Reality trips up D.C. mandates

The Washington Post reports that D.C. Council member David A. Catania (I-At Large) has reconfigured his plan to get universal health care to all D.C. residents. This is good. Catania's plan was a mandate, with a $250 fine for anyone who didn't buy health insurance, with subsidies only up to 200% of the federal poverty level - about $21,000.

George Jones, executive director of Bread for the City, shares his hopes and concerns in this May 4 article, with the piece on Blue Cross/Blue Shield's less-than-straightforward negotiations over the plan here. Jones cites Massachusetts as exhibit #1 as to whether fines work to force people to sign on for overpriced, largely worthless insurance.

Walter Smith, executive director of the public advocacy group D.C. Appleseed Center for Law and Justice, notes that Blue Cross/Blue Shield, as a federally chartered nonprofit, is legally bound to contribute to the community.

Mass Gov Looks to Single-Payer

The Berkshire Eagle reports that regarding Massachusetts' mandated insurance scheme, Governor Deval Patrick says:

"the rate of increase in premiums is a serious problem for the state system and for private individuals, families and businesses as well. . . and there's a view out there that as long as private insurance is a part of health-care reform, we're never really going to break the back of the pattern." He called for serious consideration of a single-payer universal health care solution by the next administration in Washington.

The paper cited a series from the Boston Globe outlining the state's problems with their new system, which forces people to buy private insurance. In particular, the Berkshire paper noted,

Patrick inherited inaccurate assumptions about the cost of state-subsidized health insurance from the Romney administration, which created the program along with Beacon Hill lawmakers. (It's laughable whenever the presidential flunk-out blasts "Hillary Care" as socialized medicine, since it's based largely on "Romney Care.") Patrick's budget proposal for the upcoming fiscal year includes $400 million in extra health care spending — taxpayers would be responsible for nearly half of that, with the federal government counted on to supply the rest.

With the Bush administration now seeking massive cuts in health-care and other non-military spending, the immediate prospect of relief from Washington looks bleak. A McCain presidency would amount to a Bush third term when it comes to domestic spending. A Clinton or Obama administration would produce a sea-change, but it's unlikely the federal government will be in a position to bail out Massachusetts if health care insurance spending spirals out of control.

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The state program is run by the Commonwealth Connector, which hooks up uninsured residents with the appropriate coverage. Jon Kingsdale, head of the program, told The Globe in no uncertain terms: "This is not sustainable if we don't deal with affordability." Proposed solutions are vague or half-baked at this point, ranging from a $1-per-pack increase in the cigarette tax (a great idea anyway) to help fund the state's health program to plans by a pharmacy chain to put affordable clinics in its stores to deal with basic maladies (a highly-debatable idea). Down the road, tighter regulation of hospital fees and insurance rates may have to be considered.

To put it simply, unless and until the cost of health care — much of it administrative, tied to the bureaucratic jungle of dealing with private insurance carriers — is contained and reduced, the Massachusetts reform program is in jeopardy. And this would bode ill for any universal health care program, with or without mandates, nationwide.

Mandates To Buy into a Sick System

Democracy Now has a transcript from their 8 February 2008 show with Juan Gonzalez and Robert Kuttner that includes a transcript from the Obama/Clinton debate that had the spontaneous audience applause for single-payer.

Kuttner makes excellent points on mandates -- "My point is that a mandate, in a situation where the whole system is sick, makes that sickness the problem of the individual. Instead of putting a gun to people’s heads, typically people who can’t afford good quality insurance, and saying to them, “You must, under penalty of law, or pay a tax or pay a fine, go out and find decent insurance,” it’s so much better policy to just have insurance for everybody. Then there’s no question of a mandate.

"I think it’s a very bad position for progressives to back into, because it signals that government is being coercive, rather than government being helpful. Now, we can split hairs and argue whether Obama is being principled or tactical, but I think his discomfort with the idea of a mandate is something that I applaud. I wish that both he and Clinton had gone all the way and said, let’s just to do this right and have national health insurance. I think they could have used this as a teachable moment. They could have bought public opinion around. Medicare is phenomenally popular. Medicare is national health insurance for seniors. Let’s have national health insurance for everybody."

Here's the transcript from the debate:

SEN. HILLARY CLINTON: We cannot get to universal healthcare, which I believe is both a core Democratic value and an imperative for our country, if we don’t do one of three things. Either you can have a single-payer system, or—which I know a lot of people favor, but for many reasons is difficult to achieve—or you can mandate employers—well, that’s also very controversial—or you can do what I am proposing, which is to have shared responsibility.

Now, in Barack’s plan, he very clearly says he will mandate that parents get health insurance for their children. So it’s not that he is against mandatory provisions; it’s that he doesn’t think it would be politically acceptable to require that for everyone. I just disagree with that. I think we, as Democrats, have to be willing to fight for universal healthcare.

SEN. BARACK OBAMA: What they’re struggling with is they can’t afford the healthcare. And so, I emphasize reducing costs. My belief is—is that if we make it affordable, if we provide subsidies to those who can’t afford it, they will buy it. Senator Clinton has a different approach. She believes that we have to force people who don’t have health insurance to buy it, otherwise there will be a lot of people who don’t get it. I don’t see those folks. And I think that it is important for us to recognize that if, in fact, you’re going to mandate the purchase of insurance and it’s not affordable, then there’s going to have to be some enforcement mechanism that the government uses. And they may charge people who already don’t have healthcare fines or have to take it out of their paychecks. And that, I don’t think, is helping those without health insurance. That is a genuine difference.

