Paul Krugman: Mandates and Mudslinging

Barack Obama is using right-wing talking points to claim that his health plan is better than the plans of his rivals, but it isn't:

Mandates and Mudslinging, by Paul Krugman, Commentary, NY Times: From the beginning, advocates of universal health care were troubled by ... Barack Obama’s plan, which ... wouldn’t cover everyone. But they were willing to cut Mr. Obama slack..., assuming that in the end he would do the right thing. ...

The central question is whether there should be a health insurance “mandate” — a requirement that everyone sign up for health insurance... The Edwards and Clinton plans have mandates; the Obama plan has one for children, but not for adults. ...

[U]nder the Obama plan, ... healthy people could choose not to buy insurance — then sign up for it if they developed health problems later. Insurance companies couldn’t turn them away, because Mr. Obama’s plan ... requires that insurers offer the same policy to everyone.

As a result, people who did the right thing and bought insurance when they were healthy would end up subsidizing those who didn’t sign up for insurance until or unless they needed medical care. ...

The fundamental weakness of the Obama plan was apparent from the beginning. ... But ... Mr. Obama, who just two weeks ago was telling audiences that his plan was essentially identical to the Edwards and Clinton plans, is attacking his rivals and claiming that his plan is superior. It isn’t — and his attacks amount to cheap shots.

First, Mr. Obama claims that his plan does much more to control costs than his rivals’ plans. In fact, all three plans include impressive cost control measures.

Second, Mr. Obama claims that mandates won’t work, pointing out that many people don’t have car insurance despite state requirements that all drivers be insured. Um, is he saying that states shouldn’t require that drivers have insurance? If not, what’s his point?

Look, law enforcement is sometimes imperfect. That doesn’t mean we shouldn’t have laws.

Third, and most troubling, Mr. Obama accuses his rivals of not explaining how they would enforce mandates, and suggests that the mandate would require ... nasty, punitive enforcement: “Their essential argument,” he says, “is the only way to get everybody covered is if the government forces you to buy health insurance. If you don’t..., then you’ll be penalized in some way.”

Well, John Edwards has just called Mr. Obama’s bluff, by proposing that individuals be required to show proof of insurance when filing income taxes or receiving health care. If they don’t have insurance, they won’t be penalized — they’ll be automatically enrolled in an insurance plan.

That’s actually a terrific idea — not only would it prevent people from gaming the system, it would have the side benefit of enrolling people who qualify for S-chip and other government programs, but don’t know it.

Mr. Obama, then, is wrong on policy. Worse yet, the words he uses ... make him sound like Rudy Giuliani inveighing against “socialized medicine”: he doesn’t want the government to “force” people to have insurance, to “penalize” people who don’t participate.

I recently castigated Mr. Obama for adopting right-wing talking points about a Social Security “crisis.” Now he’s echoing right-wing talking points on health care.

What seems to have happened is that Mr. Obama’s caution, his reluctance to stake out a clearly partisan position, led him to propose a relatively weak, incomplete health care plan. Although he declared, in his speech announcing the plan, that “my plan begins by covering every American,” it didn’t — and he shied away from doing what was necessary to make his claim true.

Now, in the effort to defend his plan’s weakness, he’s attacking his Democratic opponents from the right — and in so doing giving aid and comfort to the enemies of reform.

Comments

[Dickeylee]

Thanks Paul for calling out Obama on this. His plan looks like more big pharm and big insurance. Tying him to Rudy is exactly the right analogy here, maybe there is something to that distant blood relationship to Darth Cheney...

[Robert Waldmann]

This time I agree with Krugman's criticism of Obama. Thanks again for linking to me when I disagreed.

[kharris]

Is it an image issue? Do "nice guys" run to the middle, even when the middle has been violently jerked to the right by a vast right-wing conspiracy?

Is it mere political calculation? Create a difference with the other guys, then harangue the other guy over the difference? In the case of health care issues, there is a pretty obvious history of successfully misleading the public due to the complexity of the issue involve. That is the same situation that has allowed politicians to bow to insurance industry wishes without any political repurcusions. Is that awful, least-common-denominator politics where Obama is on health care?

Is Obama easy to hoodwink? Did he simply end up locked in a room with a bunch of bad ideas and walk out sounding like this?

Anybody?

[Patricia Shannon]

What a conundrum for Anne. Which of her heroes who can do no wrong will she defend, Paul or Obama?

[Lafayette]

Article: That’s actually a terrific idea

No it isn't.

Health Care in the US, like a University Education, is too damn expensive. When I tell friends here in Europe that a GP visit costs four times as much in the US as in Germany or France, they smile in disbelief. When I tell them a university education can cost as much as 100 to 150K$, they blanch. (The latter is nearly free in most of Europe.)

There is no plan, proposed by any of the present candidates, that proposes containing costs of two strategic attributes of the nation, Health Care and Higher Education. Frankly, I can’t think of two more important Public Services than these two – aside, yes, from National Defense and Local Security.

Neither can I think of two that would be more effective in lowering Income Inequality were they more affordable/accessible to all.

There is ample proof that the European Health Care systems are world beaters. But, no one dares draw them as “Role Models”. After all, its “socialize medicine”! Say those two words and thousands will ask you to wash out your mouth!

The European Education system is not a world beater – except that of the UK, perhaps. Still, it graduates a lot of people (closing the gap on the US at 27% of the population that receives a university-level degree versus 30% in the US). And, with time it will surpass the US, since it remain cheaper (because it is government subsidized entirely) and therefore more accessible/affordable by more of the lower classes that need it most.

And, finally, as regards, Health Care. I predict that however we foist the uninsured onto the rolls of private insurance companies, insurers WILL find a way NOT to pay for the necessary services - since their motive is not Health Care For All but Profits For Themselves.

It is a failure of good logic to apply market pricing for Public Services.

