Paul Krugman: Clinton, Obama, Insurance

Why you should care about the differences in the Clinton and Obama health care proposals:

Clinton, Obama, Insurance, by Paul Krugman, Commentary, NY Times: The principal policy division between Hillary Clinton and Barack Obama involves health care. It’s a division that can seem technical and obscure — and I’ve read many assertions that only the most wonkish care about the fine print of their proposals.

But as I’ve tried to explain in previous columns, there really is a big difference between the candidates’ approaches. ... Specifically, new estimates say that a plan resembling Mrs. Clinton’s would cover almost twice as many of those now uninsured as a plan resembling Mr. Obama’s — at only slightly higher cost. ...

Let’s talk about how the plans compare. ... The ... big difference is mandates: the Clinton plan requires that everyone have insurance; the Obama plan doesn’t. Mr. Obama claims that people will buy insurance if it becomes affordable. Unfortunately, the evidence says otherwise.

After all, we already have programs that make health insurance free or very cheap to many low-income Americans, without requiring that they sign up. And many of those eligible fail, for whatever reason, to enroll.

An Obama-type plan would also face the problem of healthy people who ... don’t sign up until they develop medical problems, thereby raising premiums for everyone else. Mr. Obama, contradicting his earlier assertions ... is now talking about penalizing those who delay signing up — but it’s not clear how this would work.

So the Obama plan would leave more people uninsured than the Clinton plan. How big is the difference? ... Jonathan Gruber of M.I.T., one of America’s leading health care economists, ... in a new paper ... finds that a plan without mandates, broadly resembling the Obama plan, would cover 23 million of those currently uninsured, at a taxpayer cost of $102 billion per year. An otherwise identical plan with mandates would cover 45 million of the uninsured — essentially everyone — at a taxpayer cost of $124 billion. Over all, the Obama-type plan would cost $4,400 per newly insured person, the Clinton-type plan only $2,700.

That doesn’t look like a trivial difference to me. ...

As with any economic analysis, Mr. Gruber’s results are only as good as his model. But they’re consistent with the results of other analyses... And that’s why many health care experts ... strongly support mandates.

Now, some might argue that none of this matters, because the legislation presidents actually manage to get enacted often bears little resemblance to their campaign proposals. And there is, indeed, no guarantee that Mrs. Clinton would, if elected, be able to pass anything like her current health care plan.

But while it’s easy to see how the Clinton plan could end up being eviscerated, it’s hard to see how the hole in the Obama plan can be repaired. Why? Because Mr. Obama... has sabotaged his own prospects.

You see, the Obama campaign has demonized the idea of mandates — most recently in a scare-tactics mailer sent to voters that bears a striking resemblance to the “Harry and Louise” ads run by the insurance lobby in 1993, ads that helped undermine our last chance at getting universal health care.

If Mr. Obama gets to the White House and tries to achieve universal coverage, he’ll find that it can’t be done without mandates — but if he tries to institute mandates, the enemies of reform will use his own words against him.

If you combine the economic analysis with these political realities, here’s what I think it says: If Mrs. Clinton gets the Democratic nomination, there is some chance — nobody knows how big — that we’ll get universal health care in the next administration. If Mr. Obama gets the nomination, it just won’t happen.

Comments

[lonesome moderate]

After all, we already have programs that make health insurance free or very cheap to many low-income Americans, without requiring that they sign up. And many of those eligible fail, for whatever reason, to enroll.

I'm not sure what Krugman is talking about here. I was unemployed for seven months in 2002 in the wake of the dot-com bust, and could not find any option for health insurace, other than paying a fortune to my former employer to continue with theirs. Is there some new program that has come on line since then?

[turquoise]

Professor Krugman,

So Obama gets a B plus on the healthcare test.

Are you happy now?

But Obama scores more than Billary in all other tests and has a better overall score.

So I will go for Obama.

You have said that if Obama “tries to institute mandates, the enemies of reform will use his own words against him.”

You think the same enemies of reform will give a free pass to Hillary simply because of her pre-election policy stance? Give me a break.

Prof. Krugman, wake up and smell the coffee.

[Bruce Wilder]

PK: "If Mr. Obama gets to the White House and tries to achieve universal coverage, he’ll find that it can’t be done without mandates . . ."

Krugman is simply wrong. State after State have tried mandates, and it never works. Never. Let Krugman show a State, where a mandate has worked.

Politically and practically, you cannot police the healthy poor and lower middle-class and force them to apply for and pay for insurance. And, you cannot penalize people who get seriously ill, for not buying insurance earlier, (except, perhaps, in a wholly nominal way).

If you really want universal coverage, you want tax-financing, and presumptive enrollment -- everyone is covered, by default and the only way to opt out is to buy insurance.

If you have the votes for a set of taxes, which will eventually escalate to the order of 8-12% of GDP, then you can have universal health care. I think that is doable, but it will require a series of incremental reforms, each of which fails forward to the next step.

In this regard, Kerry had a very good proposal in 2004, for tax-financed reinsurance. It wasn't very good campaign politics -- policy proposals with any details rarely are. But, conceptually, it was brilliant. Reinsurance is a benefit for insurance companies and self-insuring employers: they can foist their "losses" off on the government program.

It is relieving insurance companies of their adverse selection risk -- a lot like letting banks securitize subprime mortgages and sell them to the government. And, it has one attractive feature. Just as securitization of bad risks made banks eager to loan money to people that they would not otherwise want to, so re-insurance would make health insurers very friendly people, who really want to help everyone.

Politically, it is neutralizing a vicious guard dog of a political lobby by throwing them the red meat of a government hand-out -- a thoroughly proven method of political governance.

So, there's an approach that doesn't involve mandates. It does involve tax-financing, and leads, I think, to presumptive coverage. That's where we need to head toward: tax-financing and presumptive basic coverage.

Mandates sound terrible. That's the lesson of Obama's "Harry and Louise ad". You think Obama's campaign putting that out damages the prospects of legislative action a year and a half from now? Wait until McCain puts out the same thing, and declares that Republicans will protect the poor from such depredations.

And mandates sound terrible for a good reason: they are lousy, stupid policy. (And, yes, I know how adverse selection works.)

[knzn]

Single-payer advocates should support Obama, precisely because his plan won't work. Clinton might actually succeed in getting through a health care program that will be reasonably successful and therefore stable. Once a program has become stable and entrenched, the chance of moving to single-payer will disappear. Obama's plan has an obvious flaw, and if it passes (and it should be easier to avoid a Republican filibuster if Krugman is on record having criticized it), then it will eventually become clear that it needs to be fixed. The fix could then move us toward single-payer.

[LJM]

Single payer isn't so great if you don't have access. Having health insurance you can actually use, because providers accept it is more important. If everybody can have the sort of coverage members of congress get, that is primo health coverage. So long as their's choice in providers and they can't turn anybody away, like they do with medicare and medicaid, it's a step in the right direction.

As for the Harry and Louise brochure, that was ugly. I remember Harry and Louise. They sucked, big time.

[Rainbolt]

I'm not so sure that the Fed's need to get involved, other then to be of support to the states that do not have these kinds of services.

Our Country has a responsibility to each citizen, and this kind of service is best tailored to the needs of the individuals in each state. In the state of Washington, for example, we have licensed naturopaths, acupuncturists, midwives, & allopathic physicians.

The choices abound- due to the efficiency of the state's licensing standards. It's time we look at the models that are working in the U.S. and build on them.

My choice to live here -25 years ago- was primarily due to these laws that provide more services in alternative medicine-rather then in most states where a variety of health care options do NOT exist.

[Bruce Wilder]

knzn: "Single-payer advocates should support Obama, precisely because his plan won't work. Obama's plan has an obvious flaw, and . . . it will eventually become clear that it needs to be fixed. The fix could then move us toward single-payer."

Very elegantly put. You could moonlight as a political scientist.

[Bruce Wilder]

Links to a couple of other opinions on mandates, campaign politics and public policy.