Amy Goodman points this out: "It’s interesting to note something Hillary Clinton says in that clip. When she mentions a single-payer system, the audience applauds and cheers, even though it’s an option rarely seriously discussed by politicians or the corporate media. And Hillary Clinton acknowledges the applause by saying, “I know a lot of people favor [it], but for many reasons [it’s] difficult to achieve.” She doesn’t explain why she thinks it’s difficult to achieve. And polls repeatedly show a majority of Americans favor it. An A.P. poll in December found nearly two-thirds of voters want universal healthcare, in which everyone’s covered in a Medicare-type program, while more than half of voters explicitly said they support single payer."

Kuttner replied that "one of the reasons that it’s difficult to achieve is the lack of leadership on the part of leaders like Hillary Clinton and, for that matter, Barack Obama. I mean, if you had Hillary Clinton and Barack Obama say, 'You know, this is an intramural debate that we should not be having, this debate about mandates; we should do this right: we should have national health insurance,' public opinion would turn around on a dime. And instead of it being this fringe idea, all of a sudden, just because the two of them had blessed it, it would become a mainstream idea, and we would be having a debate that we should have been having all along."

Amy Goodman is a national treasure.

Mandates Do Not Equal Universal Coverage

There's a well reasoned piece by RJ Eskow at Huffington Post on mandates. He points out the maddening nature of Clinton claiming that Obama's health plan isn't universal because it doesn't include mandates.

A lot of good progressive people are fooled on this. Particularly galling was the woman who wrote in some place to express her dismay over not being able to vote for Obama because she was in favor of universal health care. Geez. Eskow points out that the Massachusetts' plan is more "mirage than miracle," and that "the plan will leave 20% of that state's uninsured without coverage, and the real number may be higher. Why? Because there is a wide band of people who would suffer financial hardship if compelled to pay the premiums, and it's financially infeasible to subsidize them all."

And look at what mandates might do to a family of four. While Clinton won't tell us the percentage of income she'd tie to mandates, many analysts have been using 10%. If premium assistance is provided up to 300% of the poverty level, a family of four trying to survive on $75,000 could be forced to pay $7,500 to insurance companies or in health copayments. The alternative could be tax penalties or garnished wages. That's profoundly unfair. I also believe it's a serious misread of American political culture to think that kind of mandate could ever get through the legislative process....

Adding 10% to struggling families' financial burdens is nothing more than a highly regressive tax to be paid to wealthy insurance companies, which is why insurance companies prefer the Clinton plan.

Agreeing with the WSJ

This is a bit scary.

There is a part of me that is pretty sure that if the Wall Street Journal's certifiably malicious editorial page is against it, I'm for it.

On the other hand, I know for certain that it's wrong to garnish someone's wages or impose liens on their mortgage to force them to pay for private insurance.

The WSJ's article, misleadingly titled "Saying No to CoerciveCare" (that should be "Saying No to Coercive Private Insurance") noted that labor unions launched the last minute revolt against the mandates in California Gov. Schwarzenegger's plan and caused its downfall -- 7-1 in committee.

This defeat has national political implications. Hillary Clinton, for example, has denounced Barack Obama for refusing to include an individual mandate in his health-care plan. Yet many California unions argued that a mandate would force uninsured, middle-income working families to divert money from more pressing needs toward coverage whose price and quality they cannot control.

I'm no economist (but I'm married to one, something that leads to many, many conversations on true costs and the need for marketplace transparency, as well as mini-lectures on fixed vs. variable costs, and other truly boring matters) but the WSJ author seems to be making a leap to claim that health insurance costs have gone up in Massachusetts mandates because of heavy regulation and increased demand. Insurance costs are supposed to go down when you increase the risk pool, as supposedly happens with mandates. That's because suddenly all the healthy free riders who before had gambled that they weren't going to get sick are paying into the system. More money in the system, fewer claims per capita (because those folks are indeed healthy) and voila, costs per capita go down. Except they didn't.

The author instead seems to be suggesting that costs for health insurance would go up with increased demand in the same way that costs for a rare but suddenly popular dog breed would go up after everyone realized they wanted one.

No surprise to hear that regulations are also blamed. Those are the regulations that say that health insurers have to actually give some value for the money -- that they have to give a percentage of the value, for instance, that people in France get for their health dollars spent.

It's also no surprise that the private insurance industry cannot in fact give that kind of value for the dollars we pay them. Unless you're a shareholder or CEO. Good value received per share in that case.

The cost of health insurance went up 12 percent last year in Massachusetts -- twice the national average.

No one is escaping the financial sting. The state health-care bill for fiscal 2008-2009 is expected to touch $400 million -- 85% more than originally projected. Still the state won't be able to fully shield those it subsidizes from the premium increases. But uninsured folks who don't qualify for government help really get pounded. Before the hike, the cheapest plan for uninsured couples in their 50s cost $8,200 annually. Now, unless government bureaucrats hand them an exemption, they might well find it cheaper to pay the penalty -- up to half the price of a standard policy -- than purchase insurance. That is, pay to remain uninsured. This is legalized extortion: TonySopranoCare.

The government response to rising premiums is, unsurprisingly, price controls. The Commonwealth Health Insurance Connector Authority -- the bureaucracy created to oversee RomneyCare -- is considering prohibiting underwriters from raising premiums more than 5% for unsubsidized plans, meanwhile requiring them to cover 40-odd benefits from hair prostheses to chiropractic services. If companies can't scale back coverage, they'll have to compromise care; and the Connector is perfectly willing to assist.