[Alex Tolley]

It is a pity that PK didn't note that Kucinich has universal, single payer, healthcare as part of his platform. He's been arguing that this is the best way to go, even if politically difficult/unpalatable.

[Bruce Webb]

Alex while it is certainly true that Kucinich deserves to be taken more seriously it is not going to happen, and if it did it would require some serious examination of his performance and policy positions and racial rhetoric back when he was dubbed the 'Boy Mayor' when he was mayor of Cleveland (1977-79). Let's just say he wasn't always the Model of a Progressive Major General.

A stopped clock is right twice a day, that DK is right on Iraq and perhaps right on Health Care, and admitting that those are probably the two biggest issues facing America today, still it doesn't add up to the case for a Kucinich Presidency, on balance the day that DK gets gravitas is the day a meteorite lands in his shoes.

[calmo]

Definitely not a "run to the middle" post, kharris...continuing that delicate interrogative:Is Obama easy to hoodwink? Did he simply end up locked in a room with a bunch of bad ideas and walk out sounding like this?Reminds me of my reaction to w's cabinet shuffle...where I came to the conclusion that his handlers were not interested in my vote but a more "hoodwinklable" segment (Don't get upset you hoodwinkables, you know who you are.).
So Krugman doesn't carry much influence with that group. Obama's counsel seems to think that the risk of alienating Krugman (and base) is worth the gains "sounding like this" to a less demanding audience that may or may not be pried from watching the NASCAR event.
I'm not sayin democracy has this flaw (hoodwinkability), just that years of media cultivation create quite an overburden for the likes of Krugman to remove with a few articles...not likely read with kharris sensitivity, you know?

[NLS]

Obama is still awesome and it would be good to show the world something else besides white bread.

[RW]

"...it would be good to show the world something else besides white bread."

Another Condi Rice and Clarence Thomas fan perhaps; so a vote for Alan Keyes would be cool too, eh?

MLK must be spinning in his grave.

[Sonia]

Paul Krugman is quite correct some folks will not voluntarily buy into a pool that covers othes perceived have higher expected costs than themselves. Any insurance that is not individually rated means that some healthy folks are paying much more than their acturial risk. Where Paul Krugman goes wrong is to assert without explanation that each of the Democtratic proposals has strong cost controls. Electronic medical records might improve medical care but would certainly add costs in the short run and it not clear how much savings would occur in the long run. Requiring that new (or old) technologies demonstrate some degree of cost efficiency sounds good until your child doesn't get someone's idea of a new chemo treatment. Providing the current standard of care to many more individuals insured and not insured now not getting it would extend life and most likely increase not decrease costs. With a mandate, subsidies given to relatively high earners in good health could be retargted to lower income workers. Changeing the malpractice system to provide more to the injured parties and less to lawyers is a good idea but isn't likely to reduce costs by much since a lot of malpractice currently goes un-noted.

[NLS]

RW,

You left out the first part of my quote. Condi Rice and Clarence Thomas are far from "awesome."

[dissent]

It illustrates what has happened to this country politically that the Hillary health care plan is very much like the Nixon plan, proposed in 1973 (which went nowhere in the turmoil of Watergate etc).

In other words, liberal Dem has become what moderate Republican was in the 70's.

No wonder we have soaring health care costs AND soaring inequality AND stagnant wages AND ... etc ad nauseum.

I never understood why folks who ostensibly care about 'national security' don't care about affordable health care, tuition, etc.

Something like 17,000 people die every year because they lack health insurance - a conservative estimate. It's hard to believe the froth about 9-11 from conservatives when they don't give a hoot about this death toll.

I figure that Republicans don't care because they don't care about Americans. They've become addicted to treating Americans like trash in the interest of higher profits.

[economides]

I am sorry to say that Krugman's piece contains way more mud than anything the candidates have said to weach other: "giving aid and comfort to the enemies of reform" ? Wow. So Obama is a traitor to the democratic party. Well, Maybe he is stealth muslim too.

Is the biggest problem with health care, coverage or cost? Are the 18,000 people who die each year, really among those who are so healthy, and probably young, that they think they don't need health care? Medicare has universal coverage and yet is afflicted by the similar escalating costs that is going to put both public and private budgets into serious difficulty. Why is that?

And about Social Security. Obama proposes taxing the wealthiest 6% of Americans in order to close a looming budget deficit. And that makes him a secret agent for Karl Rove, how?

Ugh.

Universal coverage may include some

[anne]

Sonia:

"Where Paul Krugman goes wrong is to assert without explanation that each of the Democratic proposals has strong cost controls."

Agreed, with a possible exception. John Edwards has a health care plan that would make Medicare a general competitor along with private insurance companies. Medicare could extend insurance coverage to any adult or child, while private companies would have to compete as they do now for those over 65. As Medicare has a significant cost advantage over private insurers this would likely lead to lower costs in time.

There are no meaningful cost controls that I can find in Barack Obama's or Hillary Clinton's proposals. I believe Paul Krugman understands this but thinks significant cost controls are politically impossible.

[anne]

"And about Social Security. Obama proposes taxing the wealthiest 6% of Americans in order to close a looming budget deficit."

Interestingly, Social Security has a massive and growing surplus and all that is looming is continuing growth in the surplus.

The point is simple as when Barack Obama chose to propose undermining Social Security for the sake of a compromise with conservatives who will never compromise on trying to destroy Social Security. Obama is similarly undermining the possibility of health care reform by playing to conservative stereotypes about ending choice in our health care possibilities and decisions.

[RW]

What Anne said.

I suppose we can assume it's the influence of his relatively conservative economic advisory team but Obama's proposals WRT health care and tax reform have generally been the least progressive among the leaders in the primary race and frankly do appear to honor or at least give credence to a couple key Republican talking points.

NLS,
I guess as long as awesomeness trumps color we're all right then but, as noted above, I don't consider Obama a standout as presidential candidates go whatever his other virtues may be. Sorry.

