Paul Krugman: The Mandate Muddle

Just say no to false Republican talking points:

The Mandate Muddle, by Paul Krugman, Commentary, NY Times: Imagine this: It’s the summer of 2009, and President Barack Obama is about to unveil his plan for universal health care. But his health policy experts have ... concluded that the plan really needs to include a requirement that everyone have health insurance — a so-called mandate.

Without a mandate, they find, the plan will fall far short of universal coverage. Worse yet, ... health insurance will be much more expensive...

But Mr. Obama knows that if he tries to include a mandate in the plan, he’ll face a barrage of misleading attacks from conservatives who oppose universal health care in any form. And he’ll have trouble responding — because he made the very same misleading attacks ... during the race for the Democratic nomination.

O.K., before I go any further, let’s be clear: there is a huge divide between Republicans and Democrats on health care, and the Obama plan — although weaker than the Edwards or Clinton plans — is very much on the Democratic side of that divide.

But lately Mr. Obama has been stressing his differences with his rivals by attacking their plans from the right — which means ... giving credence to false talking points that will be used against any Democratic health care plan a couple of years from now.

First is the claim that a mandate is unenforceable. Mr. Obama’s advisers have seized on the widely cited statistic that 15 percent of drivers are uninsured, even though insurance is legally required.

But this statistic is known to be seriously overstated — and some states have managed to get the number ... down to as little as 2 percent. Besides, while ... enforcement ... isn’t perfect, it does greatly increase the number of insured drivers.

Anyway, why talk about car insurance rather than looking at direct evidence on ... mandates...? Other countries — notably Switzerland and the Netherlands — already have such mandates. And guess what? They work.

The second false claim is that people won’t be able to afford the insurance they’re required to have... But all the Democratic plans include subsidies to lower-income families... In fact, the Edwards and Clinton plans contain more money for such subsidies than the Obama plan. ...

Finally, Mr. Obama is storing up trouble for health reformers by suggesting that there is something nasty about plans that “force every American to buy health care.”

Look, the point of a mandate isn’t to dictate how people should live their lives — it’s to prevent some people from gaming the system. Under the Obama plan, healthy people could choose not to buy insurance, then sign up for it if they developed health problems later. This would lead to higher premiums for everyone else. It would reward the irresponsible, while punishing those who did the right thing and bought insurance while they were healthy. ...

So how much does all this matter?

Mr. Obama’s health plan is weaker than those of his Democratic rivals, but it’s infinitely superior to, say, what Rudy Giuliani has been proposing. My main concern right now is with Mr. Obama’s rhetoric: by echoing the talking points of those who oppose any form of universal health care, he’s making the task of any future president who tries to deliver universal care considerably more difficult.

I’d add, however, a further concern: the debate over mandates has reinforced the uncomfortable sense among some health reformers that Mr. Obama just isn’t that serious about achieving universal care — that he introduced a plan because he had to, but that every time there’s a hard choice to be made he comes down on the side of doing less.

Comments

[jacksmith]

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

[James Killus]

Whew. First off the gate is intense.

Anyway, while it's aesthetically disappointing to have Obama try to stake out the rightmost position in the Democratic Party, from the crude basis of the media Shadow Play, it makes cynical sense. Hillary is actually the DP centrist, but gets regularly attacked as being an extreme leftist (jeez, you should hear the Noise Machine chattering now about having found evidence of her actually having had conversations with Communists when she was a legal intern). That tends to give Edwards a free ride in more left leaning (please understand, this is America, where "left leaning" consists of not falling over the right railing) policy suggestions.

However, I think that the Obama ploy is doomed, because, when push comes to shove, the real right flank of the Democratic Party will do what it always does: vote for a white male. And there's Edwards again, smiling that courtroom smile.

[calmo]

jack says Well I could go on. And on. And jack does.

ps jack, some of us are old and well, crotchety....not able this late in the evening to take it allllllll in, so I'll have to get after it tomorrow morning, because my 'get up an go' is nothing like yours, you know?

[Dickeylee]

Limbaugh calls him the "Breck Boy", because the Republofachists really fear him the most. HRC, they have a built-in 40% already against her, and we all know that B. "Hussein" O. will absolutely be pulverized next fall by the Republofachists and their smear campaign. Edwards is really the one they fear, a trail lawyer with actual courtroom results. One who can sway a jury can sway the undecideds next fall. So keep on smiling that courtroom smile John, keep on smiling.

[Dickeylee]

Hey Mark, could you institute a posting rule that a response can't be more than twice as long as the article? Admire your spunk there Jack, but Jeeeez!

[reason]

Jack - get yourself a blogger account (free and confidential) and post a link. Just a summary here.

[Bruce Wilder]

The politics of Krugman spanking Obama seem to confirm a changing dynamic in American politics.

I find it hard to take seriously any of the policy sketches, which Presidential campaigns put out. And, I take seriously the notion that universal coverage is both a key desideratum and a critical feature of any stable, workable system.