As reported in the Boston Globe, the Connector is encouraging insurance companies to include only a limited network of cheaper physicians and facilities in some plans to hold down premiums. Patients who wish to see more expensive providers will have to dig into their own pockets. Dr. Steffie Wollhandler, a professor of medicine at Harvard University, worries that the Connector will revive Gov. Romney's original idea of enrolling poor people in plans that only offer access to neighborhood health centers ill-equipped to treat anything beyond routine ailments. Forcing people to buy substandard care they cannot afford is not universal care, she says. "It is a hoax." And so Massachusetts is marching toward a system of two-tiered medicine -- the alleged market inequity that universal care is supposed to cure.

Imagine that. Steffie Wollhandler approvingly quoted in the Wall Street Journal.

Clinton Won't Discuss Penalties

The NYTimes reports that in discussing her health care plan that includes forcing people to buy private health insurance:

When asked for a third time whether garnishing people’s wages was an option, Clinton told Stephanopoulos: "George, we will have an enforcement mechanism, whether it's that or it's some other mechanism through the tax system or automatic enrollments." She went on to say that enforcement of her mandate was less important than the fact that her plan requires all citizens to have coverage, while her rival, Senator Barack Obama of Illinois, would only require children to be covered, according to the article.

The issue of health care mandates has become a central topic in the Democratic primary contest because it represents "one of the few substantive differences" between Clinton and Obama, reports the Times. Clinton insists that the mandate is key to achieving universal coverage, while Obama argues that the "use of government subsidies to reduce the cost of insurance, would effectively guarantee coverage to anyone who wants it." Some Obama advisors pointed to Massachusetts, which recently implemented an insurance mandate, as an example of a state that has "failed to enroll nearly half of its uninsured despite imposing a modest first-year tax penalty of $219."

California Mandate Plan Goes Down

It was good news regarding ABX1 going down in California. Here's from the LA Times:

Senators said it was too risky a financial commitment when California faces a $14.5-billion budget gap that could force them to cut existing healthcare programs. Schwarzenegger has proposed $2.9 billion in healthcare cuts over the next 18 months.

"It doesn't matter if there are these good things in the bill if there isn't the money to pay for them," said Sen. Sheila Kuehl (D-Santa Monica), who chairs the health panel and has proposed that the state take over the role of providing medical insurance. "We can't simply say to the people of California, 'Go buy insurance.' "

The defeat may be a poor omen for national efforts to overhaul the country's healthcare system. The three leading Democratic presidential candidates -- Hillary Clinton, Barack Obama and John Edwards -- all have proposed similar programs aimed at expanding private insurance while allowing people who have coverage they like to keep it.

The NYT also had a story on this, with this great quote:

“I just came to the conclusion that the working people are going to end up paying for it,” said Senator Leland Yee, Democrat of San Francisco, who announced his opposition before a committee meeting last Wednesday. “There’s control for everybody else — the employers are protected and the insurance industry. The only group that’s vulnerable is the working people.”

I understand that good people believe that mandates can work. Good, smart people, in fact, who've been at this far longer than I have. But that's part of the problem. These good folks are still shell shocked from the last battle. We can't fight the last war. Conditions are different now. More people have been hurt, the insurance industry has very little credibility. It may well be that we have to do this incrementally. But forcing people to buy private health insurance policies from for-profit companies is a deal killer.

Gooz on mandates

From Merrill Goozner's Gooznews: on forcing people to buy private insurance:

... according to the Boston Globe's Health Blog, the intellectual architect of the Mass plan, Jon Gruber of the Massachusetts Institute of Technology, is admitting that a mandate can only work if there are sharp penalties attached to it since many low- and moderate-income households, even with subsidies, can't afford health insurance on their own. It's also likely that some young, healthy workers will skip buying insurance if they can get away with it. "The mandate has to be enforced," he told the paper. “We need to think beyond what looks mean and do what’s right.”

This is a prescription for dooming any national effort for universal coverage. We're going to impose heavy penalties on people who are already having a hard time paying their bills? Don't forget that the bare bones plans they will buy to meet the minimal insurance standards will probably have high co-pays and deductibles. From the perspective of a moderate-income person whose employer doesn't provide health insurance and who doesn't qualify for subsidies, this will cost them more money for the same care they now receive (emergency room care). The only difference is that they won't have the bill collector hounding them (or the hospital forgiving the bill) after they receive care. What kind of plan is that?

I've heard that before -- "This mandate has to be enforced. We need to think beyond what looks mean and do what's right."

Wasn't that Pol Pot's motto?

Slippery slope.

(Whoops. Did that look mean?)

Sarkisyans: Insurance Is Not Healthcare

The California Nurses report that the Sarkisyans testified yesterday against Gov. Arnold Schwarzenegger's ABX1.1 mandates bill. After their insured, 17-year-old daughter was denied a transplant, it's the Sarkisyans' experience that insurance isn't the same thing as health care.

How many of us must lose loved ones before this murderous industry is stopped?

How many families must become activists before our neighbors see that it could be them next time -- and act upon that understanding?

I've become a skipping dvd on this issue. The idea that forcing people to pay for-profit insurance companies is part of a solution to our health care crisis is like thinking that forcing shopkeepers to pay protection money to the Mafia is a solution to a crime wave. Which is what the health insurance industry is. A legalized crime wave.

Thank you to the Sarkisyans for taking their anger and grief and using it for good. It would be easier, and possibly more mentally healthy, to just forget about it. But how to save other 17-year-olds from the same fate, then? Thank you to the Sarkisyans.

