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Clinton, Obama, and Health Insurance Mandates

As a centerpiece of her now-uphill battle for the Democratic presidential nomination, Hillary Clinton continues to attack Barack Obama because his healthcare plan does not call for an individual insurance mandate -- that is, a requirement that all Americans purchase a health insurance policy -- whereas her proposal, like the recently-scuttled Schwarzenegger-Nunez bill in California, includes such a mandate.

Whether the government should require everyone to purchase health insurance is a difficult issue about which reasonable people may differ. (Full disclosure: I am an unpaid member of a health care policy advisory committee for the Obama campaign, but I personally favor individual mandates as part of comprehensive health care system reform). But the sound argument to be made in favor of mandates is very different from the one reiterated daily by Clinton. As a result, her criticisms of Obama on this point are wrongheaded and disingenuous. Let me explain:

Clinton alleges that, simply because it includes a mandate, her plan would lead to universal health insurance while Obama's would not. This is not true. Obama would institute health insurance market reforms and subsidize health insurance policies for the poor, making insurance more affordable, but he wouldn't require adults to purchase insurance, at least at first. (He is open to mandates down the road if, after the reforms and subsidies reduce costs, a large number of healthy "free riders" still do not buy coverage). Clinton wants to require all Americans to purchase health insurance, but she refuses to describe how she would enforce such a requirement. Just as many drivers get behind the wheel of a car without coverage in spite of auto insurance mandates -- 25 percent of Californians, according to estimates -- many Americans simply would ignore a health insurance requirement. Massachusetts mandates that individuals buy health insurance and even threatens fines if they do not, but 20% of that state's citizens still remain uninsured.

Mandates would reduce the number of uninsured Americans significantly only if accompanied by the strict enforcement of a severe penalty, such as garnishing the wages of anyone who fails to submit proof of insurance with their income tax return. Clinton has refused to propose a penalty and enforcement structure for the mandate that she trumpets so loudly, and she has dodged the question of whether she would exempt the poor from the requirement. This makes her call for mandates meaningless rhetoric, and the claim that her plan would cover everyone false.

What makes Clinton's criticism of Obama really off the mark, though, is that she is trying to market mandates as a benefit for the large number of currently or potentially uninsured Americans, when mandates actually are a concession to constituencies that otherwise might favor the status quo against attempts to make insurance more affordable. Auto insurance mandates are good for the people who might be hit by an uninsured motorist, but they are hardly welcomed by the uninsured who feel, rightly or wrongly, that they can't afford coverage. Similarly, health insurance mandates are good for people with insurance, employers who would be forced to pay into an insurance pool, and private insurers who would face greater regulation under a reform plan, because expensive subsidies that would be required to help the "sick" uninsured to purchase coverage would be at least partially offset by requiring the "healthy" uninsured to contribute their fair share to the system. But telling someone without insurance that the government will force him to buy it at whatever price the market charges is unlikely to convince him that his problem is solved.

To see why Clinton's argument is nonsensical, consider that the country could achieve nearly universal health insurance immediately simply by enacting an individual mandate coupled with a truly draconian penalty for non-compliance. But so what? This would be good for Blue Cross, Health Net, and Aetna, but the worried middle class wouldn't sleep any better at night knowing the government was going to force it to buy unaffordable insurance than knowing that it might have to go without unaffordable insurance. Clinton understands this, of course, which is why she refuses to discuss penalties or enforcement.

Clinton could reasonably argue that, as president, she would need to accept an individual mandate in order to win Congressional backing for market reforms and subsidies that would truly help the uninsured. Instead, she chooses to claim that mandates are themselves the goal, because doing so allows her to falsely charge that Obama is less committed than she is to the real goal of making affordable health insurance available to all. Her choice of tactics can be rooted only in a cynical belief that her attacks can succeed because the issue is just too complicated for most voters to understand.

Dan Weber (www):
Obama would institute health insurance market reforms

I have no doubt that our messed up insurance market is in dire need of improvement. I also accept that government might have the ability to improve things, but I'm always nervous when they get involved.

What are ways in which Obama wants to reform the market? Allowing individuals to buy without the tax penalty vis-a-vis employers? Encouraging insurance companies to enter into long term contracts? Allowing for people to opt out of coverage they don't need?
2.26.2008 4:53pm
bla bla:
I don't really think anyone on this website is going to like either Obama or Clinton's plan, so I'm not really sure what the point of this post is.
2.26.2008 4:57pm
guest 2:
I think that you are incorrectly calling their plans health insurance when they are really heath care. The difference is not negligible. Health insurance would have a large deductible and be for emergencies and would be combines with an HSA for regular health care. Health care, which is what is being pushed by Democrats provides total coverage at an unsustainable price.

My gut is that mandates would cost too much to enforce compared to the increase in coverage that would result.
2.26.2008 5:05pm
Ted Frank (www):
Both candidates mention the "45 million uninsured," but neither has a plan to insure the 9 million of those uninsured who aren't US citizens. So they should either stop using the 45 million number, or stop saying they're going to insure everyone.
2.26.2008 5:06pm
Mahan Atma (mail):
Occurrences of "Obama" on the VC front page: 23
Occurrences of "McCain": 1

One wonders why you guys don't want to talk about the Republican candidate so much...
2.26.2008 5:07pm
Malvolio:
So Clinton attacks Obama's plan as not sufficiently draconian and harsh on the poor -- and Mr. Korobkin's defense is, no, it's Clinton's plan that isn't draconian and harsh!

As the kids say, Wtvr.
2.26.2008 5:08pm
Captain Ned:
Individual mandate? I know the Commerce Clause has been extended to the point of absurdity, but a Federal requirement for all citizens to purchase government-sponsored health insurance might finally cause SCOTUS to remember the 9th &10th Amendments.
2.26.2008 5:08pm
Ben P (mail):

I don't really think anyone on this website is going to like either Obama or Clinton's plan, so I'm not really sure what the point of this post is.


I think that's putting it gently.

My gut reaction was "Comment declaring either plan to be socialism in 5....4....3....2..."


