December 05, 2007

I Need To Go On Fewer Man Dates

Sigh. Yes, the reason the progressive health policy community supports mandates is because we desperately want to screw over poor people. Is primary season over yet?

I could go into the reasons for a mandate in really great detail, but since I've been over every inch and aspect of individual mandates at excruciating length lately, let me just offer the simple and easy one: It's critical for reforming the insurance industry.

You have to do something to end the selection problems bedeviling the insurance system. On the insurer side, you impose community rating, which means they have to offer insurance to everyone, at the same price. But let's say you impose that without a mandate. What happens? Well, a whole lot of people reason that they don't need to buy insurance. After all, the second they do need insurance, they can purchase it, no penalty. The smart move in such a world is to avoid the system when well, only pay in when sick. This will, of course, destroy the system.

So you impose a mandate so everyone has to buy coverage. The insurers can't risk select applicants, the applicants can't game the system. Without the mandate, you can't reform the insurance system. And if you're not going to reform the insurance system and not going to achieve universal coverage, then why not focus on something else?

Maggie Mahar has much more. So does health care expert Len Nichols. It's worth noting that the need for universality -- either through an employer mandate, a government mandate, or an individual one -- wasn't a controversial point among liberals until Obama brought out a plan without a mandate of any sort. Indeed, his plan is, in some ways, the worst of both worlds: It eschews single payer and its close relatives for the more moderate, less expansive, less disruptive structural design that mandates were created to complete, but also doesn't have a mandate. So the mechanism for building on and reforming the system is broken, but he doesn't construct something new to replace it.

December 5, 2007 in Health Care, Politics of Health Care | Permalink | Comments (37)

December 03, 2007

A Man Date And A Movie

Jon Cohn has a long exploration of the policy debate involved in how many people Obama's plan leaves uncovered. The answer is...we really don't know. It depends how strong the employment mandate is, how lavish the subsidies are, how much the plans cost, what's defined as the minimum coverage threshold, etc. Jon's conclusion is forthcoming, but mine basically remains: If you're not substantively striving for universality, you're not going to get universality. Too much will get bargained away. Additionally, you can't make the necessary reforms to the insurance market without putting everyone in the coverage pool. The point of the reforms is not merely to keep insurers from gaming consumers, but to keep consumers from gaming insurers. You can't have one without the other. And lastly, because he's not relying on a coverage mandate, Obama relies heavily -- more so than Edwards or Clinton -- on employer-provision. I'm not necessarily against channeling some insurance through employers, but further strengthening your reliance on that system seems like a tremendous mistake to me.

This seems to me like a policy compromise that's searching for a rationale, and because various people want to support Obama, rationales are being constructed. The world is full of smart people who can think up smart reasons for not-so-smart things. But at the end of the day, even folks like Jacob Hacker, who are supportive of Obama's plan, had mandates in their plans. And even Obama, who is supportive of Obama's plan, has a mandate for kids in his plan. How you explain that in contrast to his attacks on a mandate for adults beats me. Obama could, of course, have come out and said that his sense of the political landscape was that a mandate wasn't popular enough, and would harm the chances for passage. But because he's made a big deal out of being bold and unbound by political considerations, he had to pretend that this was a decision made on the policy, rather than political, merits, and it's just not a very credible claim.

December 3, 2007 in Politics of Health Care | Permalink | Comments (25)

November 30, 2007


I'm hesitant to say too much on this issue lest I cannibalize a forthcoming article on a related subject, but I think folks are overlooking the political merits of the individual mandate. I'm quite open to the idea that the best electoral move is to mention the principle and refuse to define its enforcement (though I also think politicians should be rewarded for being truthful), but setting it against an actual government enrollment program, where everyone is simply signed up through taxes, sort of misses the point.

You can take a lot of lessons from 1994, but the most important political teaching was that You Do. Not. Fuck. With. What. People. Have. If Americans are concerned about health insurance, it's because they may someday lose theirs. If you guarantee that they will lose their insurance -- even en route to a better, stronger, more comprehensive system -- they will reject your plan. Status quo bias is an inescapable fact when you're talking medical coverage. And that's what you run afoul of when you centralize enrollment. What people have now is employer-based insurance paid for through premiums. They can't keep that if you're moving to a government-based system paid for through taxes. What the individual mandate does is try and square that circle: If you like what your employer is giving you, write down the premium # on this form, and we'll never bother you again. If you don't, we're signing you up for a program. Building on the current system isn't necessarily the best policy, but in a country where 80-some percent are pleased with their current insurance, it's the only viable politics.

As for concerns about enforcability, and the evils of the IRS, we're going to have to face those down one way or the other. A big political selling point of the individual mandate is that it's still based on premium payments that are transferred, privately, to insurers. It does not transmogrify the billions we're currently privately into a lump "tax increase." Such increases are much harder to sell. As Rep. Pete Stark recently told me, "[The 1994 reforms] failed because the democratic caucus in the House couldnt deal with the tax. A majority of the Democratic caucus couldn’t support anything with a tax in it." As Chairman of the House Health Subcommittee and a career supporter of Medicare-for-All, I take that judgment seriously.