Health care: a shared responsibility

Reponsibility without authority in your work is the worst of all worlds. In health care too -- and yet that's exactly where we are right now. No wonder we're so stressed. The guys with the authority, the health insurance companies, have but little responsibility. Their responsibility is to their shareholders, and they're doing just fine in that department, thank you very much. Individuals, on the other hand, are told time and again that it's up to us to find that job with good benefits, to exercise and eat healthily (amidst all the conflicting advice from experts -- wine or no wine? Coffee or no coffee? Fish or not too much fish? Vitamin C helps with colds or doesn't it?), to understand insurance policies that even lawyers can't make heads or tails of (that's the point), to hire advocates to look out for our interests with providers and insurers (or to tell our insurer that we're close personal friends with Michael Moore) -- and so on.

The public knows we need reform, but what kind of reform? That scary single-payer? Mandates forcing everyone to buy insurance from the same people who seem to be at the root of the problem? Expanding access to SCHIP? Insurance market reform? HSAs? The Commonwealth Fund released a survey of Americans' views earlier this week. Ezra Klein and the media largely picked up on the question that showed 68 percent of Americans favoring mandates forcing individuals to buy private insurance (with the government helping those who are unable to afford it).

There's more to the survey, however, beginning with the fact that support for mandates included soft support:


There is stronger agreement that financing for health insurance coverage for all Americans should either be paid mostly by the government or else be a responsibility shared by employers, government, and individuals:


Most single-payer supporters, by the way, would probably answer that question along with the majority -- that costs should be shared by employers, the government, and individuals -- as is true in most countries with guaranteed health care. Personal responsibility is an important part of the single-payer message.

Note that the portion believing that the government should "mostly" pay for health care costs is 15 percent of the total, versus 6 percent who think those costs should be "mostly" paid by individuals.

One more chart from Commonwealth Fund -- which is a treasure trove of charts in powerpoint and pdfs formats. This one shows the percentage of Americans who think there should be a business mandate:


Quite a bit higher than the numbers in favor of an individual mandate. When single-payer groups around the country have written single-payer bills and proposals (like the one modeled here in Colorado), they typically discover what we did -- that to pay for the program it's necessary to collect contributions (a tax, premium, whatever you want to call it) not only from individuals but also from businesses.

The business task force to the Colorado Blue Commission for Health Care Reform told commissioners that they could live with a 4 to 6 percent tax in order to fund health care. That would be far more affordable than the average of 10 to 12 percent they now pay -- and the quotes of 25 percent that smaller businesses with older employees regretfully decline, leaving their employees uninsured. The task force told the commission that they'd been surprised to learn the truth about single-payer during their meetings, and that members had said they could indeed support a single-payer plan. They just thought it needed to happen at a national level rather than a state level -- something with which HCAC disagrees.

Back to what kind of reform is needed. Health care is a devilishly complicated subject, encompassing many variables. It's no wonder that most people hope that the experts will hand us a solution, no wonder that folks are misled by ideologues and obscenely wealthy special interests. But consider this. At the National Congress for the Un- and Underinsured last month there was exactly one speaker among dozens who unambiguously called for single-payer. David Himmelstein, MD, told the crowd of health policy professionals and academics that single-payer financing for health care is the only sustainable, workable solution that will give Americans the kind of quality health care we want.

There was also exactly one standing ovation at this entire conference of health care policy wonks.

It was for Dr. Himmelstein.

250 Mass docs call for single-payer

The California Nurses report that Doctors Give Massachusetts Health Reform a Failing Grade - Poor Early Outcomes Raise Red Flags, Only Private Insurers Profit.

You don't say.

Starting January 1, 2008 Massachusetts residents face fines if they cannot offer proof of insurance. Yet as of December 1, 2007 only 37% of the 657,000 uninsured had gained coverage under the new program. These individuals often feel well served by the reform in that they now have health insurance. However, 79% of these newly insured individuals are very poor people enrolled in Medicaid or similar free plans. Virtually all of them were previously eligible for completely free care funded by the state, but face co-payments under the new plan. In effect, public funds for care of the poor that previously flowed directly to hospitals and clinics now flow through insurers with their higher administrative costs.

Among the near poor uninsured (who are eligible for partial premium subsidies) only 16% had enrolled in the new coverage. And barely 7% of the uninsured individuals with incomes too high to qualify for subsidies had enrolled according to the official state figures. Few can afford premiums for even the skimpiest coverage; the lowest cost plan offered for a couple in their fifties costs $8,200 annually, and carries a $2,000 per person deductible.

Moreover, the state's cost for subsidies is running $147 million over the $472 million budgeted for fiscal year 2007. Meanwhile, collections from fines on employers who fail to provide coverage are 80% below the original projections. The funding gap will widen in future years as health care costs escalate and insurers raise premiums. Already, state officials speak of making up the shortfall by forcing patients to pay sharply higher co-pays and deductibles, and by slashing funds promised to safety net hospitals.

While patients, the state and safety net providers struggle, private insurers have prospered under the new law, and the costs of bureaucracy have risen. Blue Cross, the state's largest insurer, is reaping a surplus of more than $1 million each day, and awarded its chairman a $16.4 million retirement bonus even as he continues to draw a $3 million salary. All of the major insurers in our state continue to charge overhead costs five times higher than Medicare and eleven-fold higher than Canada's single payer system.

Americans favor mandates

Ezra Klein reports on a poll finding that 68 percent of Americans agree that "individuals should be required to have medical insurance, with government help for those who cannot afford it."

So 68 percent agree that underinsurance and gouging is the answer?

I don't think so. I think that people just really want this to be someone else's problem. Like -- the uninusured!

What the hell is single-payer?