But, Krugman, politically, lays down a frame. And, that frame contrasts with the David Broder b.s. about how the Parties should stop bickering and "solve" problems through "bipartisan compromise".

"Bipartisan compromise" made a lot of sense, when there were liberal Republicans and conservative Democrats in significant numbers in the Congress. But, now almost every Democrat is to the left of every Republican. Democrats cannot compromise with Republicans, except by abandoning what makes them Democrats.

This is not a technocrat's election approaching on the far horizon. This is not a mere partisan struggle for power, nor is it a disagreement about "how" to achieve common goals. Democrats want something different from what Republicans want.

And, Mr. Bush will use his final months in office demonstrating that.

[Lafayette]

Article: Without a mandate, they find, the plan will fall far short of universal coverage. Worse yet, ... health insurance will be much more expensive ...

Privatized Health Care in America is sick

And with the "mandate", it will remain expensive.

For as long as health care in America is in the hands of for-profit businesses (both doctors and private insurance companies), then their "criteria for excellence" will prevail. Insurance companies will find ways of NOT paying for health care in order to minimize disbursements.

Someone, please [perhaps the esteemed Mr. Krugman?], tell Obama's handlers that "Universal Health Care" under the tutelage of private enterprise is a non-starter. It wont work to reduce costs and will simply continue the inexorable rise in HC service costs. Who will pay for the non-payers? The taxpayers, that's who.

This is inevitable for very good economic reasons, the foremost of which that health care services DO NOT OBEY the supply and demand curve behaviour of "markets in equilibrium".

Higher prices DO NOT SPUR more service offering in health care, do to the very nature of that offering. The supply of such service is not like increasing the cadence on a semiconductor production line. The lag in supply of qualified practitioners is measured in years and years and years.

The candidates are trying to blind the eyes of the American public with an obvious palliative Health Care solution. Key word: "universal" trumpeted across the media and everybody thinks the Health Care solution for America is had. Wrong.

The candidates just don't want to tangle with the powerful AMA, that knee-jerks at the altar of "free markets" for health care services (that assure American HC costs at four times the the level that need be for a fair return to practitioners).

Privatized Health Care in America is sick. Very sick.

[Lafayette]

Tell me how the proposition below cannot work

Mr. Krugman suggested in a column, that appeared in this forum, some months ago that extending Medicaid was the best solution. Has he changed his mind?

It is important to understand how Medicaid works because it is not a bad model upon which to build a national HC system. The above link will explain its mechanism.

Medicaid is intended for the poor. If 16 - 18% of the American workforce does not have HC coverage, can we say that it works? If neonatal death rates are amongst the highest in the nation? I suspect not.

Extending it to all citizens is a fine idea. But, how does Medicaid work? It functions by making payments to health care providers. Based upon what pricing criteria? Going rates ... those same rates that are suspected to be more than four times higher than elsewhere in the modern world.

Who funds Medicaid? Both Federal and state funds support it. Which means taxpayers support Medicaid -- as they should in a world where there is no "something for nothing". What shouldn't be is the fact that the costs are determined by HC providers at market rates. Costs should be determined by an analysis of "fair return for services provided".

This can be done in two ways. (1) The states, organized by the Federal government, can open (meaning build and furnish) Medicaid Centers that hire HC practitioners working on a Civil Service pay-scale. Then, (2) state Medicaid can sign agreements with private practitioners -- independent of Medicaid -- to provide HC-services (but at the same rates paid in Medicaid HC Centers in areas where there are no Medicaid Centers). This element will have two benefits:
* Stimulate competition healthy to both sides and
* Promote uniform coverage across the nation.

Medicaid Health Care insurance, as proposed above, must have some element of personal contribution -- or it will be abused. That can be managed by stipulating that Health Care payments be determined according to income levels. That is, the truly poor would get 100% reimbursement at 0% "deductible" in personal contribution. The "deductible" amount would increase as income-levels increase.

Health Care is a birthright of all citizens. It must be administrated by a federal authority to assure uniform accessibility across the nation at an affordable price. And, both those goals are incompatible with privatized Health Care, which is motivated by purely market-determined factors..

OK, now tell me how the above cannot or should not work.

[Lafayette]

Jack-in-the-box: 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.

Interesting factoid. Pray tell, how does one die of Cancer, Heart Disease or Stroke without coming in contact with the HC-system in America?

Become Mister Invisible?

[Barry]

James Killus says...
"Whew. First off the gate is intense."

That's not the adjective that *I'd* have used :)

[mark]

First off this is false:

First is the claim that a mandate is unenforceable. Mr. Obama’s advisers have seized on the widely cited statistic that 15 percent of drivers are uninsured, even though insurance is legally required.

But this statistic is known to be seriously overstated — and some states have managed to get the number ... down to as little as 2 percent. Besides, while ... enforcement ... isn’t perfect, it does greatly increase the number of insured drivers.