Harold Pollack: Universal Coverage and the Presidential Candidates - The Huffington Post

Mark Kleiman: Enough with the "mandates" already! - Reality-Based Community

[anne]

There is an interesting sort of hatefulness, an interesting sort of attack on women, that makes it essential to essential to destroy Hillary Clinton's very name, makes it essential to deny Hillary Clinton a proper identity.

[anne]

"State after state have tried mandates, and it never works."

Care to show the states, all those 50 or 500 states, that have tried mandates. I am all interested in such nonsense. Which state did what when?

[save_the_rustbelt]

Apparently this weekend Hillary, in answer to a question (ABC This Week), said she might garnishee the wages of those who do not buy her plan, in effect forcing them to buy insurance.

If Hillary actually knows any low income workers she knows that will force them into a food-or-housing choice which will result in them becoming homeless.

Now that is a really good policy idea!

She backpedaled a little and said she would only garnishee the wages of those who could "afford it," and she will make insurance so cheap they have no excuse.

California dreaming?

[pgl]

Mark - Dean Baker has a post where he disagrees with Paul Krugman on this one.

[anne]

"If Hillary actually knows any low income workers she knows that will force them into a food-or-housing choice which will result in them becoming homeless."

This is vicious hateful slander, vicious hate-filled lying for the sake of vicious lying. The point always being to lie, because destruction is the intent.

[anne]

A universal health care insurance plan will provide that any and all moderate and low income persons are protected completely by public health care insurance. Even as, through these last months, there has been a struggle to protect the health of 3.8 million children of moderate income parents by providing free insurance. Republicans have repeatedly denied these millions of children health care insurance.

The point of universal health care is to make sure all Americans have ready access to fine health care, and to make sure the care is completely affordable and free for all those in need.

[What About the Total Bill]

PK..."An otherwise identical plan with mandates would cover 45 million of the uninsured — essentially everyone — at a taxpayer cost of $124 billion."

Health insurance payers are taxpayers also, and mandates are another form of selective tax. Neither of these plans do anything significant to reduce our fantastic total national health care bill. They just change who pays the bill. (Mandates are a high regressive tax on the lower income group, while national health care would be a progressive tax with the rich paying more.)

Either way, if nothing is done about the US paying twice as much per capita than other advanced nations, the cost burden will be great. Why aren't the candidates suggesting taxpayer funding for national health care? It would be impossible to raise enough tax money from the rich to pay twice as much per capita than other nations spend for health care. Thus politicians come up with mandates, letting the high cost be someone else's problem.

Raising the top tax rate to 70% would only raise about $100 billion extra. Raising some other types of taxes on the rich might raise another $100 billion, for a total of $200 billion. That would not pay for even a small fraction of the fantastic total US health care bill.

[save_the_rustbelt]

Anne:

The only low income workers Hillary sees on a regular basis are her servants - gimme a break.

And if universal health care is the answer, why doesn't Hillary propose such a plan, instead of the cluttered plan-by-committee she is touting?

Her plan is only marginally different from Obama's, so why is Krugman so wild-eyed about stopping Obama? Another agenda perhaps?

PS: auto loan delinqencies are skyrocketing, so all of those people who get health care garnishees are going be in deep trouble :))

[anne]

What about the total bill is what about the total blindness and total callousness of a person who cares nothing at all about the cost of the military, who cares nothing at all about the cost of war and occupation, but cares about the cost of protecting the health of millions of needy children for what we squander in a couple of weeks in Iraq and Afghanistan.

Protecting the health of 3.8 million needy children would have cost $7 billion this year, as opposed to $200 billion this year for Iraq and Afghanistan.

Dramatic saving in health care spending could readily be achieved by cutting administrative costs, but that would take a gradual change in the provision of insurance. Saving in costs could further and more easily be realized by allowing Medicare to negotiate drug prices as the health service for veterans does.

[save_the_rustbelt]

From Dean Baker:

"That works for healthy people, but it would destroy the system because the only people buying insurance would be those with relatively high bills."

I think that is a gross overgeneralization and a real misunderstanding of how people view health insurance.

[Cynthia]

KNZN: you write,

"Single-payer advocates should support Obama, precisely because his plan won't work. Obama's plan has an obvious flaw, and...it will eventually become clear that it needs to be fixed. The fix could then move us toward single-payer."

What you seem to be saying is that it's best to propose a health care plan which is most likely to fail once it is implemented, clearing the way for the most radical of the plans: a single-payer one.

So I'll say there's more psychology than political science in this strategy -- reverse psychology, that is.

Plus it's sad to think that single-payer advocates must resort to such a strategy; after all, it smacks of dishonesty!

[life, liberty, happiness]

To use the power of the state to coerce is EVIL. It should be used sparingly.

Mandates are such a coercion -- that Hillary suggested she would garnish wages is EVIL.

There are many people -- particularly healthy, young men -- for whom it is a RATIONAL choice not to buy insurance.

But I guess you have to love liberty -- not only your own, but also that of OTHERS -- to see it. If you are for mandates, you don't love liberty -- plain and simple.

[What About the Total Bill]

Spending twice as much per capita is the real problem. The "taxpayers" already spend as much per capita on health care paid for by the gov, but we only cover half the population because the cost per capita is twice as much. If we could just spend as much as other nations per capita, we would already be able to cover the entire population with what we now spend.

[Octavio Richetta]

Professor you say:

"If you combine the economic analysis with these political realities, here’s what I think it says: If Mrs. Clinton gets the Democratic nomination, there is some chance — nobody knows how big — that we’ll get universal health care in the next administration. If Mr. Obama gets the nomination, it just won’t happen."

What is so wrong about a politician changing his mind? If Obama gets the nomination and Clinton's plan is so much better, why wouldn't he change for the better? Perhaps something in between...

[anne]

"The only low income workers ------- sees on a regular basis are --- servants - gimme a break."

What is important is always hate-filled slander. The intent being destruction for the sake of destruction.

[What About the Total Bill]

Let me suggest that a VA type gov run program to cover basic services for all. Allow a genuine free market to operate outside the system for those who want to pay for extra services.

[anne]

John Edwards proposed a plan that included expanding Medicare insurance to any employer or person who wished the coverage. This would allow for a low administrative cost insurance competitor to private insurers, and be a means of gradually lowering overall administrative costs.

That health care costs are needlessly high in America is clear from my perspective, but even small changes effecting costs are going to entail a considerable political struggle while large changes may well prove impossible.

[Georgee]

Dear Mr. Krugman,

I think Obama's plan is a good start. Your mistake is to bring this one fore front of the decision making for the primary election. Obama and Hilary are not running to be a Healthcare minister. I think a presidential candidate needs to let us know what what are their priorities and the list of what they want to achieve. But it does not mean that they need to have a complete plan. It does not work that way. In order to pass a healthcare plan, we need to have something that both sides (dems and reps) can agree to discuss. To me, Hilary plan does not have any room for further negotiation. It will most likely to be rejected. She will kill a chance of legislation that way. To me, her approach to healthcare indicates her misunderstanding of the job. Indeed, she seems to be ready to fight with republicans on Day 1 while Obama indicates his readiness to start working together with people from both parties and independents. I am sure he will not hesitate including good ideas from Mrs. Clinton and others like you.

[anne]

Veterans health services are generally admired, but these services often involve direct provision of care where Medicare is just a public insurer. Both programs can limit costs effectively, with no sacrificing of patient needs. We will however for some time have relatively higher health care costs than other developed countries since any transition will be slow in coming at best.

[reason]

What about the Total Bill,
forgive me for being confused, but isn't that what a single payer system in practice usually is? Isn't something different being proposed? I don't see how it is possible to stop the rich from getting superior service if they pay for it.

[reason]

What about the Total Bill,
forgive me for being confused, but isn't that what a single payer system in practice usually is? Isn't something different being proposed? I don't see how it is possible to stop the rich from getting superior service if they pay for it.

[reason]

... Is something different ...

[What About the Total Bill]

R..."I don't see how it is possible to stop the rich from getting superior service if they pay for it."

I don't have any desire to prevent the rich from getting better service if they want to pay for it. The French system allows the rich to pay extra if they want to, without driving up the total cost of basic services provided to the masses.