On Saturday I was cold-calling in person at a conference, approaching people and asking them if they were for single-payer universal health care. It's a bruising thing to do, because you're not insulated from people who are annoyed by your invading their space and people who disagree with your message.

But it's also instructive.

One guy was impatient. "What's single-payer?" he asked. "What is that?"

I began to explain and he cut me off after less than 10 words, saying his life was too short. "You mean socialized medicine," he informed me. "Why don't you just say 'socialized medicine'?"

He went on to say that to him, single-payer is what we already have. He's the single-payer for his health care.

He was so arrogant, dismissive and nasty that I was left reeling -- and wondering what he was doing at a "Faith in Action" conference. I suppose this is why the "heartland" feels the way it does towards academics, because that's all I could imagine that he was. But trying to put it into perspective, his observation was a good one. It's not something that we didn't already know, but it's a confirmation, once again, that the term "single-payer" is a head scratcher.

Guaranteed health care might be better. How would we describe the police or fire departments? Guaranteed police or fire? Universal police protection... with single-payer financing? State police protection? Municipal fire protection? Government-sponsored health insurance?

George Lakoff likes "doctor- and patient-run health care" -- like citizen- and police -run policing?

Or, back full circle, universal health care with single-payer financing?

I'm reminded of the Family Research Council employee who got a month sabbatical to go work for Huckabee. He said that among the things he learned were that the mainstream media were far more fair and balanced than the right-wing media, and that whenever people asked for real information, not just a soundbite, their attention would be gone after 30 seconds. And those were people who wanted to pay attention.

People want things to be easy. We want someone else to have to make the changes, to do things differently, in order to better the system. Mandates are just the ticket for that in many politicians' eyes. Since the majority of Americans do already have Medicare or employer-sponsored insurance, it's a siren call for them to hear that if we just force the uninsured to buy insurance out out-of-control costs will be solved.

They won't be.

Cost-shifting (providers charging insurance companies more to make up from losses elsewhere) is only part of the problem, and only a small percentage of cost-shifting is due to the uninsured. The rest is from Medicare and Medicaid. But even if it were mostly from the uninsured, who really thinks that companies and families would reap the benefits of forcing everyone to buy insurance -- who really thinks the insurance companies would turn around and lower their costs? This is one of the most profitable industries in the world -- has that led them to step back and reconsider their profit margins?

But from what I heard Saturday, a number of people, especially elderly women, are enthusiastic about forcing poor single moms to buy insurance. These seniors were also outraged about their personal out-of-pocket costs.

CA single-payer urges support for ABX 1 1

Stephen Schear gives a paragraph of his credentials as a single-payer supporter before urging Californians to reconsider and support the Schwartzenegger mandate plan, ABX1 1. (Why the name that sounds like a Reagan era star wars weapon?) His credentials are good. His support of ABX1 1 is unconvincing.

Schear's reasoning is that the Schwartzenegger plan will ease the transition to single-payer.

"Repeated polling, focus groups and experience have demonstrated that fear is the emotion that keeps most voters from supporting proposals for universal health care, including single payer."

Schear thinks that somehow forcing more people into private insurance will make them less afraid of single-payer, and ease the way to its eventual enactment. I read this article wanting to see his point — but it's not congealing. He writes:

"...The mandate for private health insurance is relatively meaningless, especially since ABX1 1 includes a provision that people can be excused from the mandate if buying health insurance would constitute a financial hardship. The government is not going to prosecute individuals for a lack of health insurance. The other “problems” with ABx1 1 are only problems if you compare ABX1 1 with single payer. Although there is not much in the way of cost control in ABX1 1, at least it requires insurers to spend 85% of their premiums on health care, a small advance in limiting private insurance waste. ABX1 1 will not achieve universal coverage, but it expands coverage far more than any legislation since Congress passed Medicaid and Medicare in 1965."

How can a mandate, further strengthening the key malignant element in our system, be meaningless?

Robert Reich stands on his head

Robert Reich writes a column in the Wall Street Journal complaining that mandates are nothing, meaningless, the least of our worries as progressives stand on the crest of the victory of universal health care. Or at least universally forced subsidization of the insurance industry.

But instead of celebrating, the candidates and left-leaning pundits are squabbling over whether the plans should include so-called mandates that require everyone to purchase health insurance. Talk about self-inflicted wounds. Mandates are a sideshow, and fighting over them risks turning away voters from the main event.

He doesn't address whatsoever the fact that with mandates all that's wrong and unsustainable with the American system is preserved and strengthened, in particular underinsurance and the out-of-control costs that don't provide care but only enrich a failed industry.

The WSJ article stands on its head what Reich got right about single-payer just a year ago:

... three cheers for the politician who bypasses America’s inefficient private insurance market and establishes a single payer that provides all Americans with health insurance just as good as the health insurance their representatives in Congress receive free of charge. Note I said single payer, not single provider. Americans want to keep their choice of doctor and hospital. But a single payer – either through Medicare or the federal employee’s health insurance program – would avoid the current insanity by which private insurers spend hundreds of millions of dollars a year advertising and marketing to younger and healthier beneficiaries, and seeking to discourage older and riskier ones, or people with pre-existing medical conditions. America now has the only health-insurance system in the world designed to avoid sick people.

None of that will change with mandates.

The other main point of that article was that the one good thing about Bush's health plan was that it would spell the end to employment-based healthcare — and good riddance, Reich wrote. Now, suddenly, it's to be strengthened, and we're supposed to cheer that. Inconceivable.