I need to do more research before I can make a decision on mandates myself. I do believe that there are significant problems in the Insurance market, (IE Adverse Selection, opt out problems), however, I'm unsure how to remedy those while preserving the maximum amount of market freedom and available competition.
2.26.2008 5:08pm
LM (mail):

I don't really think anyone on this website is going to like either Obama or Clinton's plan, so I'm not really sure what the point of this post is.

As part of the non-existent cohort that finds either plan a move in the right direction, thanks for fleshing out one of the differences between them.
2.26.2008 5:10pm
Michael Poole (mail):
I am curious: How does being an uninsured healthy person qualify one as a free rider?

Wikipedia's definition matches my general intuition: "'free riders' are actors that consume more than their fair share of a resource, or shoulder less than a fair share of the costs of its production." In today's health care market, uninsured people pay significantly more for a given service than insured people and their insurance providers pay. It seems like this would have to change for an uninsured healthy person to be fairly called a free rider. If so, why would that change? If not, what makes the uninsured person a free rider?
2.26.2008 5:11pm
Zombie Richard Feynman (mail) (www):
I'm not sure if a draconian penalty is needed for people to alter their behavior. I would think many people who just follow the law to follow the law, not because they decided the burden was less than the risk times the liability.
2.26.2008 5:13pm
Sasha Volokh (mail) (www):

I don't really think anyone on this website is going to like either Obama or Clinton's plan, so I'm not really sure what the point of this post is.

Good to see our readers enjoy knowledge for its own sake....
2.26.2008 5:13pm
Dan Weber (www):
Michael Poole, perhaps one could say that the uninsured are free riders because they still consume emergency care. And can usually walk away without paying any bills thus due.
2.26.2008 5:15pm
MLS (www):
Obama criticizes Clinton's plan for forcing people to buy health insurance. Fair criticism. But if it is wrong to force people to buy health insurance for themselves (mandates), how can it be ok to force people to buy insurance for others (subsidies).
2.26.2008 5:15pm
Dan Weber (www):
I'm not sure if a draconian penalty is needed for people to alter their behavior. I would think many people who just follow the law to follow the law, not because they decided the burden was less than the risk times the liability.

When an unemployed couple in their 50's looks at the cost of getting insurance, there will be enough zero's at the end of the bill to make evasion a worthwhile consideration.

Of course, given the tentacle-like way the IRS oozes into everyone's life, you'll probably have to supply a policy number on your tax return or else...
2.26.2008 5:17pm
Ben P (mail):

I am curious: How does being an uninsured healthy person qualify one as a free rider?


There's a distinction between uninsured healthy people and uninsured healthy people that have been injured.

It's more or less a plain fact that if you're injured in a significant way (IE enough to require a visit to the emergency room) and you go, you're going to get treated, regardless of whether you have insurance and or can pay. Granted, you might get shuttled to a county hospital or get put last in line, but you'll get treated. There are usually subsidies to pay for this, but they fall far short.

Hospitals in areas with significant numbers of uninsured people are often forced to either move, or charge significantly higher rates to their paying customers to make up for this shortfall, and because those paying customers rely on insurance to pay, everyones rates go up.


This also ties into the fact that in order to have a profitable business model, Insurance companies must take in more in payments than they are paying out in benefits. If we assume for the sake of simplicity that we're dealing with a limited community and a single provider, every healthy person that chooses to opt out of health insurance forces the company to have to raise their premiums to reach the break even point.

The situation is compounded because these problems interact with one another, pricing people out of the healthcare market and forcing them to seek "free" care.
2.26.2008 5:21pm
FWB (mail):
It's NO ONE's business if someone decides to go through life without insurance. In fact, the elimination of insurance, medicare, medicaid, and all other governmental programs would force the medical community to react to market forces. I raised 4 children w/o medical insurance. I paid for services including emergency room visits are needed myself.

If I can't pay, kick my ass out the door and leave me to deal with it. The government ain't the boss; it's the servant. Remember We the People .......
2.26.2008 5:25pm
FWB (mail):
Left off... Government mandated insurance is just more welfare for corporate america.
2.26.2008 5:26pm
Mark P. (mail):
This post is actually a response to Dan Klein's apology in the subsequent post, but the opportunity for comments there was not available.

I apologize for intentionally misplacing this comment, but Klein's apology is so strikingly GOOD that I can't leave it unmentioned. He was accused of making an error. He looked into it, accepted responsibility, and publicly apologized. We shouldn't expect anything more from anyone. A blog like this is a community; it should be a community that is able to forgive human error. In particular, it should be able to forgive human error when the person responsible takes responsibility and apologizes as forthrightly as Klein.

We all make mistakes. Klein accepted responibility for his like a mature adult. I'm sure that I'll make far worse mistakes in the future. When I do, I hope that I will respond the way that Klein did here.
2.26.2008 5:26pm
Bruce Hayden (mail) (www):
Before we really get started, I would be interested in what the real goal here was. It is fine to say that there are 45 million uninsured, but that really doesn't answer, at least for me, what the goal is. Some of that 45 million is totally voluntary - some above have alluded to all those 20 something esp. males who would rather spend their money on booze and women. And, of course, some are probably here illegally.

Also, is the goal to provide first dollar coverage? Or catastrophic coverage?

I would also be interested in proposals to keep the inevitable flood of mandates down. The taxpayers do not need to be paying for aroma therapy, etc. And are the candidates willing to lock in a maximum percentage of GNP for health care? Or at least the mandatory portion?
2.26.2008 5:29pm
Ben P (mail):

If I can't pay, kick my ass out the door and leave me to deal with it. The government ain't the boss; it's the servant. Remember We the People .......


You may believe personal responsibility requires that, but be aware you're in a minority.

People may disagree over policy, but most look poorly on a hospital that lets people die because of their inability to pay, and it's been federal law for more than 20 years.
2.26.2008 5:30pm
Zombie Richard Feynman (mail) (www):
I'm sure some people will attempt to dodge the system, but I do think making a mandate, even with a perfunctory penalty, would cause a great deal of the currently uninsured to sign up.

And FWB, market forces don't work so well in the health care system. The great demand for continuing to live, and the extreme asymetry in the need for the service, mean that relying on market forces alone means a lota people are gonna die.