The rich can buy a Rolls Royce without driving up the cost of a Toyota. Similarly, a well run VA type system to provide basic services to all would be completely separate from the private market that runs along side it. The total cost of VA basic services would not be impacted by whatever private services the rich buy with their own money.

[What About the Total Bill]

"...large changes may well prove impossible..."

If that is true, then there is no hope. The current proposals are just rearranging the deck chairs on the Titanic. The ship will still go down regardless.

Without major changes, costs will spiral out of control, hospitals will continue to shut down, and many will be denied basic services.

[What About the Total Bill]

As a matter of fact, if a true free market in medicine is allowed to grow up along side the VA system, prices will be low enough that the middle class can afford extra if they so choose. Our current system of state chartered monopolies, regulations that make no economic sense, and special interest group favoring mandates is exorbitantly costly.

[mike]

"The point of universal health care is to make sure all Americans have ready access to fine health care, and to make sure the care is completely affordable and free for all those in need."

the point of the government is not to take care of its citizens from cradle to grave. i prefer obama's plan (if UHC does make its way through) to hillary's because i have a choice to opt out. i can only dream of being able to do that with something like social security.

[anne]

http://krugman.blogs.nytimes.com/2008/02/04/health-care-thoughts/

February 4, 2008

Health care thoughts
By Paul Krugman

Just a note to explain where I’m coming from on all this.

I believe that universal health care has to be THE central item in a progressive agenda — not just because it’s the right thing to do, but because of its political economy implications. As I explain in Conscience of a Liberal, Republicans went all-out in 1993 to block health reform because they feared that success would reinvigorate the progressive agenda. And they were right.

Now, if I had my way I’d just go to single-payer, Medicare for All. But that’s politically impossible, at least for now. What had me hopeful was that the Democratic candidates seemed to be offering a more feasible path that could work politically: regulation, subsidies, mandates, plus public-private competition that could eventually lead to single-payer.

Obama’s plan fell short — but I was initially willing to cut him slack, figuring that it could be improved. But then he began making the weakness of his plan a selling point, and attacking his rivals for getting it right. And in the process he has systematically trashed the prospects for actually achieving universal coverage.

The Obama plan is still vastly preferable to plans that rely on tax credits and the magic of the marketplace. But from where I sit, a dream is dying — and progressive Obama supporters, caught up in the romance of his candidacy, don’t understand that he’s actually undermining their cause.

[anne]

"I prefer Obama's plan (if UHC does make its way through) to Hillary's because I have a choice to opt out. I can only dream of being able to do that with something like Social Security."

Always viciousness all the time, because viciousness is what compassionless conservatism is about. The point of compassionless conservatives is to destroy Social Security and Medicare along with making universal medical care for yuounger Americans impossible.

[Denis Drew]

Obama seems to be more in touch with the real world of wage deprived Americans than our academic liberals.

Imagine a future in which families were mandated to buy a health plan -- some purchase the one with the $10,000 deductible (the cheapest legal option?) -- okay; they have obeyed the law -- but now those families end up in the emergency room MORE OFTEN, instead going to their family doctor's office, because they were forced to use up their family doctor money buying what Obama correctly calls "home insurance."

Remember, $40,000/yr is more like the REAL (just above) poverty line for a family of four (not the official line based on three times the price of an emergency diet) and $55,000/yr is roughly median family income these days. Most families are not far from poverty -- though their numbers sound just fine -- while med insurance climbs and climbs. (Obama is oh so right describing policies with $10,000 deductibles as home insurance, not health insurance.) Forcing rising premiums down the throats of families with shrinking real world incomes is flirting with disaster in many cases -- and would impose disaster outright in many hanging by a thread families.

So-called subsidies tend to be set at a proportion of the -- IN REALITY -- 50% discounted fed poverty line. I really believe our academic liberals have much trouble envisioning the existences of anyone below 50 percentile income (why you almost never hear Dem candidates so much as mention the average Americans' most desperate economic need, massive re-unionization -- nor criticize a ridiculous minimum wage raise that may end up nearly a dollar below 1956's minimum wage -- $7.93 adjusted* -- in REAL buying power by 2009) -- and here we go again.
********************
"...can't be done without mandates", Paul? You mean universal coverage based on PRIVATE insurance can't be, don't you? Which private insurance contributes to our health cost being double those of comparable economies.

Again and again: Medicare for all ought to be the easiest program in the world to sell: Medicare is the plan most folks happily look forward to relying on when they are older and perhaps much more in need of even critical care -- why in the world should they hesitate to rely on it now while they are young and usually healthy?

[anne]

"Imagine a future in which families were mandated to buy a health plan -- some purchase the one with the $10,000 deductible (the cheapest legal option?) -- okay; they have obeyed the law -- but now those families end up in the emergency room MORE OFTEN, instead going to their family doctor's office, because they were forced to use up their family doctor money buying what Obama correctly calls 'home insurance.' "

"Imagine a future in which families were mandated to buy a health plan -- some purchase the one with the $20,000 deductible...."

"Imagine a future in which families were mandated to buy a health plan -- some purchase the one with the $30,000 deductible...."

"Imagine a future in which families were mandated to buy a health plan -- some purchase the one with the $40,000 deductible...."

This is deceiving rubbish.

[Michael Cain]

Veterans health services are generally admired, but these services often involve direct provision of care where Medicare is just a public insurer. Both programs can limit costs effectively, with no sacrificing of patient needs.

I live in a state with large rural areas, where some counties have no doctors that will accept new Medicare patients. These are clearly areas where government cost containment is causing some sacrifice of patient needs. Single-payer with significant cost containment will require coercion of medical professionals as well as coercion of the beneficiaries.

[ken]

The beauty about the Obama plan is that I can cancel my $390 per month health insurance policy and not worry about it.

With the money I save from paying premiums I can pay the doctor out of my pocket for the few office visits I have per year and the occasional prescription refill. I will easily be several thousands of dollars ahead after cancelling my coverage.

I have a chronic illness but with the Obama plan I cannot be denied coverage if I ever want to purchase insurance again. So if I can go just a few years without buying insurance I should be able to afford to buy myself nice new car.

I suspect I am not the only one who sees this built in benefit to the Obama plan. Small businesses especially will no longer see the need to provide anyone with coverage except for the owners. The employees can buy it on their own should they ever want or need it.

[mike]

"Always viciousness all the time, because viciousness is what compassionless conservatism is about. The point of compassionless conservatives is to destroy Social Security and Medicare along with making universal medical care for yuounger Americans impossible."

oh please. i don't really need a lecture anne with you as judge of compassionism. i haven't read it yet but per 'who really gives' supposedly the average republican makes less than the average democrat, but donates more to charity. so spare me. i'm not going to claim a group is more compassionate than another, but it certainly highlights the distinction between the 2 groups in that one believes that they hold personal responsibility for helping others, and the other group defers that responsibility to the government. and i'm just a heartless bastard if i believe the government runs everything wastefully and inefficiently right? or is that ineptness reality?

what about the young americans that do not want universal medical care? and now we have hillary talking of forcing me to be in it and garneshing my wages? what happened to being "free" in this country??

[Cyrille]

Ken, you DO realise that what you describe is precisely what would make healthcare costs even higher should Obama's plans be implemented, right? Your comment was actually criticism of the plan, wasn't it?

If not, well, then it's both extremely selfish and extremely short-sighted.

[Bruce Wilder]

anne: "Care to show the States"

By David U. Himmelstein and Steffie Woolhandler
The New York Times
December 15, 2007
Cambridge, Mass.

In 1971, President Nixon sought to forestall single-payer national health insurance by proposing an alternative. He wanted to combine a mandate, which would require that employers cover their workers, with a Medicaid-like program for poor families, which all Americans would be able to join by paying sliding-scale premiums based on their income.

Nixon’s plan, though never passed, refuses to stay dead. Now Hillary Clinton, John Edwards and Barack Obama all propose Nixon-like reforms. Their plans resemble measures that were passed and then failed in several states over the past two decades.