Policy wonks like mandates

Jonathan Cohn of the New Republic blogs that he doesn't understand the reaction to mandates from progressives: "I confess I've been a bit taken aback at the hostility it generates even from the left (which, perhaps, Obama anticipated).... the main complaint about mandates is that people are being forced to buy private insurance. But Clinton and Edwards both make a public plan available to anybody who wants it. Not only does open the door to a full-single payer plan down the road, it also guarantees that anybody who doesn't trust private insurance can get into a better option."

WSJ on mandates

The Wall Street Journal, like most right-wing echo chambers, gets part of the healthcare debate right. They note that a main difference between Obama's plan and the plans proposed by Clinton and Edwards are mandates. Clinton

said on Saturday that Mr. Obama "proposed a health-care plan that doesn't cover everybody." Mr. Obama counters that the reason many people aren't insured is because they can't afford it. Supposedly he is "echoing right-wing talking points," but he is more accurately echoing reality.

The editorial goes on to make the ludicrous claim that insurance would be affordable if it weren't regulated.

Republicans still aren't reality-based are they? I don't regularly read it: Has the WSJ come out yet to claim that the mortgage industry's woes are due to being so heavily regulated? The WSJ goes on to posit that

For "progressives," Mr. Obama's lack of a mandate is a kind of betrayal. Their political goal is to use incremental steps to gradually achieve a government-run health-care system--and Mr. Obama's steps aren't grand enough.

That does make me wonder about what healthcare progressives who have been bludgeoned into being "moderates" and "realists" think about Obama. I doubt that they feel betrayed. More likely inspired and hopeful. The WSJ thinks that healthcare is

one of the few cases where [Clinton's] triangulating produced a policy position more ambitious, and more leftward, than Mr. Obama's. [Liberals] also highlight her history as an agent of "change," if you consider Mrs. Clinton's calamitous 1994 failure with HillaryCare to be helpful experience. She's betting that Democratic primary voters will give her credit for having tried.

It seems rather to me that Clinton gets credit for the 1993 debacle in good ways and bad. She went through it, learned a lot, and likely would win change this time. Unfortunately, the change wouldn't be reform. She got beat up badly enough that she has a gut understanding of the power of the status quo — and has taken about $1 million from them at this point. Clinton does seem pretty well entrenched in the neoliberal camp. The WSJ might not like mandates, but the insurance industry sees mandates as something they could certainly live with. It's called making lemonade out of lemons.

Leaving American families with the bitter rinds.

Republican candidates talk health care

Republican talking points on health care as displayed at the New Hampshire debate last night:
(List points and discuss which elements are correct, which need rebuttal. Test Monday!)
DR. TIM JOHNSON, ABC MEDICAL EDITOR: In general, Republicans have criticized Democratic proposals for health care reform as radical expansions of the federal government's role. But many health care experts say that it is actually the Republicans' emphasis on individuals buying their own policies versus getting their insurance through employers that is a more radical change. And it raises concerns. Individual policies can be more expensive for the same coverage because of administrative overhead and sales costs.

Group policies like those provided by employers can bargain with providers for lower costs and do a better job of monitoring quality. Medical professionals caution that individual insurance may sound good on paper but it usually turns out to be very difficult for people, on their own, to find quality policies at the right cost.

GIBSON: ... We're the only industrialized nation in the world that doesn't insure all of our citizens. If we can afford a trillion-dollar war in Iraq, why can't we afford medical insurance for everybody?

GIULIANI: The reality is that, with all of its infirmities and difficulties, we have the best health care system in the world. And it may be because we have a system that still is, if not wholly, at least in large part still private.

To go in the direction that the Democrats want to go, much more government care, much more government medicine, socialized medicine, is going to mean a deteriorated state of medicine in this country. I mean, I said, jokingly, in one debate, if we go in the direction of socialized medicine, where will Canadians come for health care?

GIBSON: But do you all agree that we have the best health care system in the world?

MCCAIN: Now, tell me when people get sick where they come to to get health care...

GIULIANI: Charlie, that doesn't mean it shouldn't be improved. And I think that the notion of people buying their own private health insurance is a very good one, so long as a lot of them do it. Only 17 million Americans right now buy their own health insurance. If 50 million Americans were buying their own health insurance, because it would be just as tax advantageous to do it that way, and we had a health savings account, people -- economists believe there'd be a 30 percent to 50 percent reduction in the cost of health insurance, and quality would come up. The only thing that reduces cost and increases quality is a significant, dramatic, large consumer market, not government control.

GIBSON: You all have proposed free market, consumer-purchased insurance. And you all talk about giving tax deductions for buying insurance. Let me do a little math. The average family employer-provided insurance, when the company's buying, it's $13,000 a family. Now, you talked about a $15,000 to $20,000 deduction -- right? -- for people buying their own insurance. If you take a median-income family of $62,000 in this country, you've just saved them $3,000 on their taxes. That doesn't come close to buying an insurance policy.

MCCAIN: Sure. And next year, if you continue 10 percent inflation associated with it, it'll be even further away. And the next year after that. Because the problem with health care in America, it's not the quality. It is the inflation. And in all due respect to your expert that we just saw, he's talking about the wrong aspect of this issue. The right aspect of this issue is inflation, if we could get it under control and get it reduced so that health care costs are reasonable in America, then those people will be able to afford it... But we have to make the recipient of the health care more responsible. We have to have outcome-based results for health care. We have to emphasize wellness and fitness. One of the most disturbing things in America is the increase in diabetes, obesity and high blood pressure amongst younger Americans. So we have to award wellness and fitness...

But, again, you made a statement about European nations, they all get health care. Well, some people here in New Hampshire have been to Canada. I don't think they want that system.