[economides]

Hey Anne, winter is coming up so why should I worry about global warming in 50 years. The current SS surplus has nothing to do with the fiscal position we will be in in 10 years. eventually there is a cash flow deficit. But apparently it's treason to mention anything like this.

Frankly accusations of treason usually reflect the fear of the person making the accusation. Just like Obama is right to say it's OK to talk to the leaders of countries we may consider our enemies, it's OK to talk about reasonable policy approaches to entirely manageable problems. You are afraid that you are unable to negotiate, competently. You are afraid that the other side is just better than you are. Apparently Obama is not afraid. I guess that why you find it necessary to call him names.

[economides]

RW:

I forgot that the point was to maintain ideological purity and not actually solve problems. I'm pretty sure ideology never really solved anything.

Of course, Obama's policies for health care and SS are not remotely close to the republican positions. All this is starting to remind me of how Gephardt and Kerry took down Dean...Ugh again.

So is the health care "problem" primarily about cost or coverage?

[anne]

"I guess that why you find it necessary to call him names."

That is of course a lie, but lie away because that is what liars evidently must always do.

[RW]

economides,
Your accusations of ideological purity, treason, etc are non sequiturs, red herrings, false and extreme but now that you have modeled mud slinging for us I'm assuming we can abandon this little exchange at the tu quoque impasse. Ugh indeed.

I will assume you are not a typical Obama partisan however as, if he does win the nomination, I would prefer to vote for him with an easy mind.

[anne]

There is an interesting idea that conservatives are forever raving about, the idea that we cannot afford the need to be humane. We cannot afford Social Security or Medicare or Medicaid. We cannot even afford afford to care for millions of needy children or veterans and families lacking health insurance. Social program on program is threatened just now, but there is always something we can afford. We can afford war and occupation forever, and military costs far beyond.

So we have the Social Security or Medicare or Medicaid fiends who worry about costs, when the cost of caring for 3.8 million needy children would be about 15 days spent on Iraq.

[economides]

Interesting.

Krugman said Obama is giving add and comfort to the enemy, (is that not the definition of treason?, Anne said proposing raising taxes on the top 6% of wage earners is tantamount to undermining Social Security, a program that the person making the proposal says he completely believes in. Oh, and he is undermining health care reform, too. RW says Obama is staking out the least progressive and most republican-like positions. But I am the one who is calling names.

Traitor, underminer, liar. Those are your words.

And yet no one wants to ponder the substantive question: is it more important to cover eveyone, or bring down the cost.

While I'd prefer to do both, I don't think universal coverage will automatically reduce cost. Long-term the problem is definitely cost.

[anne]

"So is the health care 'problem' primarily about cost or coverage?"

Duh, coverage. Coverage, when the personal cost of a typical low cost Massachusetts health care insurance plan is $2,400 with a $5,000 deductible. So the fabled Massachusetts program will leave hundreds of thousands of residents with no coverage or absurdly deficient coverage.

Me, I like Barack Obama but I want more.

[Cyrille]

Universal coverage definetely will reduce costs.

Trust us Europeans on the topic.

[anne]

Yes; raising taxes on Social Security is a conservative idea, a needless and impossible policy for a program with a wonderful surplus but a policy that conservatives wish to use to undermine Social Security. This is the Andrew Samwick solution for solving a problem that does not exist.

Besides undermining support for Social Security, raising taxes for the program will make it politically impossible to raise taxes for programs that really do need proper funding. This last summer Medicaid funding for disabled children and adults was actually cut, and an by Congress attempt to reverse the cuts was vetoed an the veto upheld.

There is a now fierce struggle to continue the nutrition program for pregnant women and infants and children, but a massive Social Security surplus becomes the focus. Phooey.

[anne]

Cyrille:

"Universal coverage definitely will reduce costs."

Actually it appears to have done just that in every developed country and from what I am finding the developing countries that have moved there.

[Patricia Shannon]

Cyrille. Does your company need any middle class computer programmer/analysts who don't speak French?

[economides]

Cyrille,
Universal coverage, I think is much more preferable than partial coverage, but there are too many differences in US vs. Euro systems to think that all we need to do is provide universal coverage and then cost come down. Something else has to change. Single payer, i would think could be much less expensive than 100% mandated coverage. But even our almost universal single payer Medicare system faces a massive cost escalation problem. I just think the cost problem is more difficult and ultimately much more serious than the coverage problem.

Anne,we have a SS surplus because we raised taxes in 1983. That was not the conservatives idea. If you think it is, why aren't you advocating a cut in SS taxes and a return to strict pay as you go.

One way or the other we will have to raise taxes to cover a whole host of spending needs if or health care, for disability, for poor children and for retirees as well. I'm pretty sure that's not a conservative idea. And clearly we can afford it, which is what the democratic side of this debate should be about. Instead, you've making it into zero-sum combat where the people one your/our side are just as easy to categorize as enemies as those who refuse to recognizes the needs those taxes will address.

[denise]

Obama's strategy to target the young. The young who want to risk doing without health insurance because they're not sick and think they won't be (because only the overweight and under-exercised get sick, and it's their own fault). The young who have been persuaded to believe that they will never collect Social Security. The young who are more libertarian and think the New Deal is an anachronism. The young who believe that our divisions and partisanship are due to bitterness between Baby Boomer factions, and can be swept away by their generation (Obama is given honorary Gen-X status).

I get this from reading Daily Kos - not a representative cross section, I know, but I see these sentiments over and over. Of course, it doesn't make any sense to think he can win without the age 45+ voters, but many who aren't paying attention to the details are attracted by his end-of-partisanship message. And we must remember how many voters do not pay any attention to the details, only their feelings about the candidates.