In 1988, Massachusetts became the first state to pass a version of Nixon’s employer mandate — and it added an individual mandate for students and the self-employed, much as Mrs. Clinton and Mr. Edwards (but not Mr. Obama) would do today. Michael Dukakis, then the state’s governor, announced that “Massachusetts will be the first state in the country to enact universal health insurance.” But the mandate was never fully put into effect. In 1988, 494,000 people were uninsured in Massachusetts. The number had increased to 657,000 by 2006.

Oregon, in 1989, combined an employer mandate with an expansion of Medicaid and the rationing of expensive care. When the federal government granted the waivers needed to carry out the program, Gov. Barbara Roberts said, “Today our dreams of providing effective and affordable health care to all Oregonians have come true.” The number of uninsured Oregonians did not budge.

In 1992 and ‘93, similar bills passed in Minnesota, Tennessee and Vermont. Minnesota’s plan called for universal coverage by July 1, 1997. Instead, by then the number of uninsured people in the state had increased by 88,000.

Tennessee’s Democratic governor, Ned McWherter, declared that “Tennessee will cover at least 95 percent of its citizens.” Yet the number of uninsured Tennesseans dipped for only two years before rising higher than ever.

Vermont’s plan, passed under Gov. Howard Dean, called for universal health care by 1995. But the number of uninsured people in the state has grown modestly since then.

The State of Washington’s 1993 law included the major planks of recent Nixon-like plans: an employer mandate, an individual mandate for the self-employed and expanded public coverage for the poor. Over the next six years, the number of uninsured people in the state rose about 35 percent, from 661,000 to 898,000.

As governor, Mitt Romney tweaked the Nixon formula in 2006 when he helped devise a second round of Massachusetts health care reform: employers in the state that do not offer health coverage face only paltry fines, but fines on uninsured individuals will escalate to about $2,000 in 2008. On signing the bill, Mr. Romney declared, “Every uninsured citizen in Massachusetts will soon have affordable health insurance.” Yet even under threat of fines, only 7 percent of the 244,000 uninsured people in the state who are required to buy unsubsidized coverage had signed up by Dec. 1. Few can afford the sky-high premiums.

Each of these reform efforts promised cost savings, but none included real cost controls. As the cost of health care soared, legislators backed off from enforcing the mandates or from financing new coverage for the poor. Just last month, Massachusetts projected that its costs for subsidized coverage may run $147 million over budget.

The “mandate model” for reform rests on impeccable political logic: avoid challenging insurance firms’ stranglehold on health care. But it is economic nonsense. The reliance on private insurers makes universal coverage unaffordable.

With the exception of Dennis Kucinich, the Democratic presidential hopefuls sidestep an inconvenient truth: only a single-payer system of national health care can save what we estimate is the $350 billion wasted annually on medical bureaucracy and redirect those funds to expanded coverage. Mrs. Clinton, Mr. Edwards and Mr. Obama tout cost savings through computerization and improved care management, but Congressional Budget Office studies have found no evidence for these claims.

In 1971, New Brunswick became the last Canadian province to institute that nation’s single-payer plan. Back then, the relative merits of single-payer versus Nixon’s mandate were debatable. Almost four decades later, the debate should be over. How sad that the leading Democrats are still kicking around Nixon’s discredited ideas for health reform.

David U. Himmelstein and Steffie Woolhandler are professors of medicine at Harvard and the co-founders of Physicians for a National Health Program.

[anne]

"I live in a state with large rural areas, where some counties have no doctors that will accept new Medicare patients."

Funny thing about that, because Medicare patients have all sorts of choices of subsidized private insurance plans. So, which doctors where are refusing private insurance as well as public insurnace? Please document this.

[ken]

Cyrille,

I think their are millions of individuals and small business owners who would gladly cancell their health insuranc coverage under the Obama plan. I know I would.

We've always paid more in premiums than have employees of large companies thereby subsidizing their lower costs.

We've never been able to fully deduct the cost of our premiums, unlike the employees of large corporations who get their health insurance with pretax dollors, so we've been subsidizing their tax benefits as well.

It might be a flaw in the Obama plan from your point of view but for millions like me it is a benefit. And, after having spent years paying premiums to subsidize everyone elses insurance and tax breaks I don't feel it selfish at all to enjoy a little relief myself.

[anne]

Imagine me being able to read. Duh.

David Himmelstein and Steffie Woolhandler have not shown in the least that any state has offered a universal health insurance program with public insurance for all moderate and lower income residents and failed to increase the number of residents who have health insurance coverage.

[DoctorBob]

I admire Krugman but he is wrong. Bruce Wilder is closer to the target, but he should wait to see how things shake out in Mass.
1. Those programs for low income Americans have been slashed- Krugman should produce somebody who recently got into one, if he can.

2. Look at the budget headlines. Bush wants to increase pentagon spending- buy more submarines and high tech toys (lotsa luck against suicide bombers) and sneakily increase spending on both Iraq/Afghanistan. The surge has been so fantastic in Iraq that we must do the same in A'stan- we can pay the Taliban to kill our enemies, they will take our money. A darling of the defense contractors- Billary has more defense contractor money than old war dog Mc Cain- can't produce universal health coverage. The Chinese won’t loan us enough money. A President Billary would produce a 1500 page plan that will go nowhere; she can then claim permanent sainthood- her bullet lists show how smart she is, but they don’t persuade.

3. Anne is wrong about reducing expenses. Profit making firms must logically hold down expenses with barriers which cost money- idiots that I talk to on the phone who tell me- that disease is not my computer- how can it justify that treatment? Until we face up to the contradiction between profit making businesses and universal care, we will get the kind of universal care that exists in Latin America- guaranteed by the government but invisible because it doesn’t exist. The federal government can hold down insurance premiums- the companies will respond by jacking up their co-pays.

4. Better, more comprehensive care will cost MORE, not less, especially given the huge debts that most US physicians acquire during their training- they feel pressure to make money to pay off their loans quickly, just as the private healthcare companies feel Wall Street pressure to increase their profits.

[anne]

"I think their are millions of individuals and small business owners who would gladly cancel their health insurance coverage under the Obama plan. I know I would."

Definitive lunacy; we will have a insurance plan that will mean no one will need insurance other than those who need insurance but those who need insurance will need no insurance either.

[anne]

There is a peculiar sort of person who is so filled with disdain for women, so prejudiced that this sort of person must destroy the very name of a woman.

Remember, what is important is always showing how much disdain we can have for a woman.

[mike]

has anyone in here cared that hillary happens to be a woman besides anne?

[save_the_rustbelt]

"I live in a state with large rural areas, where some counties have no doctors that will accept new Medicare patients."

This is true in some areas, and for the record many Medicare patients do not have secondary coverage,either because they cannot afford it or don't understand it.

It is even worse for Medicaid patients.

Physicians need enough private insured patients paying higher rates to offset the lower rates of 'care/'caid.

[Alex Tolley]

Anne: "Dramatic saving in health care spending could readily be achieved by cutting administrative costs..."

If you recall, that was the idea behind HMOs. In practice, there was a one time drop in costs, then the double digit growth in costs resumed.

As someone who is currently paying through the nose for COBRA because I have no viable self insurance options, a non-single-payer plan will need to make insurance both available and affordable by making the risk pool much larger. As BW mentioned above, increasing the risk pool through reinsurance might be a good way to go if we must have private insurers. But I still don't understand why the government cannot offer standard Medicare policies and let the under 65's just pay for the plan?

[Callahan]

Health Care, ... it's enough to make you sick.

[Jean]

The thing about health insurance: you never know when you'll really need it. And in other news, there were more 'healthy' young men in the surgical/trauma ICU and on the surgical ward than anyone else. Young men take more chances.
Very short sighted. And selfish. I don't want to pay for your ICU stay. I've already paid for too many young mens' care.

[mike]

most individuals do not have insurance these days, it is provided through their employers. on top of that they are responsible merely for the co-pay. with the patient so disconnected from the pricing mechanism is it any surprise that the prices have inflated? why are people arguing about various plans to keep the patient disconnected, rather than having them participate more like other markets where competition keeps prices affordable?

[Cynthia]

There's an obvious plus to having a single-payer plan: fewer healthcare dollars will go toward lobbyists peddling half-baked plans, freeing up these dollars to go toward actual recipients of healthcare.