ROMNEY: ... [after boasting about the Mass. plan] And where the doctor -- good doctor was wrong is that it's true the insurance companies don't want to sell policies to one person at a time. It's expensive. We established what we called a connector, a place where individuals could go to buy policies from any company, and that connector would in turn send their premiums on to those companies. So the economics of scale existed. And as a result of what we did, the premiums for health insurance for an individual buying insurance went from $350 a month to $180 a month, with lower deductibles and now with prescription drugs.

We don't have to have government take over health care to get everybody insured. That's what the Democrats keep on hanging out there. The truth is, we can get everybody insured in a free market way. We don't need Hillary-care or socialized medicine.

PAUL: Charlie, you really answered the question -- you answered it in your question, because you said, "How can we afford a trillion- dollar war and we can't afford health care?" Well, that's the reason. The resources are going overseas. We're fighting a trillion- dollar war and we shouldn't be doing it. Those resources should be spent back here at home. There is an inflationary factor. We can't afford it. We do have good medical care, but the costs are so high now that our people in this country are actually going to India and getting their heart surgery done. They pay the plane ticket, the hospital and the hotel and they get it for half-price.

So it's inflation, but if you don't understand how inflation comes, we can't solve this problem. It comes from deficit financing with this war-mongering foreign policy we have. We run up the deficits. We tax. We borrow. We borrow from the Chinese. We can't borrow enough. Then what do we do? We print the money, and then you wonder where the inflation comes. The value of the dollar is down and the prices go up, where the government gets involved in certain things like housing or medical care or education, prices are skyrocketing. So you have to deal with the monetary issue to solve the problem of the medical issue.

THOMPSON: Ahem. ... So if we would stop printing so much money, we could get out of the war and provide health care to everybody.

We've got the best health care in the world. It costs more than it should. We can either go one of two ways. We can let the government take it over, and that'll lower costs, like they do in other countries. We will also sacrifice care, which nobody wants to do -- we're not going to do, in this country.

Or we can make the markets work more efficiently. There are a lot of components to that. Part of that is not just giving a tax break to the individual. That's part of it. But it's also putting them in a position to get the best prices for the care they're getting. We do that in every other aspect of our life. That's what keeps prices as low as they are. I mean, if the consumer had no concept of what the product was costing and did no shopping for it, when you could get an MRI here for one price or over here for half the price, you don't even know that to make the choice. It wouldn't work at all. So you can do that. You can open up these markets so a person can buy their insurance from all over the country. We've got various state regulations now, that, as a practical matter, prohibit that. Make the markets work.

But we're never -- let's be honest with the people. We're probably never -- if you lower costs, more people who want insurance will be able to afford it. We're probably never going to achieve total coverage. A good number of the people who are uninsured can afford it and choose not to do so. A good number of people who are eligible for government assistance, and choose -- can manage and choose not to.

GIBSON: But Government Romney's system has mandates in Massachusetts, although you backed away from mandates on a national basis.

ROMNEY: No, no, I like mandates. The mandates work.

THOMPSON: I beg your pardon? I didn't know you were going to admit that. You like mandates.

ROMNEY: Let me -- let me -- oh, absolutely. Let me tell you what kind of mandates I like, Fred, which is this. If it weren't...

THOMPSON: The ones you come up with.

ROMNEY: Here's my view: If somebody -- if somebody can afford insurance and decides not to buy it, and then they get sick, they ought to pay their own way, as opposed to expect the government to pay their way. And that's an American principle. That's a principle of personal responsibility. So, I said this: If you can afford to buy insurance, then buy it. You don't have to, if you don't want to buy it, but then you got to put enough money aside that you can pay your own way, because what we're not going to do is say, as we saw more and more people...

THOMPSON: The government is going to make you buy insurance...

ROMNEY: No, the government is going to stop...

THOMPSON: ,.. and make you pay -- I mean, the state -- your state plan, which is, of course, different from your national plan, did require people to make that choice, though. The state required them to do that. What was the penalty if they refused?...

ROMNEY: ... It actually applies to people at three-times federal poverty. They pay for their own policy. At less than three-times federal poverty, we help them buy a policy, so everybody is insured, and everybody is able to buy a policy that is affordable for them. The question is this, again, if someone could afford a policy and they choose not to buy it, should they be responsible for paying for their own care? Or should they be able to go to the hospital and say, "You know what? I'm not insured. You ought to pay for it."

What we found was, one-quarter of the uninsured in my state were making $75,000 a year or more. And my view is they should either buy insurance or they should pay their own way with a health savings account or some other savings account.

... I think my plan is a good plan that should be adopted by other states.... I would not mandate at the federal level that every state do what we do. But what I would say at the federal level is, "We'll keep giving you these special payments we make if you adopt plans that get everybody insured." I want to get everybody insured....

HUCKABEE: I think it's important to realize that the issue is not just insurance. The issue is that the whole model of our health-care system is upside down. We really don't have a health-care system. We have a disease- care system. And the insurance model that we use, we act like that if we insured everybody, we've fixed it. We haven't. Because the real problem is that our model, both in the insurance model and the health-care model, waits until people are catastrophically ill before it intervenes. And we really have to change the concept to a preventive focus rather than an intervention focus. And that means the entire system starts working on health and wellness, because 80 percent of the $2 trillion that we spend on health care goes to chronic disease. We could prevent it or we could cure it, but we don't. So it's not an issue of there's not enough money to cover people. But if a real health care system exists, it has three components: It has affordability, it has quality, and it has accessibility.