[RW]

Exactly so Cyrille,
The costs of health care are ineluctably bound up in the structure of its regulation and delivery and accepting the structure as it currently exists in the US as a given represents a significant strategic error. The extortion of economic rents and denial of care permitted under the current system in the US, which btw dedicates a significant portion of its costs precisely to those activities, must not only be challenged but a countervailing force must be introduced into play: Edward's plan does that moderately, Clinton's less so and Obama's even less than that although one could imagine building something out of the latter two given further effort.

That is how things stand now but that could change as the campaign progresses, for the better I hope. I do wish though that a single-payer plan was more seriously on the table: Debating about where we should be between the putative center and the political right may serve us better than where we are now but still does not serve us particularly well IMO.

[Cyrille]

Well, Patricia, you know I'd love to say yes...

[anne]

I do understand the wish to protect any candidate, but I think more importantly there is a need to make sure a candidate knows what is expecte for proper support. I have been complaining much more roughly about the foreign policy stance of Hilary Clinton.

[economides]

Universal coverage does not necessarily mean single payer by any stretch, and so I am not convinced that mere universality reduces cost. Leave the insurers in charge and they will still waste lots of money denying claims and raising premiums. Just try to deal with your car insurance company some time. It's a mistake to assume the (long-term) issue is primarily about coverage, and I think it is a mistake to assume coverage automatically reduces cost.

Unfortunately, None of the realistic candidates has the courage to propose single payer. That's too bad.

There is still a problem of how to actually deliver health care in a cost effective way, though, and it woudl still be an issue under single payer (just easier, I think to address).

[anne]

"Universal coverage does not necessarily mean single payer by any stretch, and so I am not convinced that mere universality reduces cost."

Agreed; which is why I prefer to focus initially on broader coverage.

[anne]

http://www.annfammed.org/cgi/content/full/5/6/511

2007

Insurance + Access = Health Care: Typology of Barriers to Health Care Access for Low-Income Families
By Jennifer E. DeVoe, Alia Baez, Heather Angier, Lisa Krois, Christine Edlund, and Patricia A. Carney

ABSTRACT

PURPOSE Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers.

METHODS A mixed methods analysis was undertaken using 722 responses to an open-ended question on a health care access survey instrument that asked low-income Oregon families, "Is there anything else you would like to tell us?" Themes were identified using immersion/crystallization techniques. Pertinent demographic attributes were used to conduct matrix coded queries.

RESULTS Families reported 3 major barriers: lack of insurance coverage, poor access to services, and unaffordable costs. Disproportionate reporting of these themes was most notable based on insurance status. A higher percentage of uninsured parents (87%) reported experiencing difficulties obtaining insurance coverage compared with 40% of those with insurance. Few of the uninsured expressed concerns about access to services or health care costs (19%). Access concerns were the most common among publicly insured families, and costs were more often mentioned by families with private insurance. Families made a clear distinction between insurance and access, and having one or both elements did not assure care. Our analyses uncovered a 3-part typology of barriers to health care for low-income families.

CONCLUSIONS Barriers to health care can be insurmountable for low-income families, even those with insurance coverage. Patients who do not seek care in a family medicine clinic are not necessarily getting their care elsewhere.

[Alex Tolley]

Bruce - PK has made the case for government single payer systems. Why should proposals from "viable" candidates only be used to counterpoint Obama? We like to talk about a "marketplace of ideas", but this seems to be more about the marketplace of the messengers.

In my mind, the most important part of the Edwards h/c plan is the creating of regional health care markets that would create large risk pools. However, it only peripherally addresses the issue of insurance companies trying to avoid paying claims. So I see this more as a stop gap that gets rid of some of the more egregious industry practices.

[James Killus]

Traitor, underminer, liar. Those are your words.--economides

I did a simple search on this page for the words "traitor," "underminer," and "liar," economides. The only example of the first two was your own post. Anne did use the word "liar," I believe referring to you. I believe that Anne is correct, though I would probably prefer the word "troll."

For my own part, I was suspicious of Obama's kumbaya rhetoric from the outset, and I've been hoping that it is pure political cynicism; trying to stake out a position at the right of the Democratic Party in hopes that his skin color is all the "leftist" credentials he needs, and that none of this has anything to do with what policies he would follow if elected.

As for voting for him, as I have noted in the past, he passes the "better than a psychotic gerbil" test, which is more than can be said of the present Republican candidates, nor the present occupant of the White House. As I am still registered Republican, I'm trying to figure whether a Primary vote for McCain or Paul would do more damage to the Party. Voting for any Republican for any position in any general election is, of course, out of the question for the foreseeable future.

[Robert Edele]

I'm opposed for health insurance mandates as it is requiring me to spend some amount of money, regardless of how much I have. It will hit the poor people who cannot afford insurance very hard. People who currently don't have insurance generally do without for financial reasons, and forcing them to pay for insurance will make their position even worse. Are people better off if they have a health plan but lack food/shelter/transport because the health plan broke their financial back? Generally people are rational, and it just doesn't make financial sense for much of the working class to buy health insurance because the sacrifices would be too severe. Better take your chances that you will fall ill than the certainty that you will be cold if you don't pay the utilities or homeless if you don't pay the rent. A much better way to have a 'mandate', and one which I would support, is to have 100% government paid healthcare or health insurance for everyone with automatic enrollment. If you are in this country, you are covered.

[Lafayette]

AT: He's been arguing that this is the best way to go, even if politically difficult/unpalatable.

Q & A's

1) Is universal coverage obtained by extending it by means of private insurance? Or,
2) Is it obtained by extending Medicaid to the deserving?

I.e., who (exactly) pays the piper and how?

These are the MegaBuck questions? Any answers? And, those answers make all the difference in the world.

Look how quiet the AMA has been about this particular political debate? Remember how vociferous they were with Hillary's plan for universal Health Care? Why the calm at AMA HQ in Washington? Because the current propositions work in their favor by herding more patients to the offices of their members -- and their high-cost of treatment.

