Obamacare: Now With Mandate
Ezra Klein reports that senior administration officials are telling him their budget will assume the existence of a “mandate” as part of a health care reform package. Since nobody except the voters ever agreed with Obama about this, it’s being greeted with all around cheer. But I still think Obama was right in the first place. It’s not that a mandate is such a terrible thing, but it’s primary purpose is to keep insurance companies in business once progressive stuff like community rating and guaranteed issue policies are put in place. If I were in congress, I’d write a bill that has community rating and guaranteed issue. Let the insurance companies fight for the mandate! Make them deliver some votes for a “compromise” featuring all three. But there’s no particular reason that this favor to insurance firms should be defined as constitutive of the progressive health care agenda.
But whatever; this debate was never especially important.
33 Responses to “Obamacare: Now With Mandate”
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February 24th, 2009 at 4:10 pm
Not important? Not important? That pop you hear is the sound of several veins in Petey’s forehead.
February 24th, 2009 at 4:14 pm
Mandates are an accounting gimmick used to make a garish public-private frankenstein system at the expense of the lower-middle-class. If American health care policy weren’t governed by idiots and industry hacks, we’d be talking about a single-payer system instead of listening to Ezra Klein, Paul Krugman and their fellow pod people drone on about various center-right corporate plans that we Must Accept in order to be Progressive.
February 24th, 2009 at 4:14 pm
That pop you hear is the sound of several veins in Petey’s forehead.
In this as in most things, Petey is utterly clueless.
February 24th, 2009 at 4:17 pm
As someone working to get good, progressive healthcare*, I’m close to Matt on this. The mandate aspect of insurance was never a particular important issue for me, since the big issue is making sure Americans have the option of good, affordable coverage, which Obama’s campaign proposal more or less gave.
(If anything, I’d sooner not see it, given comprehensive reform.)
*I’m a community activist on this issue.
February 24th, 2009 at 4:19 pm
How are they going to enforce the mandate?
February 24th, 2009 at 4:25 pm
Please tell me this isn’t going to be like HillaryCare(TM), combining the worst of public and private. The majority of Americans want single-payer, but instead they keep trying this stuff to help the insurance industry.
The majority of Americans naively think we don’t need Washington lobbyists because we have elected representatives representing us…
February 24th, 2009 at 4:29 pm
Well, frankly, I am all for mandated Medicare for All, but Obama’s plan will be a huge, big, flopping failure. It’s the Massachusetts plan, which has done nothing to slow the rise in premiums, scant little in the way of preventative care, nothing to shrink the cost of health care. I can not believe so-called progressive Democrats seem ready to jump off whatever health care sham ledge Obama proposes. We are not going to get another opportunity like this.
February 24th, 2009 at 4:30 pm
# rmwarnick Says:
February 24th, 2009 at 4:25 pm
Please tell me this isn’t going to be like HillaryCare(TM), combining the worst of public and private. The majority of Americans want single-payer, but instead they keep trying this stuff to help the insurance industry.
The majority of Americans naively think we don’t need Washington lobbyists because we have elected representatives representing us…
Oh, no, it’s not Hillarycare, she wanted to cap the amount of income any American could be asked to spend on health care, there by wringing the profit out of the for-profit health insurance industry. Obama has never suggested such a cap.
February 24th, 2009 at 4:31 pm
If you propose a plan that causes insurance companies to collapse the don’t compromise with you. They scare the hell out of voters an crush you or else you convince voters that insurance companies shouldn’t exist and crush them. Obama has said that he doesn’t think single payer is politically possible so I assume he doesn’t think it would work out so well. Vague campaign platforms are different from health care legislation so Obama will include mandates in his plan.
February 24th, 2009 at 4:42 pm
I have to disagree that this debate isn’t important.
I personally believe that single-payer is the most efficient and best way to achieve universal healthcare, but I am open to the proposition that it _may_ not be politically achievable.
One of the reasons that single-payer is universal and costs less is that there _is_ a mandate in that plan (or at least there is in all the countries I am aware of) which means that even young healthy people pay in and keep costs down for less healthy folk.
Then again, I think Obama got the better of the political debate during the campaign on the issue, since most voters are not health economists.
But now is time for realpolitik (see the Rhambo profile in the New Yorker).
February 24th, 2009 at 4:47 pm
Too bad. I always thought the lack of a mandate was the best part about Obama’s plan. Cut the insurers out entirely and offer government insurance as a subsidized choice of equal or better quality that’s cheaper for most. It won’t insure everyone right away, but after a couple decades of requiring children to enroll and requiring employers of a certain size to provide insurance (and making this the cheapest option), you’d have a backdoor to single-payer care in short order.