And if it doesn't have those elements, it's not a system; it's a maze. And what we have in America is a health care maze. It's built on the idea that we wait until people are so desperately ill that the cost to try to fix them is catastrophic and out of control. And no wonder we have a system that needs major, major attention. And by the way, just out of due respect, you said $1,000 for a repair. It's about $1,000 for a Kleenex at a hospital anymore. And that's why we need to have a totally different system that keeps you from going to the hospital in the first place.

GIULIANI: Charlie, a health savings account actually helps to accomplish what the governor is talking about. If somebody can put aside -- and the plans that we've been talking about include a health savings account. You'd have an exemption up to $15,000. If you could find a policy for $11,000, you can have a $4,000 health savings account. You would be able to buy some of your health care and your prevention yourself. It gives you an incentive over a lifetime to deal with wellness.

GIBSON: ... Look, if you're going to control costs, you got to do three things. You're going to limit access to technology, you're going to limit, in some way, change the reimbursement system for doctors and hospitals, or you're going to have to limit the amount of treatments. That's the only way we can bring costs down. And that's the third rail of health care. Which of you is going to touch any of that?

HUCKABEE: Charlie, that's not at all the way it is...

MCCAIN: I think that there's additional choice here: a choice of having outcome-based treatment. There are five major diseases that consume 75 percent of health care costs in America. If someone has diabetes, we should give the health care provider a certain amount of money and say, "Care for that patient. And if, at the end of that period of time, and that patient is well, we'll give you a reward." Rather than every test, every procedure, every MRI. And we need walk-in clinics, and we need community health care, and we need incentives for home health care as opposed to long-term care. In my state of Arizona, we adopted a proposal which incentivizes health care providers to keep people in home health care settings -- dramatically less expensive than long-term care. In Arizona, we have one-half the number, per capita, of people in long-term care facilities as the state of Pennsylvania.

Incentives to keep costs down, Charlie. There are no incentives in the system today.

Could I just mention one other thing? Both the attorney general of South Carolina -- I don't know why I mention South Carolina... and the attorney general of Iowa ... have sued the pharmaceutical companies because of overcharging of millions of dollars of Medicaid costs to their patients. How could that happen? How could pharmaceutical companies be able to cover up the cost to the point where nobody knows? Why shouldn't we be able to reimport drugs from Canada? It's because of the power of the pharmaceutical companies. We should have pharmaceutical companies competing to take care of our Medicare and Medicaid patients.

ROMNEY: OK, don't leave me. Don't send the pharmaceutical companies into the big bad guys.

MCCAIN: Well, they are.

ROMNEY: No, actually they're trying to create products to make us well and make us better, and they're doing the work of the free market. And are there excesses? I'm sure there are, and we should go after excesses. But they're an important industry to this country. But let me note something else, and that is the market will work. And the reason health care isn't working like a market right now is you have 47 million people that are saying, "I'm not going to play. I'm just going to get free care paid for by everybody else." That doesn't work.

Number two, the buyer doesn't have information about what the cost or quality is, or different choices they could have. If you take the government out of it to a much greater extent, you'd get it to work like a market and it will rein in cost.

Obama on mandates

From the ABC Democratic debate:
CLINTON: ... You know, Senator Obama has been -- as the Associated Press described it, he could have a pretty good debate with himself, because four years ago, he was for single-payer health care. Then he moved toward a rejection of that, a more incremental approach. Then he was for universal health care. Then he proposed a health care plan that doesn't cover everybody.

OBAMA: I have been entirely consistent in my position on health care. What I said -- and I have said on the campaign trail this time -- is if I were designing a system from scratch, I would set up a single- payer system, because we could gain enormous efficiencies from it.

Our medical care costs twice as much per capita as any other advanced nation.

But what I've also said is that, given that half of the people are getting, already, employer-based health care, that it would be impractical for us to do so, which is why I put forward a plan that says anybody can get health care that is the same as the health care that I have as a member of Congress -- similar to the plans that you and John have offered.

We do have a philosophical difference. John and yourself believe that, if we do not mandate care, if we don't force the government to get to -- if the government does not force taxpayers to buy health care, that we will penalize them in some fashion.

I disagree with that because, as I go around town hall meetings, I don't meet people who are trying to avoid getting health care. The problem is, they can't afford it. And the costs are too high. And so, as a consequence, we focus on reducing costs. Now, this is a legitimate argument for us to have, but it's not true that I leave them out. Your premise is, they won't buy it even if it's affordable. I disagree with that.

Walmart & Healthcare

Walmart Watch has a piece up on a Walmart employee who was hit by a semi and left brain damaged. The store paid out half a million in healthcare costs, and the family sued the trucking company so she could get nursing home care. The family won about $400,000, which Walmart promptly sued them for, since they had a subrogation clause in her health insurance policy.

What? You don't know what subrogation means?

I'm pretty sure that's part of the point. You're not supposed to know.

Walmart is cast as the bad guy in most of the blogging on this, but in fact they're not alone. Obviously we're the bad guys too, if we can't rid ourselves of a healthcare system that ruins people but protects big business and profits.

Oh, but it's not feasible according to MoveOn, ProgressNow, and the Dems.

So, taking a page from ol' Mitt Romney's playbook, the so-called progressives turn to mandates — which force people to buy junk insurance from an industry that has proven itself to be incapable of providing healthcare at a fair cost but very good at making profits.

How would Deborah Shank's family have fared under mandates? No difference. None at all. The Shanks' had insurance. They're still ruined.

Mandates are a sham. Subsidization of a corrupt private, for-profit industry.

Fascism, in fact.