Course, they were weak, so maybe your coming at this from a thinning the heard/evolution perspective?
2.26.2008 5:31pm
Crane (mail):

If I can't pay, kick my ass out the door and leave me to deal with it.


You really think "We The People" are going to support a rule like that? I guarantee you, the first time a hospital kicks out someone halfway sympathetic who can't pay but wants care anyway, there will be a huge public outcry. Not to mention, many if not most doctors would be horrified at the thought of leaving a sick person to suffer just because they can't pay.
2.26.2008 5:36pm
nudan (mail):
MLS--

You say if it's wrong to force people to buy insurance for themselves, it should be wrong to force people to buy insurance for others via subsidies.

I don't think the argument is that its wrong to force people to buy insurance for themselves, but that's counterproductive. The poor have limited resources, and may sensibly want to buy housing or food instead of health insurnance. More importantly, it would be counterproductive because the enforcement costs would probably exceed any benefit.

As for whether its wrong to force people to subsidize health care for others, I would argue that's just the nature of what the government does. When a wealthy person pays for national defense, he pays far more for the same amount of "protection" as does a poor person. Moreover, we do subsidize the care for uninsured people now, just in the form of higher premiums for our own care.

The question whether a person should be forced to subsidize another person's health car should not be analyzed by reference to unanswerable questions of "right" or "wrong," (whatever that even means) but instead by whether it creates net benefits to society. I think, certainly in the long term if not earlier, it will. 1) You will have a more productive workforce; and 2) if it comes with some sort of mandatory co-pay or something, then less health care per person would be consumed, which might be the biggest reason we have such unreasonably high medical costs.
2.26.2008 5:40pm
Dan Weber (www):
I'm sure some people will attempt to dodge the system, but I do think making a mandate, even with a perfunctory penalty, would cause a great deal of the currently uninsured to sign up.

There's a simple way to test this. Ask "how well has this worked in Massachusetts?"

There were certainly a fraction of people for whom insurance was affordable and just weren't bothering. But there were also lots of people had chronic conditions that made insurance more expensive than just paying out-of-pocket.
2.26.2008 5:45pm
Mikeyes (mail):
I'm curious, too, but more about how a president is going to be able to mandate health coverage. It seems to me that it will be the job of the Congress to do that. The president really has very little power when it comes to these kinds of solutions and Clinton's awful venture into health care is a good example.

I was on of 50 people in this country who slogged through the entire 3000 (or so) pages of Hillary-care way back when. As far as I could tell, it was too fussy in concept and it would never have a chance of passing. There is no way a president can get such a complex concept through Congress so why is everyone so concerned about it?
2.26.2008 5:46pm
Zombie Richard Feynman (mail) (www):
Huh. I'll have to look into MA more carefully.

It still seems to me universal medicare is the best system to start with, but if the two Dems want to play footsie with the HMO's, what is there to do?

Stay healty, I guess.
2.26.2008 5:50pm
Ben P (mail):

Clinton's awful venture into health care is a good example.


Which is one of the reasons Obama's approach seems more realistic on it's face.

The fundamental problem with Clinton's first approach seemed not to be in it's details (although I admit I've not studied it), but in it's execution. It was written and pressed on congress as "the president's wishes."

My impression (initial one at least) of Obama's plan is that he is more likely to view policy making as an inclusive process. The idea that he's put forward something typically seen as a sop to the healthcare industry as a part of his initial plan seems to be somewhat supportive of this.
2.26.2008 5:51pm
A.S.:
What makes Clinton's criticism of Obama really off the mark, though, is that she is trying to market mandates as a benefit for the large number of currently or potentially uninsured Americans

First of all, this is an evidence-free assertion. I am curious to know what evidence Korobkin has to support it.

More importantly, though, I find Korobkin's post missing an important point. He asserts that a mandate would not help uninsured persons. That seems to me to be incorrect. Korobkin focuses his post on people who cannot afford insurance. But this seems to me to be misplaced. The mandate would cause people who can afford insurance but choose not to purchase it to join the insurance pool. This presumably would lower the cost of insurance for everyone, thereby making it more affordable for those who cannot currently afford it.
2.26.2008 5:56pm
Dan Weber (www):
If I can't pay, kick my ass out the door and leave me to deal with it.

I see. And how does this work when you get into a car crash, are knocked unconscious and out of your clothes, and are taken naked to the emergency room?

"Does this guy have insurnace?"
"I dunno."
"Well, kick his ass out the door, then."

I love the free market as much as the next Volokher, but there are fundamental places here where we can't just leave things to the market.

The question becomes "how do we separate those things that the market can handle well from the things that the market cannot?"

There's a difference between shopping around for pricing on your dialysis and shopping around when you've broken your leg and are bleeding on the floor.
2.26.2008 6:01pm
A. Zarkov (mail):
Does either the Obama or the Clinton plan cover illegal aliens for other than emergencies or infectious diseases? I can see universal coverage for both these contingencies, but what about other conditions? Should American taxpayers foot the bill for elective surgery and the treatment of chronic conditions for the citizens of other countries? Neither candidate seems willing to answer this question. I hope they realize that the if we plan to cover anyone who can get his body across the border, the costs could escalate significantly. Don't kid yourself, if this happens we will get rationing of medical care. I hope Americans realize this downside to universal coverage.
2.26.2008 6:07pm
genob:
I'm not an expert or even somewhat well informed on this subject. But I am worried that trying to fix a "problem" for 45 million uninsured will really screw it up for the 300 million insured.

A fundamental question....just because one doesn't have insurance doesn't mean they aren't getting medical care, does it? Is the problem really that big of a problem?

It seems that the unisured are either getting care and paying for it (no problem, their choice to self-insure). Or they are getting care and are unable to pay for it (in which case the country is already "insuring" them or providing a subsidized insurance policy.)

True, the last category of people don't have access to the same level of service that I get from my generous employer-provided benefits....They don't have access to the same level of lots of things (like food, shelter, etc) that people with more money or better jobs have access to.

Maybe some tinkering with bankruptcy laws to deal with the problem of people losing their homes when a catastrophic medical condition strikes might be enough without ruining it for the rest of us?

Or is this really about being sure that everyone gets exactly the same thing? Even if it means waiting months for emergency surgery, or all the other reasons that Canadians come down here when they can afford it.