Extending Medicaid could presume mandated Health Care service pricing -- which is at the heart of "socialized medicine" elsewhere in the world. (There, I said the dirty words, "socialized medicine". Somebody shoot me ;^)

The AMA will fall on its sword collectively before accepting such a provision, since it strikes right at the heart of high-cost American Health Care. And, it hits the AMA constituency directly in the pay-packet.

There is a duality to the problem. You cannot expect to generate enough practitioners (GPs, surgeons, anesthetists, nurses, aides, etc.) by making their training onerously expensive. They will want to recuperate their efforts made with immediate high salaries. (That is just logical.) And, most of them are in their thirties by then. They've got what professional life-expectancy after they've paid of their debts? Thirty years? Hardly.

So, why not undertake to finance their studies? How much will that cost for an ample number of practioners to be coming onto the Health Care job scene after the necessary training period?

Is that amount the equivalent to the cost of a month in Iraq? A year in Iraq? Who cares how much it costs? It is clearly well within the means of this country, undeniably rich as it is.

And, please, enough of the "politically unpalatable". Who the hell is running this country, it citizens or the professional lobbies of vested interests (and its system of financing presidential elections)? The answer to THIS question is well worth considering.

So, consider it. We have met the system and he is us. (A variation on Pogo, by Walt Kelly.)

[Lafayette]

AT: In my mind, the most important part of the Edwards h/c plan is the creating of regional health care markets that would create large risk pools.

Such a proposition is tantamount to tweaking a market-pricing system that fundamentally CANNOT provide health care at an affordable cost. Because it is based upon the notion that Health Care costs obey the rules of supply and demand, which they don't. And, which is why Universal Health Care should be one of the pillars of an array of Public Services -- and not managed by privatized health insurance schemes.

So, the Edwards scheme just ain't gonna work (towards reducing HC-costs) and, should we try to implement it, we will still be talking about "Affordable Health Care in America" come the next election.

The present run of PotUS candidates, Kuchinic perhaps exempted, are scared sh*tless of the AMA and the manner in which it managed the ravaging of Hillary's attempt to implement a universal-coverage (national health) service during Bill's administration. And, foremost oamongst them is Hillary herself.

NB1: Health Care costs don't behave in the manner of other service costs because they are highly inelastic. Increasing demand does not prompt automatically more a corresponding supply, meaning that equilibrium is achieved at a higher price. The supply (of Health Care practitioners) is determined by the training system's ability to form and make available Health Care practitioners sufficient to meet the demand. This has not been the case in American Health Care since a donkey's age - and, for long as it exists as it is (based upon a high-cost university education), it will not be sufficient.

NB2: Do you know that the student's assumed cost of medical training as a doctor in France is almost "zero" -- since the annual tuition is a token sum (about $800) and the students are alloted by the state a cost-of-living stipend? And, France has medical schools on a par with the US. They are pretty good, given that the first of them were founded in the early part of the 13th century.

[Lafayette]

Further to my above comment, and its argument for educational subsidizing of Health Care education and training, is the fact that American health habits are in poor condition.

Obesity is pandemic, alcoholism and drug addiction are rampant. The American Health Care system is not, yet, responsible for prevention. That would seem to be its priority, since an ounce of prevention is worth millions of dollars of Health Care cure. The present debate (presidential, if you like) is focused on remedial schemes of Health Care, not prevention.

But, in fact, the first line of Health Care defense is Preventive Health Care. This means starting with the young and teaching them how eating well can determine the outcome of their lives. Staying slim avoids heart disease, emphysema, and high blood tension that provokes heat attacks.

In educating its population about Health Care, America isn't even out of the starting blocks …

[anne]

Please notice the title of the importantOregon health care study should read as follows:

http://www.annfammed.org/cgi/content/full/5/6/511

November, 2007

Insurance Plus Access Do Not Equal Health Care: Typology of Barriers to Health Care Access for Low-Income Families
By Jennifer E. DeVoe, Alia Baez, Heather Angier, Lisa Krois, Christine Edlund, and Patricia A. Carney

[My computer does not know how to use a "not equal" sign. The full paper is available following the abstract.]

[anne]

http://www.eurekalert.org/pub_releases/2007-11/ohs-nss112907.php

November 29, 2007

Low-Income Families Face 3 Barriers to Health Care

The study was designed to the identify barriers low-income parents face when accessing health care for their children and how insurance status affects their reporting of these barriers. DeVoe found three major barriers: lack of insurance coverage, poor access to services and unaffordable costs. Even families with health insurance had trouble affording the co-pays as well as needed medications. Families with public health insurance had trouble getting access to a health care provider. When they did gain access, they reported feeling unwelcome and having to travel long distances to get to these providers. Those without any insurance struggled to obtain publicly-financed or any affordable insurance....

DeVoe tells a story from her experience: "One of the motivating stories from my own practice was the young mother with asthma who recently came to see me with bronchitis. On her way out, she apologetically asked me to examine her son's lungs. When I asked if her son had a regular doctor, her scared eyes told me - even before she said the words - that he had lost his insurance. Recently, her employer had announced that she must pay the total cost of her family's insurance. One major problem - the cost of her monthly family premium was more than her net earnings." ...

[anne]

"Well, John Edwards has just called Mr. Obama’s bluff, by proposing that individuals be required to show proof of insurance when filing income taxes or receiving health care. If they don’t have insurance, they won’t be penalized — they’ll be automatically enrolled in an insurance plan."

Interestingly, earlier study in Oregon has shown that when a parent loses health care insurance a child is more likely to lack coverage even when the child might otherwise be eligible for public insurance. The Administration however will not allow Medicaid or SCHIP to enroll eligible children in schools.

[anne]

Then the Administration has been cutting Medicaid spending, recently cutting spending on disabled children, SCHIP spending has now been limited and coverage of children will become increasingly difficult, private employer health care insurance is becoming more expensive for employees or coverage is being cut altogether, school enrollment of children in Medicaid and SCHIP is not allowed. Even looking expressly at the effects on children, health care protection appears increasingly troublesome and makes the need for truly universal coverage appear all the more necessary.