A mandate is the easiest thing for the GOP to attack; take it out and you could have a federal system that’s much more impressive that might not achieve universal insurance at first but would quickly overpower everything else.
February 24th, 2009 at 4:48 pm
A mandate is necessary to maintain the 31% extra we pay to support universal profits for health insurance providers.
February 24th, 2009 at 4:49 pm
Yep. Once they get through the legislative sausage-making, mandates are going to be give-aways to private health insurance (which is basically their original intent anyway). Nope, can’t possibly see any potential political problems there. I like Ezra, but he’s way too deep in the weeds on this one.
I don’t see why they couldn’t fold Medicare, Medicaid, S-CHIP and FEHB into one program and just add a payroll tax as the ‘premium’ for those without employer-sponsored insurance. Individual mandates are the type of shit only a wonk could love.
February 24th, 2009 at 4:50 pm
Obama administration sources telling Ezra Klein that mandates are in play sounds a lot like a guy at a bar telling Scarlett Johansson he’s a big fan of her singing. It’s effective flattery but is it really true?
I’m still betting on ‘no mandate’ in the short run of any Obama proposal or anything Congress puts together.
February 24th, 2009 at 4:54 pm
I think the mandate is tough politically (because it’s the easiest thing for Republicans to attack), but it’s probably the best way to avoid people gaming the system by waiting to buy insurance until they’re already sick.
Basically, the non-mandate backers believe that nobody will actually choose to go without insurance if affordable coverage is available. Is that really true? It seems to me that a lot of young people understand the gamble they’re making by choosing not to pay for insurance, but do it anyway because they’d rather spend money on other things.
Unless insurance becomes really, really cheap, some people will still choose not to pay for it. What do we do when these people become terminally ill? Seems like there are three basic possibilities:
1. Letting them die without medical treatment.
2. Stick them with a big financial penalty for starting up health insurance when they’re already sick, but why should we expect these financially irresponsible people to be sitting on a big pile of cash when its time to pay the penalty?
3. Mandates.
February 24th, 2009 at 5:07 pm
I don’t care if people game the system. People gaming the system is a lot less of a problem than 45 million people being outside the system and the US spending at least 50% more per capita on health care as our chief modern economic rivals and getting the same or worse results.
If free riders want to jump into a public pool only when they get sick, let them. Just collect a penalty like a defaulted student loan. I’m less worried about free riding individuals screwing me than the health industry and so is every other person without health insurance.
Just let people check a damn box on their payroll forms and get health insurance that can’t be taken away and doesn’t lapse when you change jobs or are unemployed. That’s all people want, an end to the fear. Any cost savings, and they will be massive, are gravy.
February 24th, 2009 at 5:10 pm
pronk at 16 nails it.
I would like one of the anti-mandate (or the mandates don’t matter) crew explain how a plan to provide universal coverage and to cover all pre-existing conditions can possibly work without mandates. Where’s my incentive to not game the system by getting fire insurance (metaphorically) after my house has already burned to the ground? I genuinely don’t get it.
A single payer system is clearly the best option, and whatever option we choose now should be structured so as to seamlessly evolve into single payer. But outside of single payer, the only systems I’ve seen that make any sense are the ones that include mandates.
And if it is true Obama’s plan will now include mandates, there’s no getting around the fact that he straight-up lied during the primary about this–and I say this as someone who worked tirelessly to get him elected in the fall.
February 24th, 2009 at 5:11 pm
Good point, joejoejoe.
February 24th, 2009 at 5:12 pm
16
Or 4 let them in and eat the extra cost. Maybe impose a delay between when you sign up and when you can start collecting.
February 24th, 2009 at 5:13 pm
joejoejoe, it’s not about a few free riders screwing you. If the system is structured so that pre-existing conditions are always covered and there is no mandate, then everyone will be a free rider. Why would anyone choose to keep health insurance while healthy?
Even if the penalty equaled the amount of premiums you should have paid, it would still be worth the “risk” to only buy insurance when you get sick. There would be no downside to it at all unless the penalties were really huge. And if the penalties are huge, then what do you do to people who can’t pay them? We’re basically back to not covering pre-existing conditions.
February 24th, 2009 at 5:28 pm
I’m with Matt. I never minded the mandate too much, just the idea of making it the centerpoint of HC policy, when it was intuitive to think that the insurance companies would eventually ask for it. Mandates are bargaining chip to be spent for guaranteed access. From Thursday’s NY Times
There ya go.
On a side note, I would expect the Obama team to come up with some kind of ‘behavioral economics’ model to reach near-full participation without literal mandates.