Maybe I live in a bubble. Costs are a problem for the economy, but our basic system has never let me down, even when I was an unisured student.
2.26.2008 6:09pm
Houston Lawyer:
It is not an unreasonable gamble for many people not to have health care insurance. At 47 years of age, I know I have paid out far more in insurance premiums than I have incurred in costs. Many of the "uninsured" could pay for insurance, but they have other priorities.

What is the penalty for failure to have insurance? Is it similar to the penalty for being in this country in violation of our laws?

We could always turn medical bills over to the IRS for collection. Other countries use versions of this.
2.26.2008 6:21pm
amy (mail):
Any plan that allows DENIAL of services for PROFIT is not going to work in the long run. Improvements of service through modern information technology is great. Cost reductions as a result of early intervention and prevention is really great. General improvement of availability through increasing pay for Nurses and General Practioner physicians is great.
But any system that allows insurance providers to deny care based upon their own need for profit is simply not needed and should not be supported by progressives, or by businesses who have to compete worldwide with companies that do not have to provide health coverage for their workers.
2.26.2008 6:42pm
LM (mail):
Bruce Hayden,

The taxpayers do not need to be paying for aroma therapy, etc.


A. Zarkov,

Does either the Obama or the Clinton plan cover illegal aliens for other than emergencies or infectious diseases? I can see universal coverage for both these contingencies, but what about other conditions?


Despite being a fervant advocate of universal coverage, I'll start the bipartisan ball rolling and stipulate no free aromatherapy for illegal aliens. How 'bout that?

Don't hold me to this, but I seem to vaguely recall from one of the debates that Clinton, Obama and even Edwards placed severe limitations on the coverage contemplated for illegals. I think only Kucinich was actually advocating full benefits irrespective of immigration status. But again, I could be wrong.
2.26.2008 6:45pm
BGates:
The poor have limited resources, and may sensibly want to buy housing or food instead of health insurance.
That's a problem. We should mandate people purchase housing. Food mandates are important too - diet is a big component of health, so there should be some vegetable purchase mandate.

Another big component of health is genetic. We'll be able to decrease health costs in the long term by making sure the healthiest people reproduce the most. Anyone with a family history of longevity or certain genetic markers indicating disease resistance should be mandated to reproduce far above replacement rates (to make up for the less fit who should be strongly discouraged if not forbidden from childbearing).

[Of course we won't go that far say the mandate supporters, and thanks for the straw man. We only want control over 15% of the economy, and only for the public good, and we'd never dream of increasing government control past that point unless we thought it would reshape the country to our liking.]
2.26.2008 6:46pm
Bruce Hayden (mail) (www):
I am not sure that the poster here really understands why at least some of us are panicked at this whole idea. Maybe the worst thing for me is the possibility that it may be open ended. Mandates like birth control, cosmetic surgery, aroma therapy, etc. are one problem - once the program gets going, these additions are going to be hard to avoid, as evidenced by all the states that have mandated some very bizarre things.

Then there is the problem of cost shifting. The government in its attempts to keep its own costs down, caps payments. But those capped costs are often below the costs of the suppliers, so they have to be cross-subsidized. But most of these programs seem to be greatly increasing the capped costs, while reducing the ability to cross-subsidize. Already, it appears that primary care providers are in a big bind, some not making as much as many of the lawyers (and law profs) here, while living under much higher stress levels, due to the volumes necessary to break even.

I guess my problem here is that it sure seems to me that Hillary! and Obama! are thinking with their hearts here, and saying to heck with any adverse consequences that might occur as a result. I am open to suggestions on how the market can be improved, but all I have seen so far would seem to make the markets worse.
2.26.2008 6:47pm
Thales (mail) (www):
"I am curious: How does being an uninsured healthy person qualify one as a free rider?

Wikipedia's definition matches my general intuition: "'free riders' are actors that consume more than their fair share of a resource, or shoulder less than a fair share of the costs of its production." In today's health care market, uninsured people pay significantly more for a given service than insured people and their insurance providers pay. It seems like this would have to change for an uninsured healthy person to be fairly called a free rider. If so, why would that change? If not, what makes the uninsured person a free rider?"

I think the answer is that the benefits of both emergency care, which cannot legally be refused on the basis of inability to pay, and the expected bailout from the system for regular care would be available to the (presently) healthy who don't pay premiums into the system. The whole point of a universal insurance pool is to have there be more in premiums than in realized claims, and if only the net claimants buy the insurance, that's a systemic solvency problem. So it's the latter clause of the above definition of free rider.

Query whether the whole free rider issue could be avoided by instituting a Canada-style single payer system, and making health care a welfare benefit rather than an insurance purchase mandate or subsidy (or both). Then it would be funded by taxation rather than private payins to the pool. That seems to be a political nonstarter in the U.S., but the beneficiaries of cheaper and (mostly, to the average citizen) better health care there might have something good to say about it. As with all systems, Canada has drawbacks, notably the high tax burden (though our current system ain't cheap in this respect either, and it's failing a lot of people) and difficulty obtaining certain services promptly, such as organ transplants.
2.26.2008 6:49pm
Bruce Hayden (mail) (www):
Despite being a fervant advocate of universal coverage, I'll start the bipartisan ball rolling and stipulate no free aromatherapy for illegal aliens. How 'bout that?
Let me suggest that the problem is deeper than that. Aroma therapy for anyone would seem to be too much.

The problem is a combination of level of care combined with creeping mandates. If the solution is universal care, then the level of universal care has to be defined up front. If not, health care is going to consume the entire budget, and then much of GDP. The reason is that no matter the problems with markets right now, they are likely to only get worse, much worse, with the abolishment of price as a limiting factor or signaling mechanism. If cost is not felt by the user of the good or service, then demand is guaranteed to go through the roof.

That is why, way up the thread, I asked for the level of care that was going to be guaranteed, and how that was going to be locked in. Catastrophic care is far more responsive to economic forces than is first dollar coverage, low deductibles, low co-pays, etc. We really need to know what is being promised here.
2.26.2008 6:58pm
A. Zarkov (mail):
"Don't hold me to this, but I seem to vaguely recall from one of the debates that Clinton, Obama and even Edwards placed severe limitations on the coverage contemplated for illegals."