[Bruce Webb]

economides says "Anne said proposing raising taxes on the top 6% of wage earners is tantamount to undermining Social Security,"

Yes, because Anne understands the argument. People have some odd misconceptions, perhaps because they simply haven't thought things through.

Raising the cap does not raise taxes on the top 6% of earners. Instead it raises taxes on the top 6% of wage earners. There is a big difference there, generally speaking outside the world of film and sports few wealthy people get much of their income from wages to start with. Obama's plan gives the top 1% a free pass. Just about 99% of the Economic Right play book are calls for a reduction of taxes on capital in favor of taxes on wages, this is just a trick play to fake left and run right. Obama's plan may seem progressive but it isn't, all it does is attempt to drive a wedge between the upper portions of the middle class against the lower portions all for the benefit of the investment class. That faint snickering you hear is hedge fund managers laughing at Obama's attempts to take the rest of the country for a ride, or worse at Obama's advisors taking him for a ride. Because whether Obama gets what he is proposing or he doesn't at this point hardly matters, each comes close to disqualifying him.

Mechanically pushing more current dollars through Social Security does nothing for future solvency, it actually serves to weaken the system by increasing future General Fund obligations. Moreover a cap increase simply makes it more difficult to restore progressivity elsewhere in the tax system, having slapped a 6.2% increase on the professional class you can expect them to resist any other increases in top rates, which in turn gives people who draw their income from returns on capital a free pass. If you really want progressivity then press for the Bush tax cuts to sunset on schedule, don't muddy the picture by laundering funds through a Social Security system that won't need extra funds for a decade (if you are pessimistic), probably not for a decade and a half (if you are realistic) and then at rates much smaller than the tax increases proposed.

Moreover Obama's plan sends the wrong narrative signal. It simply reenforces the Economic Right's line that all government social programs are inherently flawed. The very notion of Social Security 'crisis' exists has been one of the bigger barriers to implementation of Universal Coverage, if we can't even get retirement security right, why would we want to rely of the government to handle health care finance? On examination Social Security financials are actually in pretty fine shape, it is just that few people have taken the time to look at them, or have been scared off by all those columns of numbers. As someone who has looked at those numbers I can tell you that Obama's plan and language are counterproductive, he is powering a narrative that is fundamentally hostile to Social Security, whether he (and some of his supporters here) understand that or not.

[Bruce Webb]

Alex, perhaps DK got too much of the blame for the disaster that was Cleveland when he was mayor. Unlike Hilary, Obama, and Edwards Dennis DOES have executive experience, he just doesn't seem to have done a particularly good job. Moreover the oppo research writes itself, one site alone produced these gems:
As a Congressman, he amassed one of the most anti-abortion voting records in Congress, one especially unusual for a Democrat. Fair enough, Kucinich was raised Catholic. He voted to criminalize partial birth abortions, to deny American servicewoman the right even to pay for their own abortions overseas, to prevent Washington, D.C. from funding abortions for poor women with nonfederal dollars, against research on RU-486, even against health coverage of basic contraception for federal employees. In 1996 he told Planned Parenthood that he did not support the substance of Roe v. Wade. He received a a 95 percent position rating from the National Right to Life Committee, versus 10 percent from Planned Parenthood and 0 percent from NARAL. I know some prominent bloggers who would not be amused by this. If they knew it. Which they may not until and unless DK gets some traction. Now having pissed off a large portion of the base, especially among women, maybe this guy from an industrial city can nail down the blue-collar male vote? Hmm, I don't think many autoworkers will find this particular piece of prose the red meat they might be looking for. "The energy of the stars becomes us. We become the energy of the stars. Stardust and spirit unite and we begin: one with the universe, whole and holy. From one source, endless creative energy, bursting forth, kinetic, elemental; we, the earth, air, water and fire-source of nearly fifteen billion years of cosmic spiraling." -- Kucinich, in the "Journal of Concious Evolution" Now if this piece had been written under the influence of one thing or another back in the Summer of Love it could be put aside as some sort of youthful exuberance, but this the second paragraph of a speech to a Peace Conference in Croatia in 2002. Look I tend to be a bleeding heart liberal who believes you should at a minimum try diplomacy before war. But man this guy puts all the standard wingnut stereotypes about liberals in a solid package.

I am not going to link to the site, this page is fundamentally a hit piece on DK and probably not totally fair. But you can bet the other candidates' Oppo Research people have it bookmarked. The only reason he hasn't been blown out of the race already is because it would be a waste of powder while alienating that portion of the Party that admires Shirley McClain (when Kucinich was more or less down and out in the late 70's he stayed at Shirley's house).

It really doesn't matter how good your health care plan may be, a public record that defines you as 'Pro-life flake who has made spiritual journeys with Shirley McClain' does not exactly scream 'Electibility'

[Alex Tolley]

BW - You seem to be justifying why DK is not a viable candidate (which I agree with) but not why his idea for healthcare should be the one that PK endorses, or at least uses to counter Obama's idea.

Lafayette: I would be more than happy to vote for "socialized medicine" for the US, as long as it does not end up like the National Health Service in Britain before I left at the end of the 1980's. I quite liked the Canadian system when I lived in Toronto (late 1970s).

Regarding the regional markets. The value of this system is that it would provide risk pools so that the insurance companies couldn't cherry-pick . However, without some serious changes to the regulations it does bnot solve the problem of insurers acting a profit-making intermediaries that will continue to game to system to maximize profits. Frankly they should be given their marching orders and told to exit the business. But I am also cognizant that once California mandated earthquake insurance and the insurers quit the policies, that the state offered insurance was far to expensive to buy resulting in most people not bothering to insure, no doubt hoping FEMA would bail them out when the time came.