People with money that live in low risk areas have insurance. If we tease out the 14.5% of uninsured drivers we will see it's a lot higher in cities where risk is higher and the risk of hitting another uninsured driver is much higher. For which your insurance company will have to pay for the damage of your car. Which means an insurance company that offers insurance in that area must charge more for those that want insurance.

Let's see what old Kruggy has in store for you with respect to Health insurance.

Yes, people with insurance will have to subsidize those who don't have insurance. Which means those with insurance will reduce their coverage by increasing their deductable.

But wait a minute, you say. Those that don't have health insurance can't cover out of pocket expenses the way those who currently have health health insurance. Thus, they need full coverage.

So, there you have it. Those who don't have health insurance will now have more coverage and not pay for it. And those that do have health coverage will pay for it and have less coverage then those who don't currently have health insurance.

[Cyrille]

Does anyone here understand mark's post?

[Noni Mausa]

It's discussions like this that remind me forcibly how foreign is the US idea of "health insurance equals health care". Everybody is either pleased that they have health insurance, are frightened that they don't have health insurance, or worried about what their health insurance covers. This focus on insurance affects how they think about policies when proposing ways to provide healthcare for all Americans. It leads Americans to contort their thinking into a posture that allows them to include "insurance ".

Here in Canada, at least in the province of Manitoba, all permanent residents get a health card. On health coverage is a six digit number which is your provincial health card number and stays with you for life. When you go to any hospital or clinic, you show them your health card number and that plus your information goes to allow billing for whatever services you get. It's not a fancy card either -- just a little green scrap of folded paper, no photograph, no nothing.

The process is so transparent and so universal that I have to remind myself that the Americans don't have anything resembling this.

All Americans should wake up every morning, light a candle and repeat 23 times before breakfast, "Health care is not health insurance."

Noni

[mark]

Yep, so all we need to do is have the government print up cardboard or plastic cards and put a candle in the window.

LONG AS I CAN SEE THE LIGHT (J.C. Fogerty)

Put a candle in the window, 'cause I feel I've got to move.
Though I'm going, going, I'll be coming home soon,
'Long as I can see the light.

Pack my bag and let's get movin', 'cause I'm bound to drift a while.
When I'm gone, gone, you don't have to worry long,
'Long as I can see the light.

Guess I've got that old trav'lin' bone, 'cause this feelin' won't leave me alone.
But I won't, won't be losin' my way, no, no
'Long as I can see the light.

Yeah! Yeah! Yeah! Oh, Yeah!

Put a candle in the window, 'cause I feel I've got to move.
Though I'm going, going, I'll be coming home soon,
Long as I can see the light.
Long as I can see the light.
Long as I can see the light.
Long as I can see the light.
Long as I can see the light.

[save_the_rustbelt]

My fear is that healthcare reform will be driven by the people (politicians, economists, and Jack) who know the least about healthcare, and who do not spend Christmas Eve sucking junk outta people's lungs, or go to the ER at 3:00 am to put busted people back together.

All of you who are contempuous of physicians, do not patronize them - simple.

Jack is a moonbat.

[Noni Mausa]

Pardon?

What does that have to do with the price of health care?

[save_the_rustbelt]

"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."

Must be a full moon.

[Noni Mausa]

sorry rustbelt, I was sort of replying to our new contributor Mark, not you.

[ken melvin]

As with his social Security, if Barack's plan was to garner support from the media; it seems to be working.

[save_the_rustbelt]

noni

I thought so :)

[skeptonomist]

I would think that mandates would be a great selling point to insurance companies, who would love to get all the low-risk people who currently choose not to buy insurance on their rolls. Short of single-payer, if the insurance companies do not support the plan it will be hard to pass, as we know from the failure of the Clinton plan. Hatred of socialism from the right does not extend to corporate welfare.

(R. Samuelson at WaPo seems to think that the voluntary non-participation of some people in health insurance is a virtue. Or at least his plan based on individual self-interest would encourage this.)

[calmo]

From PK:giving credence to false talking points that will be used against any Democratic health care plan a couple of years from now.Another round of Obama bashing (ok, criticism, --possibly true talking, possibly false talking) [you wouldn't dare accuse me of pushing "talking points' would you? Would you?] as he tries to distinguish his candidacy from the other front runners?
And so it appears Obama's advisors are not the same ones as Krugman's (izat a stretch: Krugman consults other humans for his views?)[recall those individual ants people...so utterly stupid, but the colony, such a beacon of intelligence!...far from the maddening crowd of talking points, yes? no? scuse me while I consult...]
There was a pile (anthill) of non-voters last time (evidence supporting the ant/colony intelligence distribution thesis --trust me you individual ants), but (from my colony of so withit advisors)[only some of you dummies] Obama is after them...and is willing to alienate an ant or 2 like PK...and possibly do no real service to the Dem Party.