Needless to say, the aim of these half-baked plans is to keep a select few fat (unhealthy) and happy, whereas the aim of a single-payer plan is to keep the populace at large lean (healthy) and happy!

[Bruce Wilder]

Cynthia: "Plus it's sad to think that single-payer advocates must resort to such a strategy; after all, it smacks of dishonesty!"

Welcome to politics, Cynthia. The devil is in the details.

I wouldn't call it dishonesty, to recognize that politics is experimental.

If single-payer advocates do not have a political majority, why is it necessary to make the perfect the enemy of the good?

Why shouldn't single-payer advocates join a political majority to enact a half-measure, which, single-payer advocates (being single-payer advocates, after all) think will be
1.) an improvement
2.) will not be single-payer, and will, therefore, fail in important ways?

It might be dishonest to support enactment of a policy, which the advocates know would make things worse than the status quo, in the hopes that intensification of pain would motivate change. (That sounds like a Republican economic plan in a nutshell.)

I think mandates would fail just as surely as Barack's mandate-less plan would fail to achieve its goals. Either the Clinton plan or the Obama plan would be an improvement, though, a step in the right direction.

Would it be dishonest for me to support either candidate? Because I am going to support the Democratic candidate for President. I will do so after considering the alternative, which, apparently, is going to be a guy, who would rather spend $200 billion a year on a 100 years of war in Iraq, than spend an incremental $200 billion on health coverage for everyone in the U.S.

I am not, technically, a single-payer advocate; I actually don't think strict single-payer is a good idea, because of problems of scale and institutional complexity. I am an advocate of tax-financing and presumptive basic coverage, but that's a fine distinction, and many could not find the difference with advocacy of single-payer.

Medicare-for-all, the most popular form of single-payer, does not look all that appealing to me, because I see problems with Medicare's reimbursement systems and bureaucracy; Medicare's bureaucracy, though, is to be preferred to the bureaucracy of private insurers, dedicated to cutting off desperate people.

If single-payer gains traction, I am not going to ally myself with its opponents, just because I think Medicare-for-all might turn out to be less than perfect, less than utopian. If single-payer, Medicare-for-all was enacted, I would expect it to have significant short-comings. Would it be dishonest of me to support such a proposal?

To be honest in American politics, it is necessary. first of all, to be a Democrat. It was not always so, and will not always be so, but right now, to be a Republican is to be a hateful liar, or a fool, or both. To be neither a Democrat or a Republican, to just sit it out, is to be, simply, a useless fool. Just the way it is. No law of man or nature makes it so. But, it is so, at this moment.

The Democrats are running two candidates, who present themselves as relatively conservative. That's because the Democratic Party is trying to pick up relatively conservative Republicans and Repubican-leaning, who have become, in the Age of Bush, refugees from a Republican Party of torture, perpetual war, national bankruptcy, and rampant political and business corruption.

Krugman is irritated, because neither Obama nor Clinton sounds like the kind of progressive or liberal he would prefer. In the present political conditions, the Democrats should be trying to elect a candidate, who brings lots of people to identify with the Democratic Party. The goal should be, not just to elect a Democrat, but to make the Democrats the Majority Party, by drawing into the Party, people who might, in other times and circumstances, identify with the Republican Party. I think Barack Obama has a remarkable talent for being able to speak to people, who have been identified with conservative politics and the Republican Party for a generation or more. If he can undermine some of the politics of hate and resentment and reaction, which have made "liberal" a dirty word, and kept people voting Republican, I say, "go for it".

Krugman is frightened, that Obama will give away the store, that the Republicans will seize him, when he appears to give an inch, and they will seize another mile. I am not that frightened. So, when Obama brings up Social Security with people, who have been trained to think Social Security is in terrible trouble, I understand he needs to do that, to bring them into the political conversation. And, if he suggests raising the cap on FICA taxes -- which is good policy -- I say, yeah. Krugman says, nay.

Progressives will not become politically potent again by making themselves rigid and doctrinaire, in the vain hope that the Republicans can be "fought" into submission. Progressives will become politically potent by drawing the conservatives out of political alliance with the crazy reactionaries, and into conversations with progressives about incremental reforms to move the country forward. Every step will be half-a-loaf, judged from progressive aspirations (if I may mix metaphors shamelessly); the trick is to get moving and keep moving, not to freeze-up into rigidity.

I don't see the point with Krugman's hate-on for Obama. I don't see the point of arguing mandates in a political campaign.

Mandates are a half-measure, at best. At best. The only reason mandates even come up is because Democrats do not think anything better is politically possible. The task, now, is to make something better politically possible by winning an election.

[DRR]

I always thought the Healthcare problem in this country was that for so many uninsured, healthcare was simply unavailable to them, being working poor. Now I come to find out from the "Mandates or Bust" crowd that the real healthcare problem in this country is not forcing people to purchase insurance. Just do that and problem solved! Universal Coverage baby!

Create a state run healthcare system that's available to everyone and pay for it thru general taxation like every other fricken civilized nation. This could easily be done by expanding Medicare to everyone. That's the only "Universal Healthcare" that matters. A "Universal Healthcare" "plan" that consists of taking the 45 million uninsured and forcing them to purchase insurance, then bragging how you've solved the healthcare problem barely deserves the name.

[save_the_rustbelts]

The assumption that any of these plans will cause dramatic savings in healthcare administrative costs is very suspect.

In the long run, maybe? But we should not count on this for our salvation.

[anne]

"Has anyone in here cared that ------- happens to be a woman besides ----?

Evidently the rotters who belittle a woman candidate by destroying her name are completely conscious of what it is to have a disain for women and conscious of how a woman can be belittled and how other women can in turn be intimidated.

[Lafayette]

People die

Article: new estimates say that a plan resembling Mrs. Clinton’s would cover almost twice as many of those now uninsured as a plan resembling Mr. Obama’s — at only slightly higher cost. ...

Is this really the major defect of either program?

There is about 16% of the American working population that is not covered. Of those covered, there are, perhaps, 45% who have Total Coverage, which is expensive as hell. So expensive that only certain companies have the financial wherewithal to afford it AND remain competitive.

"Universal Coverage", the media sound-bite-of-the-day, is not going to solve the problem of adequate Health Care as proposed by either candidate. The WHO was very specific about the inadequacies in the American Health Care system nearly seven years ago when it had conducted and reported its Global Study.

Access to Health Care does not mean, only, universal coverage. It means what it says, "access", that is, the physical ability to get to see a doctor, which is not up to standards because hospitals are not as ubiquitous as they were when funded by local communities decades ago.

Also, there is the sad myth that Health Care coverage meant what the word says. A person is covered for illness. Well, it turns out, that depends upon the illness and, most importantly, your level of coverage.

If you've had a history of heart disease, do not expect total coverage. You ain't gonna geddit.

I hasten to add, in this context, Health Care coverage in Europe -- where 10 European countries alone figure in the top 15 -- means that you are covered irrespective of your illness and for as long as you are ill. (For instance, the President of France has just announced that Alzheimer patients will henceforth have a more complete coverage as their livability extends with modern treatment. Meaning the families are not faced with the obligation to assume the enormous cost.)

If you have cancer, expect to be treated until you die in most European countries -- even if that entails nursing costs at your home or a hospice. The modalities may differ depending upon the duration, but no one needs to sell their house in order to obtain the equity to treat a debilitating illness.

Regardless of which package is finally put up by these two candidates, neither will provide the same level of Health Care coverage as most European countries . Why not?

Because to do so would require current practitioners to lower the rates they charge. Reducing their fees means lowering their average income of $150,000 per year. These rates are so high so as to make some treatments astronomically costly. Which is why private insurance refuses to pay for them.

Which means, unfortunately, people die not only from mistreatment but non-treatment.

Will one of them be YOU?

[LJM]

It's strange how healthy young guys who don't pay for health insurance, because they say they never need it are always the ones who get hit by a truck or get shot or one of those accidental things like falling off a ladder that winds up being enormously expensive to treat. Insurance is like an umbrella. You never know when you're going to need it. Even young healthy guys can get appendicitis, serious back pain, then there are those pesky sports injuries that in knees alone keep some doctors in their McMansions. Krugman is right. Everybody has to pay to make it work.