[Lafayette]

BW: Obama's plan gives the top 1% a free pass.

Wow! Just the people who are contributing to his campaign! How convenient.

Obama, aside from the colour of his skin, is no better nor any worse than the rest of them in the pack.

It's business as usual. Political business; that is, vested interests that have long since understood how money spent is the key ingredient in electing a politician. (Why this should be astounds any clear headed thinker. Unless one assumes that selling a presidency is like selling soap powder on TV. "Ours washes whiter than theirs!")

Discussing the nitty-gritty of policy, however, that can wait till they are elected. And, yet, it is the nitty-gritty that determines our lives.

Remember the "Great Debate" surrounding foreign policy just before lead-head's reelection? Neither do I -- because there was none. And, yet, unilateral intervention in Iraq, based upon fraudulent justification, has changed our lives -- particularly for more than 3000 solders who died over in the sandbox. (Where was the press to debunk Dubya's claim that Bin Laden was in league with Saddam Hussein? The two hated one another's guts.)

There is NO serious differentiation in significant policy matters amongst the leading candidates. The campaign is turning into a beauty contest, just as it has in the past. The candidates say nothing that could offend any particular voter clique. Issues are simply NOT a question in this campaign -- read the platform statements and divine their intent for yourself.

Anyway, a lot of good it will achieve knowing what "they said they would do" before voting day because it very rarely correlates with what "they actually do" after they get elected. (Anyone still waiting for the "Education President"? The train left the station 7 years ago.)

All the more reason to introduce public referendums, initiated by constituent petition, to vote down laws that doesn't appeal to the voters or promote ones they want. It is the only bona fide Check & Balance against a headstrong Executive who pushes legislation through Congress because of the latter's complacency or its payback for campaign funding. We can never know what lobbyists are doing behind the scenes, until it is much too late. The damage, by then, is done.

A referendum on the War in Iraq today would stop its funding tomorrow and commence an orderly withdrawal the day after.

[Lafayette]

Article: he doesn’t want the government to “force” people to have insurance, to “penalize” people who don’t participate.

Elementary, my dear Watson

This is electoral posturing claptrap.

If national health coverage was based upon extended Medicaid and patients were reimbursed for Health Care services based upon a percentage (100%, 90%, 80%) of a mandated base price for the service, then how are they being penalized for not participating.

It is key that claimants pay something. If you give it away, totally free, it will inevitably introduce abuse. This has been amply demonstrated within the national Health Care systems in Europe.

The question then remains, Who provides the service and how? That's easy. Those doctors who sign onto a national Health Care "convention", which is an agreement to accept state mandated pricing for Health Care services. And we must presume that the pricing will be established to provide fair compensation. (Perhaps not 100% of current fees, which are hallucinatory, but enough to make a decent living.)

Doctors can chose to remain "outside the convention" and charge whatever fees they like. States can also invest in establishing/furnishing clinics and hospitals where "conventioned" practitioners can work. "Conventioned" doctors need not make any investment in expensive equipment to get themselves up and running.

In effect, "conventioned" Health Care professionals become state functionaries. They are not directly paid by the state, but

C'mon, this ain't rocket-science. The biggest hurdle is taking on the AMA lobby in Washington, which will be VERY ANGRY that the present system, that supports high revenues for their members, is being undermined.

And, such a nationwide Health Service, for it to be affordable, needs practitioners who have not paid through the nose for an education and seek the highest going rate (of revenue) in order to repay their debts.

Elementary, my dear Watson.

[Bruce Webb]

Alex, if someone wants to take the elements of DK's health plan and push it then fine, I doubt he actually wrote it to start with. But whatever your intentions, the following seemed to suggest that Krugman should have given some validation to DK's campaign. It is a pity that PK didn't note that Kucinich has universal, single payer, healthcare as part of his platform. No it is not a pity, it is an understanding that in politics you can't always separate the message from the messenger. There are lots of good health care proposals out there, I even have one under formulation, but I would have no expectation that Krugman would pimp it for me, even though at this point my chances of getting elected President are only removed realistically from DK because I made no effort the get on the ballot. To mention DK in the context of discussing Obama's plan is to give DK weight he has not really earned.

[alex tolley]

BW - I understand your point of view, but PK does support a single payer healthcare system. It is a bit disingenuous to ignore a candidate's policy that you would most closely associate with, in favor of another candidate whose policies are a compromise. He could easily have said something like - "Mr. Obama, then, is wrong on policy. A policy which would work is a single payer one. Of the leading Democratic candidates, Mr Edwards policy ...".

There is no reason why candidates cannot adjust their policies in the light of reasoned analysis, rather than sticking with possibly half-baked ones that their advisors think they can get the largest fraction of the electorate to go along with and the least resistance from the lobbyists for the status quo.

[Lafayette]

AT: ... and the least resistance from the lobbyists for the status quo.

So, lobbyists have the power to influence elections?

That's American democracy, for you. A hundred years ago Tammany Hall "bought votes" by means of patronage. It worked, but was inevitably made illegal.

Today, lobbyists "buy votes", but it's legal.

This is called "progress"? No, it's called "America". Where most values are expressed in dollars and cents.

[Leonard S. Charlap]

I don't usually follow this blog and it may be too late to stick on this stuff on this thread, but here are two screeds which may interest the participants. BTW I am a mathematician.
***********************************************
On Social Security:
1. The demographics: Doom sayers say, “In 1945, for every Social Security beneficiary, we had 42 workers paying in. By 2002, we had just 3.3 workers per beneficiary. By 2030, we'll have only 2.2 workers per beneficiary.” So what. I presume they somehow want us to conclude that Social Security is going to pot just by looking at this one statistic, i.e. this single statistic (workers per beneficiary) dominates all other inputs. Since they do not tell us the state of Social Security at any point, we actually can conclude nothing from this argument, and if we put in its current state, this argument shows exactly the opposite of what they want us to conclude!