Ok, since when did individual candidates sacrifice their platforms (this is the term they all use fellow ants, to describe the ground beneath their feet. tis) for the interests of the Party?
Since McCain gave w that great big hug after losing the primary. You're right...too easy for the colony.
The media in its present hands will take care of the talking points, yes?
"giving credence", dang, I'm a badass for that, you?

[anne]

http://matthewyglesias.theatlantic.com/archives/2007/12/robert_samuelson_is_a_heartles.php

December 7, 2007

Robert Samuelson is a Heartless Monster
By Matthew Yglesias

I'm surprised yesterday's Robert Samuelson column * hasn't come in for more derision:

We need to have a candid debate about health care in 2008, but the odds are against it. The fact that covering the 47 million uninsured already looms as the centerpiece of this debate is a warning sign that it won't be serious. We're told that the uninsured are our biggest health-care problem, but they aren't. Runaway health spending is.

Yowza. It seems to me that what "our" biggest health-care problem is probably has a little something to do with who we are. Evidently the plight of the uninsured isn't a big problem for Robert Samuelson, but it's a problem for an awful lot of the uninsured people. Similarly, the risk of losing insurance is a problem for an awful lot of people. Maybe if we all got paid Samuelson's salary to churn out inane columns, everyone would share his perspective on the world. But it's really a bizarre perspective. He moans: "These proposals would inflict 'pain,' and candidates who embraced them would invite political ruin." Pain would invite ruin because people don't like policies that will make them worse off. It's a perfectly reasonable thing for voters to want to avoid.

* http://www.washingtonpost.com/wp-dyn/content/article/2007/12/05/AR2007120502235.html

[anne]

"We need to have a candid debate about health care in 2008, but the odds are against it. The fact that covering the 47 million uninsured already looms as the centerpiece of this debate is a warning sign that it won't be serious."

The fact that covering the 8 million uninsured children already looms as the centerpiece of this debate is a warning sign that it won't be serious.

The fact that covering the 5.6 million uninsured veterans and families already looms as the centerpiece of this debate is a warning sign that it won't be serious.

The fact that covering the disabled uninsured who have been dropped from Medicaid already looms as the centerpiece of this debate is a warning sign that it won't be serious.

[Bruce Webb]

Obama's slogan might as well be "I am the (cautious) CHANGE candidate"
WSJ: Seeking Clues to Obamanomics
What do you need to know about Obama's economic team? Well the WSJ Opinion page seems to be impressed by how centristic they are. (Alarm bells should be going off). What does George Will think about lead advisor Austan Goolsbee
Economics is the only academic discipline that in recent decades has moved in the direction that America and much of the world has moved, to the right. Goolsbee no doubt has lots of dubious ideas -- he is, after all, a Democrat -- about how government can creatively fiddle with the market's allocation of wealth and opportunity. But he seems to be the sort of person -- amiable, empirical and reasonable -- you would want at the elbow of a Democratic president, if such there must be.Well you can add whistles, sirens and foghorns to those alarm bells. Because the George Will seal of approval is pretty close to the Mark of the Beast for progressive thinking people. Then you note that another top advisor is privatizer Jeffrey Liebman and the third is David Cutler who the WSJ piece identifies as favoring mandates but who is now faithfully following the party line Health Mandates: A Talk With Obama Health Advisor David Cutler. Taken together and scored on the Bold Scale from tapioca to tabasco, well just say I am tasting a lot more mushy pudding than heat from this team. I don't have anything against Obama particularly, I just don't think a campaign slogan of "Don't rock the boat unnecessarily, it wouldn't be prudent" is going to galvanize the electorate in the way he needs to break through. We already have a sensible centrist running in the person of Clinton, I don't see how running to the right of Hillary makes sense at all.

[barry payne - economist]

An elitist attitude among conservatives for medical care constitutes the worst case of "the perfect for the few being the enemy of the good for the many".

Politically, much of the U.S. lines up on medical issues the way it does on matters associated with income inequality.

When conservatives apply the "you can make it too" standard to all occupations and incomes to justify "free market" outcomes, it has an analogy in medical care.

It's like the "brass ring" effect of Hollywood - many wanna-be aspirants (patients) line up with hopes for stardom (treatment) and only a few make it.

For example, the economic benefits of switching to a model like the VA Hospital or Canadian model could yield hundreds of billions in net benefits.

But such models eliminate much of the upper crust of medical care constituting the most expensive, specialized exotic medical care and drugs that cater to a small percent of patients.

The current availability of medical care in the U.S. is emphasized by conservatives for the most unlikely and costly cases, usually laced with the melodramatic threat of death or suffering when such treatment is "threatened" with universal plans.

The public relations industry has figured out that a substantial number of "What's the Matter with Kansas" people will vote to support, for example, a brain surgeon and MRI machine even if it displaces generic drugs that could cure 200,000 children of a sore throat, because the latter doesn't register on the political radar while the former is easily cast in a "Surgeon Saves Child from Tractor Accident" commercial.