I have not heard that. But Schwarzenegger has advocated covering illegal aliens. He submitted a CA plan for medical insurance while declaring a financial emergency for California! Are we to believe that Obama and Hillary are less generous? Moreover it's one thing to say that as a matter of principle that illegal aliens should not get coverage, but another to actually enforce such a policy in an effective manner. Look at our current immigration policies mostly talk, and no action. Even minimal action is met with stern opposition from the ACLU and immigrant rights groups. I have no confidence that illegal aliens won't get coverage at a tremendous cost to the US taxpayer.
2.26.2008 7:08pm
Bruce Hayden (mail) (www):
Query whether the whole free rider issue could be avoided by instituting a Canada-style single payer system, and making health care a welfare benefit rather than an insurance purchase mandate or subsidy (or both). Then it would be funded by taxation rather than private payins to the pool. That seems to be a political nonstarter in the U.S., but the beneficiaries of cheaper and (mostly, to the average citizen) better health care there might have something good to say about it. As with all systems, Canada has drawbacks, notably the high tax burden (though our current system ain't cheap in this respect either, and it's failing a lot of people) and difficulty obtaining certain services promptly, such as organ transplants.
Note first that the U.S. operates as a backup or release valve for Canadians. If they can't get their organ transplants in time in Canada to save their lives, they can come down here and get them. Going to a Canadian system would likely ultimately remove that option from both countries.

Secondly, you need to define what you mean by failing a lot of people. I would also ask why they have a moral right to demand that those who work hard and live often much more healthy and maybe even virtuous lives should pay for their bad decisions and poor life styles. Yes, I know that many of the uninsured are that way for no fault of their own. But I would guess that many more have plenty of fault, ranging from having kids out of wedlock at a young age, through drug addictions, lack of exercise, bad eating habits, etc. Why is it a moral imperative for those who work hard and do things right to pay for those who don't?

I would expect that most of those here would do better under our present system of medical care than under the Canadian system (and, yes, that is because of the audience here). You are, in essence, asking those of us who are doing better to sacrifice for the common good.
2.26.2008 7:10pm
Orangutan (mail):
I have a question/challenge:

Economically, how come health care for-profit is preferable to "socialized" government-run health care?

I realize both systems have problems, but the current status quo does not seem to work, where the "socialized" approach seems to work modestly in other countries (judging simply by life expectancy and quality of life).

Examples:
Here, with for-profit care, a sickness will cause many families to declare bankruptcy (100,000 a year just from cancer), thus making them victims twice over. Creditors lose out, the economy suffers, etc.

Here, the average family pays around $12,000 a year in health care costs (no cite, but feel free to google it). The congress has just enacted a $600 per family stimulus package; wouldn't a $12,000 stimulus (even if it comes with higher taxes) be a hell of a lot more stimulating?

Here, corporations are being crushed by increased health care costs for their workers, making them uncompetitive internationally. GM reportedly spends more on health coverage than it does on steel. Wouldn't freeing up that health care burden allow them to become more profitable, resulting in higher wages, more jobs, expansion, etc.?


There certainly may be valid counter-arguments, but I have not heard them.
2.26.2008 7:12pm
PersonFromPorlock:

Massachusetts mandates that individuals buy health insurance and even threatens fines if they do not, but 20% of that state's citizens still remain uninsured.

Two points: Massachusetts is a 'commonwealth', not a 'state'; and it's denizens are 'subjects', not 'citizens'.

Incidentally, if you increase the ability of people to pay their medical bills, guess what? The bills will get bigger. There's no other practical effect except that insurance companies make a pile. This really does have all the hallmarks of the Democratic party's being bought by the insurance industry.
2.26.2008 7:12pm
Orangutan (mail):
One more thought:

I don't know if this remains true, but I once heard a commentator talking about the various presidential candidates' health plans. He claimed that, since McCain, Rudy, and Fred Thompson had all overcome bouts with cancer, none of them would qualify for their own proposed plans!

They would all be classified as having pre-existing conditions and denied coverage. If that's really true, then clearly the status quo is not a serious option.
2.26.2008 7:19pm
Barbara Skolaut (mail):
OK, I'll bite.

Where in the Constitution does it say the gummint is responsible for health care or health insurance?

It was the government sticking their noses into health insurance/mandated health care that caused prices to soar in the first place. What used to be covered by charity is now somehow a government responsibility.

I have a better idea than health care/health insurance, etc., mandated by the Feds. Enforce the actual Constitution, not the ones the far-left (and far-right) seem to wish think exists. And watch federal taxes go down and our lives improve.
2.26.2008 7:23pm
DiverDan (mail):
What really bugs me is that Hillary Clinton in particular, and all of the Democratic candidates in general, fail to recognize (or refuse to admit) the gross hypocracy in their position favoring governmental mandates over health care. Hillary in particular has always been an ardent supporter of Roe v. Wade, but the very essence of the Roe v. Wade decision is a right of privacy that protects one's personal decisions on medical care from governmental intrusion. There is simply no way to structure a government funded and administered single-payor health care plan without the government getting deeply involved in personal decisions on health care. Even the decision by government to cover, or refuse to cover, certain procedures or medications necessarily gets the government involved in personal decisions over medical care. Does Hillary believe that the right of medical privacy recognized in Roe v. Wade applies only to fertile women, and ends at the uterus? If, god help us, either Democratic Candidate is successful in pushing through one of their Rube Goldberg "Health Care Reforms", count me as one more than willing to challenge its constitutionality based on Roe and its progeny.
2.26.2008 7:27pm
Left-Right-Left-Right:
Zarkov: I have no confidence that illegal aliens won't get coverage at a tremendous cost to the US taxpayer.

Wouldn't it make more sense long-term to provide preventive care via offering a health insurance plan available to anyone regardless of immigration status rather than forcing the uninsured to tie up the ER?
2.26.2008 7:28pm
The General:
so, if I'm young and healthy and don't have too much money to spend on insurance I won't use and I decide to forego purchasing health insurance, can I expect the gestapo to beat down my door and arrest me? Why penalize people who make a rational decision that they don't need health insurance?