[anne]

Alex Tolley:

"But I still don't understand why the government cannot offer standard Medicare policies and let the under 65's just pay for the plan?"

After months of national effort we have not even been able to protect the health of 3.8 million needy children, and after months of effort in Oregon the same protection of the health of needy children has been rejected.

Meanwhile compassionless conservatives preach that we need to feel more pain to really appreciate being able to have any health care at all.

So, extending Medicare as John Edwards suggested seems a long long way away.

[Bruce Wilder]

anne: "Imagine me being able to read. Duh.

"David Himmelstein and Steffie Woolhandler have not shown in the least that any state has offered a universal health insurance program with public insurance for all moderate and lower income residents and failed to increase the number of residents who have health insurance coverage."

No, they haven't. They are advocates of universal health insurance with publicly-funded insurance for all. As am I.

I quoted them, to show how poorly mandates work in creating a system, where subsidies for private insurance are combined with a requirement that poor and middle-income people buy private insurance (i.e. a mandate).

Krugman addressed himself to mandates.

Krugman's criticizes Obama on mandates as being both bad politics and dubious policy. I take the opposite position. Mandates, imo, are dubious policy, and it is bad politics to try to advocate for mandates, as if they are the sine qua none of universal health care.

In this comment thread, I have provided one article and two links to serious political commentary that backs my position. Serious commentary from people, who genuinely want to see universal health care and who want a Democrat elected, and from people, who know what they are talking about.

Anne, no one says you have to agree. You are capable of reading and reaching your own judgments. But, my comments and opinions are not such that I think I deserve your arch sarcasm. I don't object to your calling people on their nonsense. But, until I start spouting nonsense, I will expect your respect.

[anne]

Oh me oh my, I have a touch of the vapors; where are the smelling salts, Oscar?

Whether France or Germany or Sweden or Spain or Japan or Taiwan or Norway or Australia, all successful universal health care programs for all the differences they may have requite that all have health care insurance protection.

R-e-s-p-e-c-t. Duh.

[anne]

"Mandates sound terrible. That's the lesson of Obama's 'Harry and Louise ad.' "

The lesson of the ad is lie and lie again, at all costs lie, since the ad is a lie and such lies have long worked.

[how]

is the price of something like a hip replacement determined in france?

[lonesome_moderate]

There is a peculiar sort of person who is so filled with disdain for women, so prejudiced that this sort of person must destroy the very name of a woman.

Remember, what is important is always showing how much disdain we can have for a woman.

Methinks that, if she wants to be called "Clinton", then she should put the word "Clinton" on her campaign materials. In every video or still of her campaign appearances that I have seen there are many supporters holding up "Hillary" signs, with not a "Clinton" in sight.

I'm sure that Ms. Clinton has her reasons why she markets herself with her first name, some of which might even reflect unfavorably on our society. But I do not think that I am being "prejudiced" or "filled with disdain" if I simply take my cues from her as to what she should be called.

[Joe]

I think Anne may be off her meds...

[anne]

A candidate's name whether first or last is of no concern, but a prejudiced distortion of a candidate's name as used in this thread is of concern. I have no objection to tough criticism of any candidate, prejudice is different.

[anne]

http://krugman.blogs.nytimes.com/2008/02/01/obama-does-harry-and-louise-again/

February 1, 2008

Obama Does Harry and Louise, Again
By Paul Krugman

The Obama campaign sends out an ugly mailer. * Sorry, but this is just destructive — like the Obama plan, the Clinton plan offers subsidies to lower-income families. And BO himself has conceded that he might have to penalize people who don't buy insurance until they need care. So this is just poisoning the well for health care reform. The politics of hope, indeed.

"Hillary's health care plan forces everyone to buy insurance, even if you can't afford it. Is that the best we can do for families struggling with high health care costs?"

* http://www.politico.com/blogs/bensmith/0108/More_negative_mail.html

[Bupa]

anne:

"I have no objection to tough criticism of any candidate, prejudice is different."

thanks for that clarification anne. From reading your knee-jerk reaction to any person who criticized Hillary or her campaign platform (on this post or others), including the thoughtful BW, in any way as being a "peculiar sort of person who is so filled with disdain for women, so prejudiced that this sort of person must destroy the very name of a woman...." I was worried that you have become a raving self-loathing lunatic.

Hillary is a woman so if you criticize her you are an anti-woman lunatic.

Hilary is an American so if you criticize her you are an anti-American lunatic.

Hilary is a human being so if you criticize her you are an anti-human lunatic.

Hilary is a mammal so if you criticize her you are anti-mammalian lunatic.

Hilary is an animal so if you criticize her you are anti-animal lunatic.

Thank you for clarifying your position anne. I was getting worried for a while.

[anne]

Belittling a person as a woman is a vicious prejudice, and that is precisely what was done. But, there are some sad people for whom prejudice against women is beyond understanding and must even be defended at all costs.

[anne]

"Politically and practically, you cannot police the healthy poor and lower middle-class and force them to apply for and pay for insurance."

"Poor and lower middle-class" people will not have to pay for health insurance in an approach to universal health care. Poor and lower middle-class people in Massachusetts are being covered by the state.

[calmo]

Lots of heat here...tenderizing more than just the opposing race horse, yes?
So distracting...like this, now that I see the pattern and have no qualms about it: in whose interests izit that this circus never narrows the Parties' interest but only the contenders within those camps? Consider the run-off if New England would always play New York in the SuperBowl on account of the pre season sifting that only decides who is quarterback and chief waterboarder.
It appears (thar she blows!) a lot of misconduct is going under the bridge from 2 terms of colossally bad government.
Or maybe it's early yet and we will see the corruption issue resurface...and the 2nd coming.

[mike]

i think this country is perfectly ready for a woman president. i just don't think it's ready for hillary. man or woman i'd dislike her ideas just the same anners :*

[anne]

Mike:

"I think this country is perfectly ready for a woman president. I just don't think it's ready for Hillary."

Understood, and completely fair.

The argument on health care insurance broadening is whether we are willing to develop an inclusive insurance program, public or private. A partial insurance program will be self-defeating, even if insurance coverage is completely private, because unless if we are willing to abandon those needing health care there must be payment for the care.

Currently the cost of health care for those with private insurance is higher because of the need to cover the costs of the uninsured. For those willing to go with no insurance, there are still taxes to pay for public health care and should a person choosing no insurance need care there must be payment and often from the insured.

[Cynthia]

Bruce Wilder,

Sounds like you might be in favor of a voucher plan...

If I'm not mistaken, though, Israel was one of the last developed countries to take a stab at vouchers, but dropped them in favor of a single-payer plan, simply because vouchers were plagued with way too much fraud and abuse!

[Detlef]

Uhh,

just to mention it...
There are European countries without a single-payer system but with mandatory health care insurance.
Germany would be an example. Mandatory health care insurance for workers introduced in 1883.

Of course, the health care market here is highly regulated and the for-profit health insurance companies have to compete with publicly owned non-profit health care funds.
So I don´t quite understand your "horror" with mandates?

Mind you, I´m not saying that this is the best system.
But most health care discussions on the Internet seem to mention just the USA and then Canada and the UK with their single-payer systems.

@knzn:

And single-payer advocates " should support Obama, precisely because his plan won't work".
Does that mean that
a) Obama and his team are incompetent enough to device a plan that won´t work or
b) Obama and his team are knowingly advertising a plan that won´t work?

I don´t know but if I thought a German politician would try one of those two options I´d be furious. Incompetent or lying, which is worse?
Normally I associate these two words with the current Bush administration...

And how can you be sure that a failure here will bring you closer to a single-payer system? Isn´t it equally possible that a failure here would set back the whole idea of universal health care coverage for another generation?

Disclaimer:
I am not an American citizen. So I can´t vote in your primaries. I really don´t care which candidate you choose.
So forget your accusations that I´m biased against gender/race/competence/change/hope or whatsoever.