The individual mandate will still face hurdles as we argue over enforcement, but it basically trades away certain amount of economic efficiency in order to evade the political implications of nationalizing health spending. Figuring out how to enforce it -- which will really only take a modified version of Obama's language, that it's not as if people
don't want health care -- is an easier sell than trillions in "new" taxes. And the idea that these plans will automatically enroll individuals in health care should, for liberals, be an exciting prospect, one they're enthusiastic about advocating for. How you enforce this on the tiny remnant who refuse to pay their premiums is a really weird place to focus, and applies as much to Obama with his mandate-4-kidz as it does to Edwards and Clinton.

Also, read

November 30, 2007 in Politics of Health Care | Permalink | Comments (33)

November 27, 2007

Edwards and the Man Date

As Jon Cohn rightly points out, John Edwards probably has the best of the Man Date positions, favoring a (slightly vague) version of automatic enrollment: Every time you come into contact with the medical system, you'll be signed up for a plan. "Basically," Edwards says, "every time [people] come into contact with either the healthcare system or the government, whether it's payment of taxes, school, going to the library, whatever it is they will be signed up."

I'm a bit curious as to how that'll work -- how does it interact with the subsidies? What happens if someone just says no? How do you force them into the billing process? Is the public plan the default? -- but as a basic approach, it's probably quite achievable, and is good way to basically erase the uninsured population. To think of it in a sightly clearer way, his individual mandate works a bit more like a government mandate -- the onus is less on the individual to seek coverage, and more on the government to present them with it. Assuming the policy works, the individual mandate would really only exist in odd cases when individuals simply refused to accept insurance -- in which case, it would be like if they declined to pay their taxes. Beyond that, it would largely be the government sending you a form that either enrolls you in insurance, or records your preexisting enrollment.

So, as it stands now, Edwards has the best, and most defined, mandate plan. Hillary is second. And Obama, for all his talk, simply doesn't have one. Some say, "well, these mandate plans don't actually establish universality. I know this guy Bob, right, and Bob lives in Montana, and he's got, like, sixty fucking guns, big guns, and also a butterfly knife, and he hates the government, and won't sign up!" Maybe so. But these plans actually strive towards universality and construct mechanisms which could plausibly achieve something very, very close. That Obama's doesn't is a real failing, both on the policy merits and on the politics. If he thought man dates were too unpopular, or too ineffective, he should've been bolder in response, not more timid. That's not what his campaign was sold as.

November 27, 2007 in Politics of Health Care | Permalink | Comments (124)

Barack Obama Has No Man Dates, Continued

This is the smartest defense of Barack Obama's health care plan that I've seen. But I don't agree with it. I have to run, but the short version is that you can't actually have this wonderful system everyone's talking about without full buy-in. The insurance industry really can't offer community rating -- which is to say, they can't offer health care coverage at flat rates, disregarding preexisting conditions and the like -- if individuals don't have to participate in the system. In that world, they really will get nailed by adverse selection, as healthier folks forego insurance and sicker types sign up in droves. Universality isn't just a nice moral decision, it's part of the bargain with the insurers -- and you can't force them into community rating without it.

Then comes the question of whether mandates work. Barack Obama believes they do. He's got one for children. Surely he doesn't mean to say that "Americans aren't going without health care because they don't want it, it's because they can't afford it. But the reason their kids are going without health care is that their parents don't want to give it to them."

The third point is a bit airier: Universality should simply be a non-negotiable bottom line. I made this argument at greater length yesterday, but the idea that we're all in this together is key to progressivism, and if you can't even sell something with the obvious rhetorical advantages of medical coverage for everybody, you may as well pack up your toys and go home. It's just an absurd place to pull up on the reins -- bad policy, yes, but my hunch is, a huge political error. You'll lose support on the left, won't gain any on the right, and will give opponents an easy way to attack your plan. "We're spending all this and we're still leaving 20 million uninsured? Typical liberal efficiency, I guess."

And fourth, the rhetoric he's using will, later, be turned on progressive reformers. He's constructing an argument, that will be attributed to leading liberal Barack Obama, that battles against universality. The way he's engaging on this issue is actually, so far as I can tell, setting back the cause of reform. That's bad in the particulars, of course, but it also suggests, to me, that Obama hasn't spent much time thinking abut how to achieve universal health care reform.

