Individuals get sick, therefore they should pay for health care. Costs for this service are massive and unpredictable, therefore insurance is the best payment approach. We’ve made a social decision not to let people die in the streets, therefore insurance must be mandatory.
Continuing down the employer mandate road will exacerbate the problems of our system at a national level and, if adopted unilaterally by Massachusetts, give our competitors, from Indiana to India, an advantage they will exploit. The result will be a relative loss in jobs and income. Employer mandates also offer no structural answer for people who work outside the wage economy, such as home-makers, and the unemployed.
The objective is health care for all. The best way to make that happen is to adopt the most efficient possible solution in which (a) everyone is treated equally at a basic level, because every life is precious, and (b) individuals can choose the providers that best meet their needs, because that will create market discipline. The most realistic way to achive those goals is to work within the existing insurance system; sever the inefficient and fundamentally irrational connection between employment and health insurance; and provide assistance to the least well off to help them purchase insurance.
The devil is in the details. A national health care system — the system adopted in most of the developed world — would be best of all. In the harsh world we live in, however, I believe mandatory individual health insurance with public assistance for the least well off is the most realistic way to broaden coverage, save money, and make the state health care system more efficient. Pushing employer mandates will just result in delay and ever-more-complex regulatory proposals because fundamentally it doesn’t make sense.
greg says
This post reads like a long list of conclusions, desperately lacking evidence, premises, or reasoning. I’m not saying I disagree, necessarily. It’s just impossible to evaluate a conclusion in the absence of its justification.
stomv says
Why do you think that employer mandates will drive down employment but individual mandates won’t? After all, don’t you think employers look at the total cost of living in the area when considering where to open shop? Furthermore, it’s not really a coincidence that states with low cost of living are growing faster than states with high costs of living.
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By enforcing a(n unethical) mandate, you’re driving up the cost of living, further exacerbating the dillema that Massachusetts is the only state in the Union actually losing population. What will we do for tax base with people leaving — and pushing down taxes collected as well as property values, a double whammy?
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The argument that a tax on businesses is bad but passing that cost directly onto workers is good is foolishness. While I agree that increasing coverage will be good for a number of reasons, I don’t think requiring those who are currenty uninsured (read: not well employed, and hence generally broke) to start shelling out for insurance is more responsible than requiring the largest companies to cover their own employees.
daves says
There is a lot not to like about employer based health insurance, too. Workers lose coverage when they get laid off. Different employers may have different plans, causing distruption when workers change jobs. Premiums and employee cost sharing amounts vary from employer to employer. Because some employers don’t or can’t offer coverage, job mobility is reduced. Employers are given powerful incentives to descriminate against workers who may get ill, workers who elect family coverage, and workers whose family members become ill. The system reduces medical privacy. Its killing the budgets of our cities and towns.
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Its a lousy system and a historical accident. Almost all employers would love to figure a way to get out of the health benefits business (hence, the rise of “consumer driven” healthcare plans). Even employers who are screwed by the current Massachusetts system (they pay a big percentage of the premium, plus a surcharge) fear a mandate that will bake the current system into law forever. They dislike getting screwed, but they fear mandated employer based health coverage even more.
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Our current system is very, very broken.
stomv says
… that linking employment to insurance is nonsensical in a time when employee turnover is much higher than a generation ago, and employers are far more likely to use contractors and other non-permanent employees. Add to this that the “service economy” results in far more self-employed types, and it’s crazy.
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But, legally requiring a large set of individuals to enter a legally binding contract with a private contract is tyranny. There are no other instances where this has ever happened in tUSA to my knowledge.
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Car insurance? Nope. You don’t have to own a car.
Eminent domain? Nope, at least not until recently, and that SCOTUS case raised quite a few eyebrows. Besides, one could always sell the land to another private individual who would then be forced to sell it. Besides, a transaction-type contract isn’t anything like an insurance or other ongoing-relationship type contract.
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As for the incentives for employers to discriminate against those likely to get ill: I’m not so sure that the discrimination happens too often. For one thing, the beancounters who would be able to demonstrate the difference in the bottom line don’t often have much influence over the mid-managers making the hiring decisions, and were it to go up and then down the chain of command, there’d be plenty of paper trail or, at the very least, whistleblower opportunity.
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At the end of the day, single payer health care seems to be the most efficient way to cover many people and lower the health care costs. Furthermore, it would reduce employment costs for the kinds of businesses who pay good salaries, thereby encouraging more of those kinds of businesses (white collar work) to move in. The retailers aren’t going anywhere, and now their employees would have health care too.
rightmiddleleft says
who abuse their bodies and want us to pick up their health tab. Whenever the government gets in to the act there is no individual sense of responsibility. To burden the employers to pay for that lower income group who not only do not care to help themselves sets the stage for a real healthcare crisis . The elderly, disabled and those who cannot help themselves is one story , but those lazy bastards who abuse their bodies and live off the fat of the land and only complain day after day should not burden those who actually get up in the morning and have a job. From what I can see after two months of reading this blog ,there does not appear to be many bloggers on this site that understand that basic concept.
eury13 says
but I have the same response as I do when people talk about “welfare mothers with 10 kids”. Personally, I believe that there should be a safety net for people, whether we’re talking about the ability to provide for one’s family or the ability to get medical care when we’re sick. I have no problem with smokers, drinkers and druggies getting healthcare if it means that everyone else does too. People aren’t going to abuse their bodies more simply because they know that they get to go to the doctor later. What we should be focusing on is making sure that people get regular, preventative care instead of waiting until they end up in the emergency room, which costs substantially more.