[mike]

i'm still wondering how prices are determined in a UHC plan, are they going to be set through price controls?

also does it really end up being insurance? insurance companies take premiums and invest them in the market and look for returns. is the gov going to do that? or are they just going to add up the costs of everything and hand the taxpayers a big socialized bill?

at some point an insurance company will stop spending money trying to fix someone - how will that point be set with UHC?

[anne]

"I'm still wondering how prices are determined in a UHC plan, are they going to be set through price controls?"

Prices as with any insurance system are essentially set by bargaining. Blue Cross / Blue Shield negotiates with emergency care facility managers on reimbursement and fairly recently the largest emergency care facility in Rhode Island threatened not to accept Blue Cross / Blue Shield payments. Ultimately prices are negotiated with or implicitly agreed to by suppliers from drugs on, by the French health care or veterans health care administrations.

There are all sorts of conflicts that will occur in negotiating. There was a conflict in Sweden over whether to even supply flavored anti-biotics for children as opposed to plain because of the cost difference.

[anne]

There are all sorts of differences among doctors as to which private health care insurance to accept. There is price fixing through insurance companies, but there are doctors who refuse to be part of different insurance programs. I am continually hearing about complaints over pricing or insurnace coverage for psychiatric-psychological services. Such services are evidently a problem for veterans as well.

Remember, much to my surprise, there turn out to be several million veterans and families with no access to veterans health care and no private insurance.

[bizmarts]

We should be talking about a near term goal of universal single-payer-health-care services provided by health professionals to all citizens; not wasting precious time, talent, or effort to support a gaming enterprise which has no medical abilities in therapeutic assistance.

It is perverse that popular discourse in America even allows such a conjunction as "health insurance" when one should have absolutely nothing to do with the other.

Preventative and GP level medicine is discounted or ignored by the insurance industry, while catastrophic or terminal care becomes the bogeyman from which one can be protected, completely ignoring the fact that everyone living will die with or without insurance.

Medicare, Medicaid, and the VA Hospitals, not to mention Congressional Health packages have proven to work well, with administrative costs in the single digit percentages; while HMO's and Insurance costs generally are in the 20-30% range. Worse yet, the care from the latter are generally inferior to the former; except when the Federal programs are starved for funding, or hindered from efficient operation for political reasons.

[Detlef]

i'm still wondering how prices are determined in a UHC plan, are they going to be set through price controls?

Probably. :)
Do you really think a for-profit health care insurance company doesn´t try to negotiate a lower price for themselves?
I´ve read enough posts on American blogs about health care to decide that hospital costs aren´t the same depending on your health insurance company.

also does it really end up being insurance? insurance companies take premiums and invest them in the market and look for returns. is the gov going to do that? or are they just going to add up the costs of everything and hand the taxpayers a big socialized bill?

Isn´t that too simple?
Insurance companies of course take premiums and invest them in the market.
But insurance companies also look at the risk.
If the probability of an insurance event (is that the right term) is very high, insurance companies simply would deny coverage or demand outrageous premiums. Just look at hurricane coverage in Florida etc...

I´ve read that the states there are now offering insurance for that? If true, shouldn´t you direct your outrage there?
Towards something that it already existing?

at some point an insurance company will stop spending money trying to fix someone - how will that point be set with UHC?

Actually, I opted out of the mandatory German public health care funds. I´m insured in a private for-profit health care company.

You know something?
They pay 2.1 times the amount of money a German public health fund would pay a doctor. Which is why I´m really popular in a doctor´s office in Germany.

If I don´t need the insurance for a year, they pay me back a monthly payment. Up to not needing the insurance for three consecutive years, you´ll get three monthly payments back.

Plus they are legally required to put 10% of your monthly payments in a lockbox. Helping to pay for your medical requirements once you´re old and probably sick.

Despite all this, private health insurance companies seem to make a profit in Germany. Why else would they still offer insurances?

Oh, and just to mention it.
We do have minimum requirements for all public health care funds and private companies. So you can compete on premiums or voluntarily covering additional treatments.

[2slugbaits]

Since Krugman is willing to concede that the final healthcare plan under a Hillary Clinton Administration is apt to be quite different than the healthcare plan posted on her website, why isn't he willing to apply that same logic towards Obama's plan? I think it's at least as likely that Obama's plan will move left as it is that Hillary's plan will move right. The big difference is that if Hillary Clinton wins in November she will have to try and push through a healthcare plan with a slim Democratic majority. If Obama wins, that's not likely to be a problem. In fact, Obama's problem is more likely to be Democrats wanting to push healthcare reform more towards single payer.

[anne]

Detlef, that was another excellent summary. I would trade for the German public-private health care insurance program in a moment.

[Bruce Wilder]

OK, for the sake of a better argument, I am going to switch sides, and try to make Krugman's argument for him. This should highlight what fails to convince me -- whether it is my lack of understanding or his -- and, then, maybe, someone (other than anne) can jump in, and educate me.

It is my perception that the core concern for Krugman is how policymaking, in general, has evolved during the course of the conservative ascendancy started by Reagan and continuing through the Gingrich era and, now, George W. Bush.

The general pattern is one of ruthless propaganda, tendentious analysis, authoritarian legislative tactics, and cavalier executive agency administrative decision-making. Good faith does enter into it at any stage. Proposals start out as bald-faced lies: WMD and easy victory, healthy forests, clear skies. So-called "think tanks" in Washington -- many of which consist of little more than a fund-raising newsletter, a couple of hack writers and a fax machine -- generate an alternate reality of policy analyses, full of manufactured factoids and ill-conceived speculation friendly to the narrow-minded interests of very rich folks. Congress is treated as a rubber stamp -- whatever deliberative or investigative oversight functions it might once have had are treated with contempt even by Republican members, and bills are voted without being read, earmarks multiply into the tens of thousands, so-called filibusters occur on every significant bill proposed. Finally, the executive branch carries legislation into execution with the single-minded determination of inexperienced hacks substituted in for the professional respect for law and expertise of the civil service.

There's a lot of discussion in this comment thread about whether it is right to advocate for a policy or program that will be less-than-perfect, that will, inevitably, fall short of its goals. For earnest progressives, settling for half-a-loaf is regrettable. But, for over 25 years, the modus operandi of Movement Conservatism has been the deliberate breaking of government programs, the introduction of technical errors in the design and administration of government programs.

Going way back, the S&L crisis was the result of such a "technical error" in regulatory controls. The current banking crisis and credit crunch was the result of a failure to regulate. The reconstruction of Iraq was corrupted into a catastrophe, which was nevertheless very profitable to Halliburton and Erik Prince and other Republican favorites. The Republicans enacted an incredibly costly Medicare drug benefit with a huge "donut hole" to bedevil needier recipients, while maximizing the benefits for drug and insurance companies.

Republicans, with control of the Media, have been remarkably successful in blunting criticism of their ethics-free politics and political administration of government. He said / she said journalism promotes the idea that "everyone does it". Democrats have raised a high-minded protest against Republican efforts to corrupt election processes, and Republicans have transformed that into a crusade against bogus "voter fraud", which is just an excuse to continue to elaborate Republican vote suppression efforts.

In this context, policy-making with Republicans in the room is a very dangerous business, indeed. "Bi-partisanship" is a sucker's bet. Republicans will partipate only to try to force a fatal error.

Krugman is suspicious of any Democrat, who doesn't see clearly that this is the fixed reality of politics. Krugman is suspicious that Obama's claim of personal awesome-ness in getting everyone to sing kumbaya simply signals a willingness to be taken in, in the take-no-prisoners world of Federal politics, circa 2009. And, Krugman has found the smoking gun, which is Obama's reluctance to advocate for health care mandates, and willingness to criticize Clinton's proposal, which includes health care mandates. Obama's unwillingness to embrace mandates combines with what Krugman regards as the naivete of his can't-we-all-just-get-along we're-all-purple-states-now rhetoric to yield a fatal lack of ambition and a willingness to open a door for Republicans to sink even an enacted program with a fatal, "technical error" in design.

The technical error in design associated with mandates is that without a mandate, adverse selection will mean that only the sick and those at high risk among the currently uninsured will seek coverage, raising the costs of policies for those seeking insurance. Lots of people will gamble on not paying the very high cost of a health insurance policy, and the number of insured will not rise.