Oh, and anyone promoting government run health care should be sure to mention that it will result in the deterioration in quality care, a loss of privacy, being forced into treatments you don't want, long waiting periods for care, physician shortages and having a big government run bureaucracy decide whether you're worth saving or not. But at least everyone will be covered...right?
2.26.2008 7:28pm
Thorley Winston (mail) (www):
I am not sure that the poster here really understands why at least some of us are panicked at this whole idea. Maybe the worst thing for me is the possibility that it may be open ended. Mandates like birth control, cosmetic surgery, aroma therapy, etc. are one problem - once the program gets going, these additions are going to be hard to avoid, as evidenced by all the states that have mandated some very bizarre things


Agreed which is why the most worrisome mandates that Clinton and Obama's plans each include isn't the individual or employer mandate, it's that BOTH plans would require that any private insurance plan sold anywhere in the United States have as many or MORE mandates than are covered in the rather generous plans offered to federal employees. In other words the problem we have right now in which instead of buying health insurance which covers things like major medical, we're instead forced to buy prepaid health care (which is why it's so blasted expensive) would be made worse rather than better under their proposed "reform" and even more people would be priced out of the private insurance market.

So what happens is this -- Obama and Clinton's plans both impose new mandates on the private market which make it even more cost-prohibitive for people to buy health insurance BUT they'll give you a subsidy if you go into a government-run plan. Their idea of "market forces" is to essentially regulate people (even more so) out of the private market with new mandates but subsidize them at taxpayer's expense if they go on the dole.

It should be pointed out though that McCain has come out in favor of John Shaddegg's proposal which would let consumers pick from any plan sold anywhere in the United States rather than just the ones which meet their home State's mandated benefits requirements. For those who favor free markets and federalism, this is a pretty clear contrast to Obamacare and Hillarycare 2.0.
2.26.2008 7:33pm
Orangutan (mail):
Oh, and anyone promoting government run health care should be sure to mention that it will result in the deterioration in quality care, a loss of privacy, being forced into treatments you don't want, long waiting periods for care, physician shortages and having a big government run bureaucracy decide whether you're worth saving or not. But at least everyone will be covered...right?

How is that different compared to a huge health management organization? Other than the fact that the government is not presumably looking to deny coverage to make a profit...
2.26.2008 7:33pm
Lively:
If our health care is ever socialized (and that's the way it may go), then I predict some doctors will set up a "self-pay" practice and only accept patients who pay cash.

Then wealthy people who do not want to wait for their health care ration, will go to the cash only doctors.
2.26.2008 7:35pm
Thales (mail) (www):
"I would also ask why they have a moral right to demand that those who work hard and live often much more healthy and maybe even virtuous lives should pay for their bad decisions and poor life styles. Yes, I know that many of the uninsured are that way for no fault of their own. But I would guess that many more have plenty of fault, ranging from having kids out of wedlock at a young age, through drug addictions, lack of exercise, bad eating habits, etc. Why is it a moral imperative for those who work hard and do things right to pay for those who don't?"

I don't think it's a moral imperative, but it may be something we as a society nonetheless politically decide to do because it makes society better off as a whole. Also, I question your premises: For example, I'm not sure that it is "morally" better for the filthy rich but hard drinking Mickey Mantles of the world to be able to afford liver transplants doled out on the basis of ability to pay, than for a poor person who lives "right" but has a non-lifestyle related chronic illness to be refused care because he has not proved his superior virtue through accumulation of wealth.

"I would expect that most of those here would do better under our present system of medical care than under the Canadian system (and, yes, that is because of the audience here). You are, in essence, asking those of us who are doing better to sacrifice for the common good."

I am not asking anyone to do anything. I would point out though, that the status quo asks us to sacrifice for parts of the common good--the indigent (Medicaid) and the elderly (Medicare)--in a way that is rife with inefficiency. Given that reality, if an improvement in the system could produce better average results at lower average cost (counting both private and social costs), isn't that a more desirable system than the status quo? On average, people in France, Great Britain, Germany, Japan and Canada live longer, have lower infant mortality and lower incidence of most disease (lifestyle related or no), than those living in the U.S. All of these are rich industrialized democracies with some form of socialized medicine. You can't credibly tell me that all of these countries are suffering unduly from the systemic burdens of drug addicted teenage mothers, or Cadillac driving welfare queens for that matter or that all are relying on the U.S. as a safety valve.
2.26.2008 7:36pm
Pyrrhus (mail) (www):
re free riders

Forgive me if this post is redundant to one of the ones above, but in the top half of comments there seemed to be confusion about Korobkin's reference to Obama's plan having a problem with free riders. I'm guessing the reference was to the below problem:

Obama's plan is susceptible to free riders because it promises to give low coverage to all without forcing people to buy in. So you can "free ride" by waiting until you get sick to buy coverage, and possibly even dropping it after your bills are payed. So you can free ride by paying less (even if you are not healthy) than healthy people who sign up for Obama's plan for the long term (rather than just when they get sick), and still consume more health care than healthy people who sign up over the long term.
2.26.2008 7:37pm
Orangutan (mail):

If our health care is ever socialized (and that's the way it may go), then I predict some doctors will set up a "self-pay" practice and only accept patients who pay cash.

Then wealthy people who do not want to wait for their health care ration, will go to the cash only doctors.


I think that's accurate, but is that a bad thing? A government-run system does not mean private insurance will not live on and profit. It only means people who want to upgrade will simply have to pay more.

I think of it along the lines of law enforcement:
The police are a government-subsidized program, but there is nothing stopping someone from hiring a body guard or a private detective to supplement that system. Why would health care be any different?
2.26.2008 7:41pm
Kazinski:
I'd like to see the McCain create a Universal Catastrophic Insurance plan that would be structured as a block grant to the states. It would be funded, at least partially but ending the employer health insurance deduction. Individuals and Families would then have option of privately buying coverage for the first 2500/5000 of medical costs, self insuring, or Medical Savings Accounts. This option would have the benefits of putting most health care expeditures in a free market economy, yet leave a safety net for those with serious illnesses, and likely solve the rationing/overuse problems of single payer systems. The poor would still be covered by existing medicare systems up to the 2500/5000 deductible.

