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
href=”http://bluemassgroup.com/showDiary.do?diaryId=562″>cell
phone use while driving (Bob and David
don’t mind, I say outlaw it); and we’ve heard from <a
href=”http://bluemassgroup.com/showDiary.do?diaryId=1598″>Bob on
individual
mandates (pro) and <a
href=”http://bluemassgroup.com/showDiary.do?diaryId=1588″>David,
at length contra.
Where do I sit? In the uncomfortable middle. I’m the only non-lawyer of
us three,
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*
(<a
href=”http://www.roadmaptocoverage.org/pdfs/Roadmap_Synthesis_Summary.pdf”>and
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
href=”http://bluemassgroup.com/userDiary/comments.do?personId=757″>AnnEM’s
many comment<a
href=”http://bluemassgroup.com/userDiary/comments.do?personId=757″>s
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
the table.
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
would do.
*I don’t rule out incremental progress towards that goal — that’s a
political question, not a moral one.
smadin says
I think possibly the biggest problem in this whole debate is that so many people (especially those on the side of individual mandate/no employer mandate) seem to be treating health insurance as just another consumer product, about which consumers can reasonably be expected to make informed and sound decisions. But health care really isn’t like other consumer goods, and very few individuals have, or should be expected to have, the kind of broad and deep medical knowledge they’d need to make really good decisions about their own care, and especially about preventative care. That’s why we have doctors, after all: to be a repository for that expertise, and based on that expertise to provide us with the best advice and translated-into-plain-English rationales for choosing one or another treatment option.
<
p>
It seems very likely to me (though I admit this is just speculation, I haven’t got any sort of research or statistics to back this up) that an individual mandate would result in three things: first, obviously, the state would claim full health care coverage of its citizens, which would be true on paper; second, employers would be less and less likely to offer insurance plans as part of their employee benefits; third, the overall level of quality of the heath care citizens receive would go down, because more individuals trying to get the most “affordable” insurance would choose low-coverage, low-premium, high-deductible plans, and would fail to get preventative care, and fewer employers would pay for better coverage for their employees.
lynne says
Nice comment! So apt. You are exactly right – delivery of services for consumers is often best delivered by the private sector, but this is a case where that is NOT true. It’s too important for our society to have healthy citizen to leave it up to the not-so-tender ministrations of the private market.
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p>
Your worry that individual mandates will lead to all that makes sense to me…without expertise, but just common sense, it seems that all those things are possible.
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Speaking of which, I need to find out when I have to visit the specialist for my Swiss cheese kidneys…
tim-little says
I’ll second Lynne’s kudos of your post; you’ve hit the nail on the head with the problem of thinking of health care as just another commodity.
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p>
To add to your list, I think that an individual mandate has the potential to lead to increased illness (as people put off preventive care), leading to higher rates of personal bankruptcy (as people are forced to pay high-deductibles when they do get sick), higher crime rates (given a direct relationship between poverty and crime), and less social stability in general.
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I think this illustrates a fundamental problem with what Bush refers to as an “ownership society” — that is turning over social welfare programs to the free market, whether it’s social security, heathcare, education, or what have you. A society is only as strong as its foundation, and if you erode the pillars of society — food, clothes, shelter, education, and medicine — the rest of the structure will come tumbling down.
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To free market fundamentalists (including, I’d wager, most Republicans), however, everything is a commodity, and the market is the most efficient mechanism for delvering a product or service to the consumer at an acceptable cost. Those who are priced out of the market are simply irrelevant.
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The problem is that no one is irrelevant, and there are certain things — health care, social security, education, for example — that are more than simply commodoties to be bought or sold. There is a social benefit to providing for the eldery and the poor, for making sure that everyone receives a basic level of health care or education, etc. On the other hand there is a social cost if these things are not provided for, and sometimes the the free market is NOT the best way of ensuring that these needs are met. I think that this is something that most Democrats — and certainly progressive Democrats — do “get,” but which the Republicans have been working very hard to brainwash the public against for a very long time.
tim-little says
I’m certainly not advocating a top-down, command-style economy. Really public-private partnership is the ideal, I think, and a lot of the “public” decisionmaking needs to take place at the local and state levels rather than at the Federal level. However, the Federal government does need to create the mechanism that allows the local and state governments to do what they need to do.
generationalstorm says
Seems to me, a NATIONAL single payer health care system is the fairest, most cost-effective, and simplest way to do health care reform – because the efficiencies of a large, national pool of payers are far greater than the efficiencies of a much smaller, state-run health care pool.
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Obviously, that’s not going to happen for a while – but it should be at the top of the agenda for many Democrats running for offices – so that eventually we can get there.
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But doesn’t a STATE-RUN healthcare system (regardless of the specific type of mandate) work AGAINST that long term goal, of National Single-Payer Health care?
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If MA, and lots of other states adopt various forms of State-run health care systems, the incentive to ever get to a National health care system is diminished. In other words, we shouldn’t do this once in individual states, and than again nationally when the time comes, because at that point the state-based systems will be too entrenched.
tim-little says
Is that a national single-payer system is so far from becoming a reality, and that something needed to be done yesterday. People can’t afford to wait until a national health system finally comes down the pike, and so states are being left to fend for themselves. What’s the alternative, really? The status quo?
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I think you worry about redundancy when that actually looks like that might be a problem. And in the end, if the states actually are providing adequate health care coverage (an optimistic forecast), then national health care is less of a pressing need.