There. That's it. That's the best re-statement of Krugman's argument I can make. I have filled in a lot of stuff, which never makes it into his columns, but I think it pretty consistent with his book, Conscience of a Liberal.

If I haven't gotten it right, please let me know. I have concentrated my re-statement of Krugman's argument on the tie between why going mandate-less is bad politics and bad political leadership as well as bad policy. Obviously, the paramount issue of the moment is not the technical or academic policy design question, but the issues of political leadership, ambition and trust. What Obama says about the issue is being evaluated from the perspective of what the issue says about Obama.

No where in this argument is any consideration of the alternative: whether it is sensible to trust the Clinton brand, which gave us the 1994 health insurance reform fiasco, as well as such disappointments to the liberal imagination as Republican-style welfare reform. In that sense, it may be a curiously one-sided argument. I haven't seen Krugman address the alternative, though, so I don't know how to re-state an argument I haven't read.

[Bruce Wilder]

Oops.

"Good faith does NOT enter into it at any stage."

[anne]

"The big difference is that if Hillary Clinton wins in November she will have to try and push through a healthcare plan with a slim Democratic majority."

Remember, I know the future and I know how people will vote because I know such future things because I am just that way in knowing futures. Watch me know.

[anne]

The issue is simple, a health insurance program that is not inclusive will have a markedly higher cost for the insured. A candidate however has staked a campaign, has promised, to support a health care insurance program that does not include large numbers of the healthiest people in the program. So, we have a proposal for universal health care insurance that is and will not be in any way universal or reasonably affordable.

[save_the_rustbelt]

I watched the rerun of Hillary just for kicks.

I wonder which bureaucracy will be in charge of wage garnishees of uninsured Americans?

And if the wage garnishee causes a family to fall behind on their house payments, which bureaucracy will do what in that case.

The Dems should be careful with their rhetoric, it may come back to bite them.

[anne]

http://krugman.blogs.nytimes.com/2008/02/04/dean-baker-is-wrong/

February 4, 2008

Dean Baker is Wrong
By Paul Krugman

I don't write that often. But I do have to respond to Dean's critique * of my column.

First, Obama is vaguely floating ideas about how to close the hole in his plan — nothing integral to the plan. And given the way he has campaigned on the issue, he'll have a very hard time saying after the fact, "oh, by the way, you have to sign up or there will be nasty penalties if you ever try later."

Second, the odds are good that many people still won't sign up while healthy, because they won't think that far ahead. And then there will be tremendous pressure to grant amnesty when they get sick and come in seeking coverage. Imagine someone who didn't sign up six years ago, shows up for treatment, and really can't afford insurance with a 50 percent surcharge. Are we really going to able to make that penalty stick?

Third, some of those who don't sign up when healthy won't show up for insurance for years, so that a number of people who should be paying into the pool won't.

Remember, the whole Obama position has been that if you make it affordable, they will come. Now he's saying that if they don't, we'll punish them — but only when or if they show up in distress. I don't believe this is workable.

I should also mention that if the penalties are enforced, so that people who show up seeking coverage have to pay a penalty rate, guess what will happen? A lot of people will end up deciding to forgo needed medical care. This is exactly what we're trying to avoid — and it's a far nastier outcome than anything a mandate would do.

* http://www.prospect.org/csnc/blogs/beat_the_press_archive?month=02&year=2008&base_name=krugman_wrong_on_obama_and_man

[anne]

"If Hillary actually knows any low income workers she knows that will force them into a food-or-housing choice which will result in them becoming homeless."

"The only low income workers Hillary sees on a regular basis are her servants - gimme a break."

"And if the wage garnish causes a family to fall behind on their house payments, which bureaucracy will do what in that case."

Again, and always, the intent is lying and slander for the sake of destruction.

[2slugbaits]

Anne,

I can read poll numbers, which despite New Hampshire are usually right. No one believes Hillary will win more than 53% of the vote at the top end. No one believes Hillary will pick up more than 4 or 5 Senate seats. Just look at the Clinton record: Bill Clinton won re-election but after 8 years of Bill Clinton the Democratic party was weaker than it was before he became President. The Democrasts lost the House. The Democrats lost the Senate. The Democrats lost governorships. The Democrats lost state legislatures. That's what happens to the Democrats under the Clintons.

Under Obama the Democrats have a chance to utterly bury the Republicans into oblivion. It's not out of the question for the Dems to win 10-12 Senate seats and 40-50 House seats. No way that can happen under Hillary.

Your problem is that you are fixated on Hillary winning the White House. That should not be the primary objective of this election. The objective should be to smash the GOP with big majorities in the House, Senate and across the states legislatures and governorships. Think beyond 2008.

[2slugbaits]

Krugman says: And given the way he has campaigned on the issue, he'll have a very hard time saying after the fact, "oh, by the way, you have to sign up or there will be nasty penalties if you ever try later."

What a crock. So now we're to believe that Krugman's never heard of good cop/bad cop??? Presidents use the "Congress made me do it" excuse all the time in order to reverse course.

The bigger problem is that Krugman thinks Obama's strategy is to embrace bipartisanship. If that's what he thinks, then he's hopelessly naive. Obama's strategy is to use bipartisanship as an argument to break the back of the hardline wing of the GOP. Obama is not talking about negotiating with the GOP leadership; he is talking about breaking the back of that hardline leadership and then giving the more moderate Republicans a place to go. I don't understand why Krugman is unable to see the obvious.

[anne]

The shameless idea that a person will be forced to choose between health care insurance and go without food or housing under a universal health care plan is a vicious destructive lie.

[anne]

I am a poll reader ever since I was a child and I know how to read polls like no one knows how to read polls because I learned to read polls as a poll reading child so I know how to read them better than. I am the spirit of polls future and forever. Wooo.

[anne]

http://krugman.blogs.nytimes.com/2008/02/04/electability/

February 4, 2008

Electability
By Paul Krugman

One thing I'm being told quite often is that what really matters isn't candidates' policy proposals, but their electability.

What puzzles me is, why does anyone think we know anything about electability?

If we average the last five head-to-head polls, they show John McCain on average beating Hillary Clinton by 1.2 percent. By contrast, they show John McCain beating Barack Obama by, um, 1.2 percent. As far as polling evidence goes, there's no difference right now.

Obviously things can and will change. But what's your theory of how things will change?

One theory, which is an article of faith among Obama supporters, is that Clinton will unify the GOP, while Obama can attract large numbers of Republicans and independents. If this is true, one wonders why it doesn't show up in the polls already — I mean, it's not as if Obama hasn't gotten plenty of exposure — but maybe the nomination bump, or debates, would be catalyzing events.

Another theory is that Obama, once nominated, would receive the usual treatment: conservative pundits who've had nice things to say about him will start contrasting his callowness with the wonderful manliness of McCain, the swiftboaters will spread rumors about his past, etc.. Up to now it seems obvious to me that press coverage has been far more friendly to Obama than to Clinton; once he becomes the enemy, how well will his numbers stand up?

I don't know which of these theories is right. But neither does anyone else.

[david]

Perhaps one day Anne you'll answer this key question posed by Bruce:

"whether it is sensible to trust the Clinton brand, which gave us the 1994 health insurance reform fiasco, as well as such disappointments to the liberal imagination as Republican-style welfare reform."

It's the key question, and neither you, nor Krugman, has much of anything sensible to say on until you speak to it. If she's going to run on her experience in the White House with Bill Clinton, she needs to say why we shouldn't think she'll bail at the first opportunity from her promises to the left.

The argument on mandates hasn't been much enlightened here either, but I think it's really not the argument at hand in any case. Why won't a Mark Penn fueled Clinton bail?

[anne]

Bill Clinton vetoed welfare reform twice, and there was little choice in the end but compromise. The health care reform attempt led to years of constrained costs in health care that only began to dissolve nearing the close of the Clinton Administration. The attempt at a better health care bill was defeated soundly by Republican unity and immense industry pressure that made complete Democratic support in Congress questionable.

Whoever the coming President may be, however, I would hope we understand what to expect in effort by previously declared policy intent.