I think Dr's, employers and individuals would all jump on board. The States could contract with existing insurance companies to bid on the catastrophic coverage business, and they could continue selling policies to individuals, and companies could continue offering insurance as a benefit up to the 2500/5000 limit.
2.26.2008 7:43pm
Lively:
Orangutan:

The difference between hiring a body guard and health care is that the average joe walking around does not require a body guard. However, everyone needs health care.
2.26.2008 7:48pm
Orangutan (mail):

The difference between hiring a body guard and health care is that the average joe walking around does not require a body guard. However, everyone needs health care.



But isn't that an argument for universal coverage?

All I'm saying is that socialized medicine will not eliminate the demand for private/luxury health care.
2.26.2008 7:53pm
jvarisco (www):
Not to disagree so much, but does Obama seriously think there is any question there won't be a ton of free riders in the system he is proposing? If you make not getting insurance a rational course of action, of course people will do it. So why wait for them to take advantage rather than fix the system now?
2.26.2008 8:00pm
Thorley Winston (mail) (www):
On average, people in France, Great Britain, Germany, Japan and Canada live longer, have lower infant mortality and lower incidence of most disease (lifestyle related or no), than those living in the U.S.


Seems to me that we've heard that one before.
2.26.2008 8:05pm
Chem_geek:
Left-Right-Left-Right: Preventive medicine is anathema to the present insurance scheme sharks scammers industry.

They'll pay for heart attacks, arthritis, diabetes, etc., but pay for obesity prevention? Never!
2.26.2008 8:14pm
RR18:
I wonder if any of the legal scholars would comment on Senator Clinton's statement today in Ohio, apparently referring to insurance companies denying health insurance coverage to people who are sick:

"I actually think that it's unconstitutional, what the insurance companies are doing."

Ben Smith of politico.com posted the quote under the heading "a broad reading" (http://politico.com/blogs/bensmith ).
2.26.2008 8:27pm
TruePath (mail) (www):
It strikes me as somewhat unfair to criticize Clinton for not going into specifics about how she would enforce the mandates while your canidate is blating her for being mean by inflicting penalties on the poor people who might be hit with such penalties. I mean it seems to me there is a bit of a bait and switch going on here. People have a very intuitive emotional understanding of what health insurance costs now and the allegation that Clinton is being mean *in practice* rests on people's reactions to penalizing people for not paying these high bills.

Ultimately the devil is in the details. Suppose the subsidies the Clinton plan offered were so great they reduced the cost of health insurance to $1 for everyone but the indigent. Surely then it would be justified to penalize those people who didn't comply. Now obviously her plan doesn't do this but the point is whether or not this is imposing a hardship rests on complex details of the plans that people aren't really paying any attention to and it seems to me that one can have a serious debate about whether these subsidies are enough that the penalties will be reasonable but to single out the penalties on their own is to paint a misleading picture.

-----------

Anyway I think you also gloss over the real benefits of an individual mandate. The benefits acrue to everyone through decreased transmission of communicable diseases and greater preventative care. In particular government subsidy of health care means that allowing people to not purchase health insurance allows them to push the cost of their failure to pursue preventative care onto the government in the future.

Frankly though if you aren't going to bother with an individual mandage what's even the argument for 'universal' health care?
2.26.2008 8:43pm
therut:
Why not have mandated retirement, disability, life, home, auto, general liability insurance while we are at this game. Why not just pay the government a certain amount per year from birth on to care for you. They can provide everyting above plus food, clothing, education,housing,transportation etc. Why not just become a subject of the KING. We can go back in time I guess. If anyone is foolish enought to think a system like Medicare can be affordable for the whole of the citizens they are whisteling Dixie. It will come at the expense of total government control of what and who and when you get health care and by whom. Oh it will not start this way but over time the screws of government will tighten. It would have too. There is not enough money to fund it any other way. Of coarse the truly rich will still be able to buy better care but the middle class (not the Dems middle class) will be crushed and forced to like it or leave it. The practice of physicians will be destroyed over time. You will be taken care of by middle of the road physicians. The bright people will not go into medicine(which is already happening). They will work their shift and go home. I hope to God I am not here to see this and espically I hope I am not old and frail.
2.26.2008 8:44pm
Thoughtful (mail):
Chem-Geek: "Left-Right-Left-Right: Preventive medicine is anathema to the present insurance scheme sharks scammers industry.

They'll pay for heart attacks, arthritis, diabetes, etc., but pay for obesity prevention? Never!"

It's even worse than that! Why, they'll pay for pregnancy, but they won't even pay for condoms!! It's absolutely outrageous.

Chem geek makes a good point about obesity prevention. Why, if you can't get free coverage for weight loss, people will have no conceivable incentive to lose weight.
2.26.2008 9:04pm
Thoughtful (mail):
The rut, who I recall is also a physician, is absolutely right about the best no longer going into medicine. The residents I've worked with recently look at you quizzically when you suggest they might want to do some reading when they get home. Don't they already work 8-6? Surely, if they're supposed to learn things from reading, shouldn't the program provide reading time? A generation ago residents would stay late to followup interesting cases in the hopes of learning something. Now residents leave in the middle of critical situations because their shift is over and the critical patient is passed on to someone else. Of course, this has nothing to do with the perceived changes in benefits and burdens of being a physician over the last generation.
2.26.2008 9:10pm
therut:
Preventive medicine for obesity, tobacco, alcoholism and drugs does not work and is a total waste of money. Believe me I have practiced Medicine for 22 years and I have never been the one to cause or help someone to change their behavior. The more you nag the more they resist. It is hard enough to get diabetics to take their insulin right much less eat right. I have patients in the hospital 24 hours out from a heart attack or just off the vent for respiratory failure from COPD and they are outside smoking. Just lay out the facts and put the ball in their court. 99 percent will not change. It is a free country right?
2.26.2008 9:13pm
Thoughtful (mail):
Clintonian health insurance mandates are like being frisked by the TSA at airports. The latter is designed to create the illusion of safety. The former is designed to create the illusion that everyone has coverage. The homeless man with no permanent address, the heroin entrepreneur who works in the underground economy, the citizen who has successfully avoided filing income taxes for the last 8 years--all will magically be covered with a health insurance mandate. How? Why, weren't you paying attention? We used the word "mandate" right there in the first sentence of the legislation...
2.26.2008 9:15pm
Bruce Hayden (mail) (www):
Given that reality, if an improvement in the system could produce better average results at lower average cost (counting both private and social costs), isn't that a more desirable system than the status quo? On average, people in France, Great Britain, Germany, Japan and Canada live longer, have lower infant mortality and lower incidence of most disease (lifestyle related or no), than those living in the U.S.
One problem with your comparisons here is that those countries are all highly homogeneous, esp. as compared to the U.S. I would be more convinced if the comparison were between Americans of British extract versus Brits of British extraction, etc. African-Americans have a significantly lower life expectancy, on average, than many other ethnic groups here, and those countries all have low concentrations of Blacks. And our Native-Americans are probably even worse off, and those countries have essentially none of that ethnic group. Many of our Hispanics were born in third world countries. Same problem. Japan is, of course, the worst of these countries, as far as being racially and ethnically unmixed. But none of them are anywhere close to as racially and ethnically mixed as we are.

