everyone wins! Yay!

People really won't go for some sort of private mandate that involves a complicated tax credit/exemption-filing/three-times-income employer-provided blabbity-blah system after living through 8 years of bumbling, incompetence, and outright mendacity from just about every branch of the Federal government. Does anyone seriously think Medicare Part D increased trust in public-private health plans?

One of the reasons I like Obama's plan is that it uses the growing national consensus/momentum for health care reform to focus on getting coverage to the people who need it first. It stands a better chance of being enacted than any private coverage mandate, without bruising fights or hideously, incorrectly simplified news coverage. After the plan succeeds and build confidence in the Federal government's handling of health issues, it'll be easier to move to true universal coverage. Whether or not that includes a public-private partnership is yet to be determined, but starting out by telling 15 million people to give their money to profit-driven corporations- corporations that don't exactly have good reputations, mind you- is the best way to guarantee we go another 15 years without any sort of plan.

ps: What else would you expect from Hillary Clinton, consistently among the top recipients of donations from industries dependent on the system we have now?

Posted by: paul smatatoes | Dec 6, 2007 1:01:56 PM

Funny that the charge that Hillary is a top recipient of "donations from industries" is still being used. The "Health Insurance Industry" contains donations from private individuals like regular doctors and nurses. It is widely known that the charge of Hillary's enormous sums from the "Healt care industy", when these private individuals are taken, is dubious. But, hey, IOKIYATC (Its OK If You Are Trashing Clinton).

Posted by: gqmartinez | Dec 6, 2007 4:13:56 PM

keep those comments coming reading them has renewed my belief that finally truth will prevail I know that this simple statement cannot compare with the other earlier comments but I do want people to know that theirs are read and appreciated and help me to continue my education in my 86th year

Posted by: BILL KENNEDY | Dec 6, 2007 8:00:32 PM

Read Bob Somerby's Daily Howler for Katharine Seelye's journalistic felonies.

Posted by: MikeB | Dec 6, 2007 11:11:58 PM

I would guess that if you look at what aspect of health care actually uses the greatest portion of the health care dollar, it would be long term care. Visit any nursing home and you will find the poor, and the parents of professionals who were smart enough to sign over their assests so they too qualify for Medicaid. The US is long overdue for providing health care to all through a single party payer system. Use the VA as a model and give all access to necessary health care.

Posted by: MartyP | Dec 7, 2007 11:02:13 AM

Jon Gruber is a terrific economist, but I think he overstates the importance of individual mandates in creating successful health care reform. Each of the candidates' plans reflects complicated administrative, political, and economic tradeoffs on individual mandates and other matters. The most telling arguments for health reform are not found in the details of competing Democratic health plans. They are found in the daily lives of millions of people, who do not receive needed treatment, or who lose their homes and face financial ruin because they become ill.

Senator Obama, helped by leading health policy experts, has assembled a credible plan to address these elemental realities. He has the eloquence and political skills required to bring any health reform to fruition. That's why I support him, and why I believe the overblown fight over individual mandates distracts attention from more important matters.

Posted by: Harold Pollack | Dec 7, 2007 1:01:28 PM

"Can you and Paul Krugman honestly claim that the Obama plan's lack of a mandate, ... will do more to set back the cause of universal health care than Hillary's turning the mandate into a litmus test issue for progressives?"

It's not the lack of a mandate in his plan. It's the attack on mandates just to defend Obama. Obama excluded the mandate for political reasons. He didn't think it could withstand Republican attacks--ready-made distortions (aimed at the currently insured majority, who are not mandated) a la 'the government is forcing you to do this'. Now he joins in the very rhetoric that scared him off the mandate in the first place--rather than just state that his plan is not universal coverage.

He could just live up to his 'new politics' promise. Obama could say "I have a good plan to reduce costs and expand coverage, but it is not universal healthcare." Yes, that would that cost him some soundbite brownie points. Did McCain lose points by backing Bush on immigration reform? But Obama doesn't want to give up his "universal healthcare" soundbite. So instead, he joins the Republican attacks.

I don't see why Clinton should let Obama campaign on universal healthcare when he's not willing to take the political heat to actually achieve universal healthcare.

As for the emerging national consensus -- people with insurance finally getting it that it's in their best interests to cover the uninsured -- Clinton builds that consensus with her 'shared responsibility' theme. Properly framed, the mandate builds that consensus--no one gets to game the system. We all pay into the safety net. So why are you attacking the mandate -- just to defend Obama?

"Shredding the progressive coalition?" Not long ago, we read about Obama's supporters demanding he go on the attack. Roger Simon wrote on 'Politico', Senator Clinton was 'stabbed in the front' at the Philly debate. Obama's attacks were spun as 'drawing distinctions'. Clinton supports the mandate, Obama does not. Is that not a valid distinction?

Posted by: Canaan | Dec 7, 2007 3:54:04 PM

vdomeras, What private insurance companies collect in profit government plans pay out in graf and fraud. Look it up, most insurers make 10% gross, Medicare has about a 10% fraudulaent claim rate. Would you rather stockowners, think 401Ks and Union pensions make that 10% or a corrupt doctor saving up to skip the country?

Insurers also pay billions in taxes, have you accounted for those?

The majority of employers use to self-fund their medical insurance. Administrative cost ran around 6% and carrier profits where minimal as they insured a small amount of the risk. Everything you complain about is solved by self-funding yet the government limits it every chance they get. The government has inentionally destroyed a functioning system so they could try and replace it.

Posted by: NateO | Dec 7, 2007 9:50:31 PM


I'm not sure where you got your 10% figure from, but even if they are documented somewhere, there is a big difference between 10% of payouts and a company's 10% declared profits.

The Medicare doesn't advertise, employ people to reject claims, pay its executives and directors, lobby government and the public at all levels, provide perks for the medical community at anywhere near the rate that private companies do, if at all. All those costs are write offs. Your 10% would come after them.

About revenue: Government employees pay taxes too. And US government generally buys equipment and supplies from US suppliers.

If businesses didn't have to provide health insurance they could increase profits, increase their payroll or cut prices. That means a huge increase in revenue to pay for the single-payer plan as well as a real benefit to those companies that compete with other first world countries. Note that Toyota recently located a plant in Canada rather than the US and the reason they gave was health insurance costs.

I wouldn't recommend a sudden shift to single payer, but I'd like to see a fair competition between Medicare and private plans. Who knows, maybe you will be proven right.

Posted by: vdomeras | Dec 8, 2007 12:31:02 PM

As the de facto administrator of the Security Fix blog, I've spent many an hour deleting spammy links left in the comments section -
- comments that usually lead back to the same kinds of Web sites you most commonly see advertised in junk e-mail.

Posted by: Garri Azz | Feb 16, 2008 3:52:03 AM

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