In the medical industry, "commodity" care is bad because it provides many second-best alternatives that are nearly as good as the first-best and would put much overpriced care out of business.

[Patricia Shannon]

Does being taken to the hospital after you're dead of a heart attack because you didn't call an ambulance because you were poor count as contact with the medical system?

[Noni Mausa]

skeptonomist said, in part: ...R. Samuelson at WaPo seems to think that the voluntary non-participation of some people in health insurance is a virtue...

Which it is not, of course.

Insurance only works if payouts are rare in the insured group. That means you need a large group of people paying in who, by and large, will not need the service -- but might.

Ideally, the best insurance plan would include the entire population (or a large random population), structured on a co-operative basis. It would carry a minimum of dead weight in the form of expensive managers and lots of lawyers, and focus on its core function of caring for its membership and keeping costs low.

Adding the profit motive to the mix simply draws funds away from core functions. "Profit" is money paid above and beyond the actual costs of the service, supplies, the staff and their benefits, etc. Profit is inherently inefficient.

Noni
~runs for the bunker~

[save_the_rustbelt]

When managed care was introduced many consumers and many leftish politicians screamed and hollered, services were being rationed overtly and choices were limited.

So now the lefties are demanding we create a system which will ultimately lead to overt rationing and limited choices.

Granted, 15 years or so have passed, so has this been a change of head or change of heart?

[calmo]

Time for this sensible ant to saddle up beside fellow colonist, Bruce Webb (There he goes galloping off like I said the wrong ting...):We already have a sensible centrist running in the person of Clinton, I don't see how running to the right of Hillary makes sense at all. and congratulate him on enumerating Obama's advisors, sticking the pitchfork in but good...rather than dancing around like PK here on Dem solidarity.
Now about that "sensible" centrist, that we already have (Hillary, the temperate, the tolerant and the toothy (as in teeth, as in bite, as in military might))...was that a lead in to the python skit? Is Edwards just sonot "sensible" (lookit those haircuts, people!)?
Me? Obama is not convincing as a political animal...not like Mrs. Clinton. Could be just a lousy selection of advisors (do we need to examine his shortish record to see that his recent views have warped right?), but could also be a lack of experience and exposure. [Consider the entourage (years of dedicated support, grooming, financing, connections) behind Clinton and the somewhat more modest wagon behind the other candidates.]
Or it could be that the advisors, the heavies, do the selecting of the candidate...like the present administration that needs to declare "I'm the Decider" confirming our suspicions.

[Denis Drew]

Mandated purchase of private health insurance could cost nearly 45% more than Medicare for all:
Private insurance is supposed to add 30% costs (20% insurance provider paperwork and procedure denial machinery and 10% doctors dealing with multiple plans paperwork and fending of denial). 30 is 42.8% of 70: nearly 45%.

The poverty line multiples really need to be cut in half (adjusted for reality if you will) before discussion of income levels even begins — because the federal poverty line is based on the useless (if too obviously understated) measure of three times (3X) the price of the cheapest possible emergency diet (dried beans only, no canned beans please!). The 2002 book, Raise the Floor has a professionally worked out poverty line which comes to twice (2X) the official federal line.

Whatever multiples of poverty a person’s wages may be, some individuals will not be in a position to purchase insurance because of their personal situations, making for potentially tragic situations in a programs supposedly trying to help those most in need. We equally need to take into account the tragic state of wages on the low end in this country thanks to the race to the bottom that began in the early 70s. Our standards for what people should be paid are way off what they would be, in an adequately unionized country for instance — potentially leading to more misjudgment on the impact of mandates on people who really cannot afford them.

The only reason I ever see progressives offering for not advocating Medicare for all as best option is the assumption that politicians will be overwhelmed by the politicking of the insurance companies — no other objection. Seems a weak rationale for throwing their support behind a basically undesirable program right at the beginning of a national discussion. Especially when polls show most Americans support Medicare for all as the ideal way to go. Show a little moxie fellows and maybe one of the politicians will get their courage up and follow you (Huckabee?) — couldn’t happen?

[Denis Drew]

An ugly quality of mandates enforced via heavy fines -- as I believe is the case in Massachusetts -- is that they too much resemble the action of punitive drug laws: the state is going to seriously harm you if it catches you doing something which could potentially harm yourself.

Comparing health insurance mandates to auto accident mandates doesn't wash: you can decide not buy a car you cannot afford to cover; you cannot decide not to be in the state of being a human being, whether or not you have the ability to cover health insurance.

See my post above about not too casually assuming that varying ability to afford health insurance can be reliably linked to points on an income scale.

[Lafayette]

Noni: Here in Canada, at least in the province of Manitoba, all permanent residents get a health card. On health coverage is a six digit number which is your provincial health card number and stays with you for life.

OK, but WHO PAYS FOR HEALTH CARE in Manitoba?