November 27, 2007 in Politics of Health Care | Permalink | Comments (37)

November 26, 2007

Obama's Excuse

I'm getting really tired of Obama's constant excuse that his health care plan isn't universal because "The reason Americans don't have health insurance isn't because they don't want it, it's because they can't afford it." The reason Americans don't all have flat screen televisions is because they can't afford those, too. But, normatively, we think everyone should have health care. So is Obama going to make health insurance free? A dollar? If not, then there will still be a class of folks for whom health insurance does not seem a good deal, and this class of folks will still need to be in the system, as they will still have accidents, and still contract catastrophic diseases. And, in a larger sense, it will still be true that our whole society should be covered, that we should embrace our capacity to come together and have the healthy aid the sick and the young aid the old and the rich aid the poor, all with the expectation that, one day when we are sick, or old, or poor, the luckier among us will help ease our burden. This is, I believe, absolutely core to progressivism.

And this was exactly the argument that, once upon a time, I thought Obama would be making. That we as a society needed to unify, come together, make temporary sacrifices to build a better world. When he said things like "We know that government can't solve all our problems - and we don't want it to. But we also know that there are some things we can't do on our own. We know that there are some things we do better together," I figured that this was the case for Obama: His remarkable eloquence rendered him uniquely able to articulate the larger progressive narrative, that our nation must move forward as "we," rather continuing on as a country of I's. That's what his appeal to unity meant -- not just that our politics would contain fewer dirty words, but that our polity would come together, because we, together, could create a better society than was possible on our own.

But he's sacrificing that appeal in this argument. His reply is exactly what Obama likes to swear he'd never utter: A hollow soundbite. Politics as usual. Indeed, it's worse -- it's a reply meant to keep other politicians from telling the truth. Clinton cannot come back and say, well, yes, there are many Americans who are too lazy to buy health insurance or too arrogant to assume they'll need it or too overworked to actually put aside time to purchase it. Yes, we need to do this as a people, and if that means setting down some rules, so be it. We are one nation, and we can make decisions as a society, for our society. We shouldn't pretend that there will be no dissent, or no problems, or that 300 million individuals will create the same world that our polity, united, can construct.

Obama's rejoinder sounds good, but it's bad politics for the Democrats. I understand that he needs to defend his plan, but he's making an argument that, I imagine, future Republicans will quote back at progressive reformers. To me, this is worse than the Social Security stuff. At least there, he's advocating a progressive policy, if buying into a Republican frame. Here, he's constructing a conservative frame to defend a bad policy, a policy I believe his campaign regards as a mistake. He talks a lot about honesty. He should be honest. The lack of a mandate was a mistake, born out of caution, and he should rectify it.

Hell, he's already said that, if he could go back to the country's beginning, he'd choose single-payer. So if he doesn't want to turn and mimic Clinton's position, and if he instead wants to say that having thought it through, the individual mandate is the wrong way to guarantee universality, and we should simply make insurance a right, guaranteed by the government because that's what sort of country we are, and he's sorry for letting consultants constrain him, that would be great. But to see Obama, day after day, argue against collective action and universality, is deeply disappointing, almost heartbreaking. He had the capacity to elevate those ideals, to do for them what Reagan did for individualism. He's letting that opportunity, that potential, slip away.

November 26, 2007 in Politics of Health Care | Permalink | Comments (41)

November 21, 2007

And Here Comes The Industry...

I wouldn't take too seriously the idea that Mark Bertolini, President of Aetna, actually doesn't know what he's talking about. Rather, the reason he's calling Hillary Clinton's plan moderate and Obama and Edwards' plans less so is because he's trying to curry favor with Clinton, assuming that she will be the nominee and it will be her office with whom his company will need to negotiate. It's a gamble, and it may be a winning one. Aetna sees, in all of the Democratic plans, an opportunity for profit -- for the government to subsidize 47 million new customers. And they're right! The question is whether they can make these plans nothing but an opportunity for profit, whether they can rob them of the weak cost control mechanisms currently proposed, and erase the public insurer that can serve as a pressure agent on the private insurance system.

For evidence of their hoped-for future, look further into the interview, where the Aetna executive waxes rhapsodic over ending state mandates, and inadvertently explains everything that's wrong with the private insurance system. End coverage mandates, the interviewer asks, and the cheaper policies won't cover as much, right? "It's not the same coverage," says Bertolini, "but all the benefits in the Connecticut policy may not be things that I necessarily need. ... As an individual, why would I want to pay for coverage for Gaucher's disease?"

I don't know, maybe because you might have Gaucher's disease. Aetna doesn't want to pay for expensive diseases like Gaucher's, so it's trying to convince folks that they don't need the coverage. But what health coverage is supposed to do is defray the costs of treatment for rare, costly diseases. It's not supposed to excise such ailments from the coverage rolls so private insurers can be more profitable. That's why Hillary, and all the other Democrats, mandate minimum benefit levels for private insurers, and force community rating to boot. Those regulations -- which would force coverage of diseases like Gaucher's and force the insurers to cover patients with such illnesses -- are what Aetna will try and convince Clinton, or any Democrat, to excise from their plan. The question is whether they'll succeed. By lavishly complimenting Clinton now, Bertolini is hoping to better his odds when that negotiations finally comes.

November 21, 2007 in Politics of Health Care | Permalink | Comments (24)