One of the interesting and productive things about doing a multi-person
blog is the disagreements. Bob, David and I have been public about our
disagreements over, say, <a
phone use while driving (Bob and David
don’t mind, I say outlaw it); and we’ve heard from <a
mandates (pro) and <a
at length contra.
Where do I sit? In the uncomfortable middle. I’m the only non-lawyer of
so I’m blissfully untroubled by the need for clean lines of reasoned
principle. My bottom line is that I think everyone should be
able to get treatment for illnesses, and should be encouraged to
prevent illness to the greatest extent possible. So I go from there.
Universal coverage is the only possible moral position in health care*
it’s also an economic winner (pdf, see page 5)); and that requires
a mandate on someone:
either the individual, employers, or the state.
Hardly anyone who is alive today had much to do with our verkakte
employer-based health insurance system. In this, Bob is absolutely
right: We can talk all we want about how employers morally ought
to insure their workers, but let’s face it: They have a big incentive
not to do so, especially with lower-skill, and therefore more fungible,
employees. And the skyrocketing cost makes it less attractive all the
time. I might add that we self-employed people are in an especially
lousy situation in the current setup, since we don’t have a natural
pool with which to buy cheaper insurance.
An individual mandate at once unifies and splinters the risk pool:
Everyone has to be in, but in a “free-market” system, we can all be
offered plans that suit us. And the “young and healthy” (one might add
“male”) will take cheapo plans, and the rest of us pay for more care.
This sounds “fair”, but health is often not fair — that’s why we
insure it. So, I don’t see how an individual mandate helps very much,
except that everyone has to pay, and everyone is nominally “insured”,
regardless of whether they can actually afford health care,
which is, after all, the point.
As for a mandate on the state to cover everyone, i.e.
single-payer: That’s the best solution for all concerned, as far as I
can see; and in this, I would guess that Bob, David, I, and most
readers would agree emphatically on this. (See reader <a
on this, and yes, go visit Health
Care for Mass, not to be confused with the worthy,
more-established, incrementalist Health
Care for All.)
We’d save money, as does every other industrialized country’s national
health care system, and we’d likely get better results. Sure, taxes
would be somewhat higher, but neither employees nor employers would
ever pay premiums again. (Think about health premiums as taxes: Don’t
you think there would be a political uproar if taxes went up 10-14%
year after year after year?) Long-term, we should be moving in this
direction; short-term, for whatever stupid reason, this just isn’t on
So here’s my bottom line: If we’re not going to just throw the problem
at the state (as we ought), then employers and individuals and
the state need to contribute to the solution. An individual mandate
without an employer mandate just represents a huge step backward
in the current trend of cost-shifting onto individuals, who are the
least able to leverage their buying power to get a good deal. And it
still doesn’t make it easier for a person to see a doctor if he’s sick;
it just makes it more likely the hospital gets paid in the event that
something serious happens; which is, after all, more likely if the patient
can’t afford to get preventative care in the first place.
So there it is: If we can’t have single-payer, we’ve got to have both
employers and employees in on a solution, not let employers off the
hook and put all the onus on employees, as RomneyCare and the Senate
*I don’t rule out incremental progress towards that goal — that’s a
political question, not a moral one.