Private insurance companies (who recuperate the cost from companies who recuperate the cost by pricing it into their products/services) or by state/government administration, meaning taxpayers?

Who sets the prices of health care? It is nice to see that Manitoba HC is accessible by all, but is it affordable by all?

Health Care ALWAYS comes back to two questions: (1) Who pays for it and how? As well as, (2) who sets the prices, practitioners or are they mandated by the state?

HC affordability is a matter answering those two questions.

[Lafayette]

I proposed above a national health insurance scheme that is based upon the French model, known for being amongst the most accessible and most affordable -- which is why it is classified as the World's Best by the World Health Organization.

I asked if anyone thought it was not possible (and why not?) to extend Medicaid by bringing it in line with the French model.

So far, no answers.

You have all opinions, but -- frankly -- no answers. Which is why there will be No Solution to the problem. (I think it is safe to presume you are amongst the average of Americans who have reflected upon Health Care.)

Not until people understand What they want and Why they want it can they have a bona fide Health Care system.

Till then we are just mouthing words.

[William Smith]

I've said it before and I'll say it again:
My problem with Obama is that he seems unwilling to fight back against false talking points, either because his policy background is too weak to know that they are false, or because he is personally unwilling to push back when not directly confronted. In either case, it is something to consider...

[DJM]

Noni said; "Everybody is either pleased that they have health insurance, are frightened that they don't have health insurance, or worried about what their health insurance covers."
Another concern; Worried that their coverage will be jerked out from under them....or stressed because they need to stay in a job they have come to hate, because that is their only source of "affordable" insurance coverage for themselves and family. Many employers know this is the case, and often become quite abusive with their demands to work longer and harder without even the hope of a raise to cover inflation. The problems for the average citizen are very interconnected, which makes them all harder to solve even as we circle the drain.

[JRossi]

Noni writes that health insurance and health care are not identical. Excellent point, particularly in light of the looming, potentially severe shortage of primary care doctors in the US. In addition to universal insurance, another necessary but not sufficient condition for a high-quality and cost-effective medical system is having enough primary care MDs. Why? In a nutshell, continuity of care and coordination of care among specialists. Preventing heart attacks, with dietary therapy, aspirin and statins, for example, is cheaper and more effective that treating heart attacks, not to mention easier on the patient. But if there is no primary care MD, this care doesn't get provided. Diabetic complications spin out of control. Outpatient pneumonia turns into inpatient pneumonia. A little early heart failure turns into intubation in the ICU. There is no one making sure that the general surgeon doesn't order an antibiotic that blitzes the elderly patient's fragile kidneys. There no one making sure that the ER doc doesn't unknowingly intubate a patient with terminal leukemia. You get the idea.
What some do not know (and what the policy makers have not come to grips with)is that primary care is collapsing in the US. Google primary care collapse and read the ACP and NEJM articles if you're interested. Why is primary care dying? The short answer is too much work and not enough money when compared with specialty practice.

[Bruce Webb]

Whatever you think about Hillary (I think she is a lot more progressive than she is showing) there is no way she is going to allow anyone to get between her and the center. Obama wants to be seen as the Change Agent. Well man suggest some changes! And maybe some progressive ones like Single Payer. Or if that is too bold extend Medicare to all children to the age of 18 and lower eligibility to first 62 and by stages down to 55, maybe with a mandate for major medical for those in between. (The Insurance companies would fall at his feet, most of the things they have to screen for are simply wiped out of the risk pool. Not that pleasing Big Insurance is a priorty, but you get a whole lot of health coverage happening here, with them on the sidelines.)

Obama has the opportunity to reach out and educate people under 40 about the most successful government program ever, one that is widely loved by people over 50 and widely distrusted by people under 40. Instead he hires a Social Security privatizer. Its maddening. Rhetorically he claims to be a trail blazer but instead is content to walk down the center of the road.

In my view the Republican field is cracking up. Romney did not put the Mormon issue to bed, Giuliani at this point being more likely to be facing a judge than nominating them (there being some serious issues of criminality around the Shag Fund h/t TPM), Huckabee is going to forever regret the day he started his letter to a convicted rapist "Dear Dwayne .... " and then lying about the undisputed facts this week. McCain who actually has a sensible plan for immigration is by that fact doomed among Republicans (and many Democrats) who don't want to talk sense on this topic. One of them will eventually rise to the top, but as for now they have left an policy opening for Obama to exploit it. And it is Left of Center.

Democrats are dying to have a representative of the Democratic Wing of the Democratic Party to stand up. Obama has a couple of choices here. He can try to out-center Hillary and do a LieberDem move (his economic team working that direction) or directly compete with Edwards to nail down progressives and labor in the primaries. Instead he seems to be campaigning on policy positions that are more suited to the Chairman of the DLC than the head of a united, fighting Party battling for the principles of the New Deal.