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I see the appeal in wanting to penalize people who cause their own medical problems, but it doesn’t work from an ethical point of view. Someone with lung cancer who goes to the emergency room will be treated. Either we work out a system where they get coverage or we pay out the nose when they have no other options but the most expensive treatment. The only other choice would be to not treat them at all, and I don’t accept that as an option.
david says
Of all people, Bob, I should think that you would be last to accept the crushing intrusion on individual liberty that an individual mandate represents! OK to force individuals to buy costly insurance policies that they may not want, but not OK to require them to wear seatbelts or put down the cell phone while driving? Surely you jest!
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Seriously, you make good points that furthering the employer-based system has real costs. I agree that it does. But make no mistake: an individual mandate is a major-league tax on individuals, and for the same reason that businesses might leave MA rather than pay additional taxes, individuals may well make the same choice. Furthermore, the very individuals who will be most affected by an individual mandate – the young, unattached, mobile, not-well-off-but-making-too-much-to-qualify-for-state-assistance crowd, are the ones Massachusetts desperately needs to remain in Massachusetts. We are losing population, and that has got to stop. An individual mandate will inevitably accelerate the bleeding.
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We have, basically, two choices to get somewhere on covering the uninsured. We can take incremental steps to get more people covered while trying not to make things worse. Or we can try to work for a paradigm shift that would move away from employer-based care toward the only viable alternative, namely, single-payer. Personally, I don’t see an individual mandate fitting within either of those options. It clearly doesn’t advance the second goal, and to me, anyway, it doesn’t advance the first either – it will make things worse for a lot of people while not really substantially improving the situation.
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If the state wants everyone insured, it should just bloody well insure everyone.
bob-neer says
I knew I was going to get that argument from you. But, you see, I agree with the moral decision we have made as a society to provide health care for everyone (as eury notes). The only effect of the current system is to force everyone to pay more money for care that often is not particularly great. No freedom there. By contrast, as we have discussed, I don’t agree that there is a convincing argument that people should be forced to wear seatbelts or abstain from cell phone use while driving. See how easy it is. On health care, the Massachusetts argument you raise is a good one. Maybe the system is so screwed on a national basis the only practical way forward for a single state is to work with employer mandates. The reason I think individual mandates will move us closer to single payer is: (1) they help people to understand the nature of this problem, and take a measure of personal responsibility, which will create political support for more efficient single-payer solutions, and (2) they keep the insurance companies in the system, which I think is politically required if there is every to be any change at all.
jamieinca says
hmmm i wonder where you get the idea that as a society we’ve made the “moral decision” to provide health care for everyone? maybe most well-meaning people think it’s a good idea, but i honestly don’t think that’s necessarily a countrywide sentiment. just look at the comments above from rightmiddleleft who dismisses the poor unemployed as lazy bastards. no tears for new orleans there.
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one of the advantages of getting health care through an employer (at least an employer of some size) is the group benefit. as someone who had fantastic coverage for years through my job, then had to get it on my own, it really does make one think – since i’m healthy should i take my chances, or pay $350 a month for the kind of coverage i’d like? i’d be very wary of an individual requirement until i can see what kinds of options the insurance companies would come up with for single payers, given a mandate for coverage. i suspect they’d just offer the same lousy expensive coverage but up their marketing budget.
evileddie says
The part I do like about the individual madate system is that it seems to provide cheap health care to those people on the low end of the income scale. My question is: Why does it have to be mandatory? Can’t we provide a system where people can opt into that cheaper health care?
vincent says
stomv said “But, legally requiring a large set of individuals to enter a legally binding contract with a private contract is tyranny. There are no other instances where this has ever happened in tUSA to my knowledge.”
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Actually, and not so strangely, this exact phenomenon is fairly rampant in medicine. Most states have laws regarding HMOs which set physician reimbursement rates for NON-CONTRACTING physicians, even requiring the physician to obtain a provider ID from the HMO.
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How is it that a private us citizen(physician) must effectively enter a contract with another private entity(HMO) simply by government fiat. It is a clear violation of a physician’s property rights and a violation of protection against involuntary servitude. If you don’t think so then ask yourself how you would feel if the government decided your services were “needed” and therefore you should perform those services for MUCH less than you see fit. All the while making a profit for HMO executives with whom you decided against entering an agreement.
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