Today Social Security is in the best state it has ever been in—the yearly surplus last year was the largest in its history. The SS Trust Fund is $1.5 TRILLION which is also its maximum. I don’t have the figures for 2006, but they are similar. So what we have is that from 1945 to 2002, the number of workers per beneficiary decreased by 92%, but the health of Social Security is vastly better. Clearly there are other factors that dominate this one demographic statistic. Furthermore, if Social Security could improve its condition with a 92% decrease in this statistic, why should we worry about the 33% decrease they predict for the period 2002 to 2030?

2. The projections: Dr. Steven Goss, the chief actuary of the Social Security Administration is careful to point out that what he makes are _projections_, not _predictions_. They are based on assumptions, i.e. he says that _if_ this happens _then_, this will happen. These assumptions cannot be computed, he says, because they are event driven. You would have to be a fortune teller to even make an estimate. Because of this, he actually makes three projections. The one you are quoting is the “middle” projection. If you look at the record, you will see that his “high” projection has been consistently and significantly more accurate than the middle one. The high projection says that the SS Trust Fund will not go to zero during the next 75 years, SS will be able to pay all promised benefits, and there will be a surplus in the trillions at the end of the period.

3. An assumption: The middle projection of the Social Security Administration (the one you quote) assumes that the average growth in the GDP will be 1.78% over the next 75 years. If you just change this one assumption, keeping all the horrible demographics that you believe in, to 2.7% and do the exact same computation, then you get that the SS Trust Funds never goes to zero, all promised benefits can be paid, and there is a huge surplus at the end of the period. The average growth in the GDP over the last 75 years was 3.1%. I am not saying what the growth in the GDP will be (that would not be mathematics, but fortune telling), I am just saying that the exact same mathematics that gives you the bad forecast with the very low assumption, gives you a good forecast with a more reasonable one.

4. We must act now: In 1983, the SS Trust Fund was _one year_ from depletion. The government convened a commission that looked at the problem, made a few minor changes in SS (can you even name them?), and, behold, SS was safe for at least 30 years and maybe forever.

To sum up: The projections of the demise of SS are no more accurate than reading the entrails of a goat and we would be foolish to make any great changes because of them.
***************************************
On Health Care:
Let's forget the immorality of the uninsured that lets poor people die. Forget the burden on businesses that make them less competitive. Just consider health care financing as a business decision. Develop statistics for measuring how we are doing. Look at the competitors (other countries). Look at their cost. If you are honest, you will become an advocate of a single payer system. Here are some facts. They can be checked at www.pnhp.org.

If you look at the 13 wealthiest countries and rank them according to the 16 basic public health statistics, the US ranks 12th or 13th in each one. Yet, yet we spend 2.5 TIMES as much per person as the average of these countries. Other countries get much better health care at much lower cost. (As a sanity check, WHO ranked the US 37th in the world in health care, above Bolivia , but below Slovenia.) All of these other countries use some form of single payer system. Of course, they have some problems, but most of these are because they are not spending enough. We would not have those problems. In spite of all these so-called problems, they get better care. Also Medicare is a single payer system, and it is one of the most popular programs in the history of our country. The plan I like simply gives Medicare (without limitations, co-pays or deductions and with complete drug coverage) to everyone. We could do this without spending any more than we are now.

The reason for this is that we waste at least $200 Billion a year on excess paperwork by physicians and at least $100 Billion a year on high overhead (15% vs. 1.3% for Canadians) of private insurance. Look here is a simplified example of what we are doing.

Suppose you have 100 dollars to give to 10 people. You could give $10 to each person. Alternatively, you could develop criteria that determine who is deserving, and then investigate each person. You might find that according to your criteria, only 5 people deserve the money. You spent, however $75, on your investigations, so now you can only give $5 to the 5 deserving ones. We spend much too much money denying people health care.

The basic problem is that the rules are made by private insurance companies whose only goal is to make money, not efficiency or good health care. If they can save a buck by having a physician fill out a 40 page form, they will do so.

What about choice? I am 69 years old and retired. During my career I had 5 HMO's and 5 indemnity health plans. I have much more freedom of choice under Medicare than I had under any of the private insurance plans. I have no more referrals, no more in plan - out of plan nonsense. As for choice of insurance plan, why would anyone want choice if everyone had a plan that covered everything? In any case, you could still have private insurance for those who can afford it as most European countries still do.

Some opposition to a single payer system is that it is pie-in–the-sky; we will never get it through. Maybe so. That's what they said about Social Security and Medicare. One thing is for sure. We will never get a rational health care system if we do not try.

[anne]

Leonard S. Charlap, nicely precisely done.

[anne]

Leonard S. Charlap:

"What about choice? I am 69 years old and retired. During my career I had 5 HMO's and 5 indemnity health plans. I have much more freedom of choice under Medicare than I had under any of the private insurance plans. I have no more referrals, no more in plan - out of plan nonsense. As for choice of insurance plan, why would anyone want choice if everyone had a plan that covered everything? In any case, you could still have private insurance for those who can afford it as most European countries still do."

[Lafayette]

NLS: Obama is still awesome and it would be good to show the world something else besides white bread.

Politics as usual

This is exactly the sort of mindless political thinking that got us into the present mess as a nation. What we want is new ideas, not new faces (of any convenient colour).

Obama needs some intelligence, not kudos. Hillary too. Like answering the question, "OK, smart guy, where do you want to take the nation and how do you think you'll get there?" -- with some concrete answers and not just media pap for the masses.

This campaign is a farce put on by a party imbued with the notion that, since Dubya has screwed up sooooo badly, they deserve their turn at the wheel.

That NEVER was a good enough reason in a mature democracy. We deserve more than a choice between Tweedle-Dumb and Tweedle-Dee in a parlor game of "politics as usual".

This show is over. Everybody go home.