[piglet]

"I would think that mandates would be a great selling point to insurance companies, who would love to get all the low-risk people who currently choose not to buy insurance on their rolls."

But not if medical underwriting is abolsihed, because then they would have to keep all the high-risk people on their rolls too. This is how they did it in Switzerland. Since the Swiss model seems to be the only that can realistically be implemented in the US (or am I wrong) people here might be more interested in how that was done politically.

[ken melvin]

Cart horse? Horse cart? First, we need agree that all should have access to healthcare. Many on the right don't think that this should be. Thus it is, I think, that we have so much conflict in how to go about providing healthcare. If we agreed that every American should have healthcare, the next logical question is how best go about providing same. In fact, once it is agreed that all should have healthcare, different means can and should be (tried)/evaluated and the one proven to be best implemented with the option of change always possible. So, I think the dems need start with the premise that all should have healthcare and move/define the argument to one of how best ensure that all Americans have healthcare.

[skeptonomist]

Anne:

Yes, R. Samuelson can be counted on to get something, if not everything wrong; he also ignores the experience of the rest of the civilized world when he says that the costs of health care are the problem (of course, this experience is invisible also to Republican politicians). How are other countries able to provide better universal health care at lower cost? Not by greater reliance on free markets, but by making health a common concern. Krugman and others have countered the weak argument (which Samuelson doesn't even bother to make) that private research is necessary for advances in medicine.

[Noni Mausa]

Lafayette says...
Noni: Here in Canada, at least in the province of Manitoba, all permanent residents get a health card...

OK, but WHO PAYS FOR HEALTH CARE in Manitoba?

A single payer -- the provincial (and federal) government. Some costs -- prescription drugs for instance -- are paid by the patients, but there's generally help for the big stuff.

...

Who sets the prices of health care? It is nice to see that Manitoba HC is accessible by all, but is it affordable by all?

Yes.

Health Care ALWAYS comes back to two questions: (1) Who pays for it and how? As well as, (2) who sets the prices, practitioners or are they mandated by the state?

Canadian health costs are set/negotiated by the provincial health plans and the federal health department -- I don't know all the ins and outs. I think "creative tension" best describes the process.

But look at prescription drug costs, which are negotiated federally: here they are so low that American pensioners order medication and have it shipped and it's still drastically cheaper than buying it in the country where it's made i.e. USA, for the most part. (This "export industry" has subsided quite a lot in the past couple of years.)

As far as practices, these are governed by the provincial health departments, and physicians and other health workers here are independent contractors, not state employees.

You ask who will pay the cost. Hell, who's paying it now in America? Your costs are huge, and don't cover the whole populatiuon. Much of that money is wasted, at least so far as the sick people are concerned.

Single payer, if the stats from other nations using it is any indication, will cut US health costs in HALF, remove a burden from business, smooth out a lot of perverse incentives like staying in hated jobs, and almost certainly lift a great burden of anxiety from the population as a whole. Hell, even physicians would benefit, with only one form to fill out and send away for payment.

And is there a downside? How about the total collapse of the health-care-denial industry? A substantial loss of business for the bulk of bankruptcy lawyers? The disappearance of the Inexplicably Complicated Insurance Documents Industry of America (ICIDIA)? Oh, the humanity!

That's not a downside, that's a perk.

Noni

good to hear from you, Lafayette. Have you been away?

[Lafayette]

Single payer, if the stats from other nations using it is any indication, will cut US health costs in HALF

There is no proof anywhere that a 50% reduction would ensue. So, it reflects simplistic thinking that is looking for a "quick fix" to a complex problem.

If one does not want to look at the fundamentals of Health Care in terms of market equilibrium and inelastic supply, then one cannot understand its solution.

Health Care, for just such reasons, is better a Public Service than Private Enterprise (as it is). The remedy is in mandating practitioner service pricing instead of letting a "free market" equilibrium decide it.

And I tire saying it. Seeeesch!

[jeff hoffman]

Mandating practitioner service pricing sounds logical, but for many practitioners roughly 50% of their insured population has mandatory pricing via Medicare rates and the remainder are via their third party providers constantly being negotiated down towards or below medicare rates if possible. For primary MDs the answer has been to hire PAs or ARNPs to game that system into profitability. (As far as the notion expressed above that statins and aspirin save health care costs, I wouldn't know how.) The only way to cap spending unequivocally at the provider level is to capitate care (that is pay a flat per capita fee for service and force the provider to ration), a notion that had some traction with HMOs a few years back but ultimately failed to be appealing to anyone it seemed, including the patients who often could figure out that providers were incentivized to withhold care in that system. Single payer avoiding the insurers would likely be best, but as a provider I cringe at the idea that my reimbursement could be ratcheted down without recourse by the government to untenable levels from the standpoint of making my overhead. As Ken Melman suggests the issue should be framed by the Democrats much more clearly prior to the '08 election as one in which the Dems favor Universal access vs the Republican mantra that healthcare is not a right. But, as long as the insurers are positioned in the center of a plan it will fail to maximize cost containment, and that is the problem.