February 24th, 2009 at 5:29 pm
We spend 90% more on healthcare than France and get lower quality results, all while failing to cover 1 in 7 of our people. I don’t think the free rider problem should obstruct pols from changing our system now because it’s only a small reason for our broken system being broken. Make suboptimal improvements in the short run, then when a majority of people are enjoying qualtiy secure public healthcare, crack the whip on free riders to reign in spending.
February 24th, 2009 at 6:29 pm
“Not important? Not important? That pop you hear is the sound of several veins in Petey’s forehead.”
The crucial moments in this particular narrative are yet to play out.
I’ll reserve my tears, laughter, or veins popping for the appropriate moment. We’ve yet to see the hole cards.
February 24th, 2009 at 7:24 pm
The majority of Americans want single-payer,
Really? Then how come single-payer health care was rejected, twice, by overwhelming margins, in two of the bluest states in the country when it was put directly before the voters? No…..don’t tell me…..it must have been because of Republican dirty tricks, right?
We spend 90% more on healthcare than France and get lower quality results
No, we don’t get lower quality results. Or, rather, there’s no serious evidence that we get lower quality results.
February 24th, 2009 at 8:29 pm
I would like one of the anti-mandate (or the mandates don’t matter) crew explain how a plan to provide universal coverage and to cover all pre-existing conditions can possibly work without mandates.
3 options:
1. The government can simply hire doctors and open hospitals that offer free care for every American.
2. The government can pay private doctors and hospitals to provide treatment for every American.
3. The government can purchase executive or member of Congress level health insurance and provide it free to every American.
In any of those three scenarios, we provide health care as the right that it is. A mandate, in contrast, doesn’t provide anything, it just forces hard working citizens to provide money they don’t have to companies that don’t deserve it for care that will be denied.
February 24th, 2009 at 9:35 pm
Hinting that they will accept a mandate isn’t giving in to the insurance companies. I’m sure that Obama will demand that the insurance companies don’t end Harold and Louise’s retirement as a condition for going along with the mandate (you can’t “take someone told Ezra Klein” to the bank).
I think a mandate is necessary, but I’m all for getting as much a possible out of the insurance companies by threatening them with the original Obama plan.
February 24th, 2009 at 9:47 pm
– Barack Obama, Democratic Presidential Debate, January 2008
February 24th, 2009 at 11:28 pm
I think Jim is onto the right argument here, but maybe some confusion among those who don’t like mandates needs to be cleared up. Firstly, I think all progressives can agree that it should be the case that health care should be available to all who need it and also that it should be affordable to both individuals and to society as a whole. It’s reasonable to have these objectives because other wealthy nations seem to be able to do both of these much better than the U.S. Universal health care systems do this so well because they are both a universal guarantee and a universal mandate. If we require health insurers to cover anyone who wants insurance, the most eager enrollees will be people with generally poor health. These individuals are expensive to insure, but nobody with a sense of fair play would argue that needy people should pay premiums that reflect their costs; obviously we want the burden of caring for the sick to be shared across members of society. This cannot be done if healthy individuals are able to opt out of said obligation, at least not without heavy subsidization. But if everyone is to subsidize healthcare, then certainly everyone should be covered. This is what single-payer systems do. If this is our first-best outcome (where everybody pays in and everyone is covered), then a second-best approximation (since single-payer is politically unworkable somehow?) should at least incorporates the fundamental feature of universality. Once that is accomplished, bringing down costs for society as a whole require the government insurer to change the incentives in health care provision by changing its remuneration structures (i.e. less fee-for-service, more capitation and outcome-based payments, more negotiation on medication and service prices).
February 25th, 2009 at 10:18 am
steve:
1. universality isn’t evwrything. remember, mandates don’t give the public free health care. i’d rather give as many americans free health care as possible even if it isn’t everyone than to simplu force poor americans to pay for crappy insurance.
2. this isn’t single payer absolutism. go ahead and buy everyone a corporate executive level policy from an insurance company. (remember, though, that it has to be a top line policy; forcing americans into bad hmo’s which will deny them care is not helpful to them).
February 25th, 2009 at 11:06 am
The purpose is to keep insurance companies in business? If not everyone participates, you are stuck with an enormous adverse selection problem where only the sick and those likely to become sick participate, pushing the cost of insurance way up. And it should hardly be a surprise if the healthy and/or not-so-well-off decide they’d rather spend their money on something else.
Of course, there’s a real problem with mandate enforcement, which I don’t know how to solve. But dismissing this as a “favor to insurance companies” is just dumb.
March 16th, 2009 at 10:20 pm
sry i just know how to write my name in arabic
) anyway however my english not that good but i think i get the point. thanks