[jeff hoffman]

Here's another proposition: the screening exam for a 90 year old is on average of less value than that for a 70 year old. Age may be an appropriate factor in considering reimbursement for any aspect of medical care in consideration of years of life expectancy saved. Maybe the reimbursement rate for the demented 90 yo ICU patient should take that into account when comparing with a 65 yo. Age as a rough inverse estimate of the intrinsic value of care makes some sense to me. Maybe there needs to be an age limit to full medicare benefits.

[Lafayette]

JH: Age may be an appropriate factor in considering reimbursement for any aspect of medical care in consideration of years of life expectancy saved.

Age is quite possibly THE most important factor, given that most Health Care disbursement is highly age-correlated.

Consequently, with this in mind, it is appropriate to think that the young – not needing substantial amounts of Health Care – should be the ones to bear its principle burden on behalf of their elders (who will need it far more). Such a notion is consonant with respect for the elders, a valued cultural attributes of most societies (that have a far longer history than ours).

However, the ineluctable rise in HC-costs is making that burden more and more onerous. I repeat, there is NOTHING on the table that addresses the real problem of HC-cost. Fixating on “administrative expenses” cannot explain the ratio of four to one in comparison to the same costs in other developed countries.

We are mortgaging the future of our young by perpetuating the present high cost HC-system. Nothing in the proposition of current PotUS candidates indicates their intent to tackle the central problem.

[Lafayette]

NM: You ask who will pay the cost. Hell, who's paying it now in America? Your costs are huge, and don't cover the whole populatiuon

Wonders of wonders

Easy answer. The American system of privatized HC-insurance means that one must (unless covered by Medicare or Medicaid) subscribe to a corporate HC-plan.

How does this work? Easy. The companies pay for the health insurance and recuperate the costs from their product/service pricing. So, all consumers pay for the health insurance -- in fact, whether they benefit from just such a plan or not.

Meaning, if you don't subscribe to your company's plan, or if your company doesn't have one, then - sucker -- you are paying for everybody else's when you consume products/services offered by companies that do have privatized health plans. (Really and truly "fair play", huh?)

And, NM, thanks for your explanations of how Canadian "national" Health Care works. It is similar to France's nationalized HC-system. But when I explain that point, apparently posters think France is located in some other galaxy.

So, let's tell them that the country just to the north of theirs has "socialized medicine" and, wonder of wonders, it has not been smitten by the wrath of God. Not yet ...

[barry payne - economist]

THE DEATH LOTTERY
For the aged under Medicare hospice care, predicting death has become a profitable business for most while a losing proposition for others as some patients live longer than expected - to the point of bankruptcy.

Private companies shop patients for "optimal death paths" in one sector of Medicare while in the "curative" sector, milking it for all it's worth to keep them alive ... until patients hit the 6-month crossover point after which they're put on the Kevorkian treadmill.

Not that death with dignity has finally won out somewhat over the objections of Big Health and Big Religion to sustain vegetative corpses indefinitely, as it should.

The point is to highlight the rigidity and lack of reasonably continuous cost and price options along a scale that could exist absent the influence of Big Health working the system politically from the top down.

There's plenty of folks near the end of their life who would happily take the $135 daily expense (explained below) to use as they wish on the way out.

http://www.nytimes.com/2007/11/27/us/27hospice.html (full article)

"In the early days of the Medicare hospice benefit, which was designed for those with less than six months to live, nearly all patients were cancer victims, who tended to die relatively quickly and predictably once curative efforts were abandoned.

But in the last five years, hospice use has skyrocketed among patients with less predictable trajectories, like those with Alzheimer’s disease and dementia. Those patients now form a majority of hospice consumers, and their average stays are far longer — 86 days for Alzheimer’s patients, for instance, compared with 44 for those with lung cancer, according to the Medicare Payment Advisory Commission.

The commission, which analyzes Medicare issues for Congress, recently projected that 220 hospices — about one of every 13 providers — received 2005 repayment demands totaling $166 million. The National Alliance for Hospice Access, a providers’ group that is lobbying for a three-year moratorium on the collections, places the numbers at 250 hospices and $200 million ...

... Medicare’s coverage of hospice, which began in 1983, has become one of the fastest growing components of the government’s fastest growing entitlement. Spending nearly tripled from 2000 to 2005, to $8.2 billion, and nearly 40 percent of Medicare recipients now use the service.

To be eligible, patients must be certified by two doctors as having six months or less to live, assuming their illness runs a normal course. They must agree not to bill Medicare for curative procedures related to their diagnosis.

Medicare, which pays the vast majority of hospice bills, reimburses providers $135 a day for a patient’s routine home care. The hospice is then responsible for providing nurses, social workers, chaplains, doctors, drugs, supplies and equipment, as well as bereavement support to the family."