I remain doubtful that any system designed contrary to the laws of economics is likely to provide better results at a lower cost. Rather, I would suggest that your belief in such is wishful thinking. And I would further suggest that both Obama's and Hillary's proposed systems attempt to hide the fact that they try to slide around the laws of economics through smoke and mirrors, and that is exceedingly unlikely to work.

One thing that is scary to me is that the proposed mandates for coverage would seem to contravene high deductible policies as I did when I wasn't covered by a group plan. One beauty of such plans is that you have an incentive to only go to the doctor when you really need to. And that puts some level of cap on demand. But first dollar coverage, low deductibles, or low co-pays have the opposite affect, disconnecting supply from demand. Demand is artificially inflated, since those obtaining medical care are not the ones directly paying for it. And the lower the cost to those using a good or service, the higher the demand.
2.26.2008 9:15pm
Duncan Frissell (mail):
after the reforms and subsidies reduce costs,


I hope that none of our future leaders actually expect their efforts to reduce health care costs. If they do, they show a lack of historical awareness and understanding of economics.

If they were to deregulate the provision of medical services -- no FDA, no government insurance contract design, no professional licensing, no outlawry of the construction of medical service institutions; costs might drop. Otherwise, not a chance.
2.26.2008 9:17pm
Aleks:
Re: Wikipedia's definition matches my general intuition: "'free riders' are actors that consume more than their fair share of a resource, or shoulder less than a fair share of the costs of its production."

That's a bad definition. Consider a person who manages to evade paying local taxes. That person never calls the police or fire department and has no children in school. Acording to you that person has done no wrong and isn't a free rider.

Re: In fact, the elimination of insurance, medicare, medicaid, and all other governmental programs would force the medical community to react to market forces.

Yep-- by turning away millions of people and letting them die on streets. That's not hypebole since your suggestion is in full force in a number of countries around the world. Visit Haiti (for a nation too terribly far away) for a lesson in the results.

Re: Government mandated insurance is just more welfare for corporate america.

I suppose you would also have us repeal public nudity laws since those are corporate welfare to the garment industry.

Re: Going to a Canadian system would likely ultimately remove that option from both countries.

Yes, but then public demand would force both systems to behave themselves better.

Re: the deterioration in quality care, a loss of privacy, being forced into treatments you don't want, long waiting periods for care, physician shortages and having a big government run bureaucracy decide whether you're worth saving or not.

We have all of these things right now, except instead of a government bureaucrat it's an insurance bureaucrat.
2.26.2008 9:21pm
Orielbean (mail):
As a Mass resident who also administers major employer health plans and answers participant questions, I can say that the Mass system is not the socialist boogeyman that I read about in comments here.

The concept is still very market-based. Basically, if your employer doesn't pay much towards your share of health care, you can pick up a bunch of normal-looking health plans from the state system. Your income and how much paid by the employer are the 2 major factors.

Your monthly premium is about the same amount as you'd pay for a 75% employer subsidy (the standard amount for a working professional). So your waiter buddies and 7 year college students don't have to worry so much about preventative care. If you lose your job, it's much more reasonable to hop on the state plan vs picking up the awfully expensive COBRA coverage for the family.

The state also has extended the Medicaid safety net wider for elderly, disabled, etc. In my opinion, it is a better implementation than a single payer system or the other European systems that exist today, as it allows the natural competition between doctor/hospital and actuaries at the insurance companies to keep the cost of services at a normative level.

At the same time, the penalty system is keeping more participants with skin in the game - which also has the useful side effect of being able to determine which citizens will suffer from chronic conditions (due to having more people participate and become part of the data set) - this is not insignificant. If you have less than 1500 employees, insurance companies have a very hard time seeing how healthy your employees will be from year to year, which will impact your employer premium with the insurance company.

I think the Mass system is a great effort and will help provide some useful examples for the future that doesn't drag quality down, kill the poor, or punish the wealthy / taxpayers.
2.26.2008 9:24pm
Thoughtful (mail):
The Rut: "It is a free country right?"

Why, I was with you until that last sentence...
2.26.2008 9:28pm
Tony Tutins (mail):
Some comments here just stump me:

When a wealthy person pays for national defense, he pays far more for the same amount of "protection" as does a poor person.

I believe people pay in rough proportion to the amount of protection they receive because wealthy people have much more to lose than a poor person. They have to pay much more for every other kind of protection: on their mansion, on their yacht, on their jewelry, on their airplane, on their Lamborghinis and Rolls-Royces, on their life. The wealthy man needs bodyguards and armored cars, the poor man does not. The wealthy man always has the option to relocate anywhere in the world he chooses, yet somehow here they remain.

But if it is wrong to force people to buy health insurance for themselves (mandates), how can it be ok to force people to buy insurance for others (subsidies).

The government's been forcing me to buy health insurance for others since the mid-1960s (Medicare), so it must be ok. I'm still hoping it will be my turn to receive some some day.

an unemployed couple in their 50's

These are the people who need help most. My neighbors were caught in the dotcom bust. The best they could get was retail without benefits. Which leads me to
free riders.

People are relatively healthy from 20 until 40 when they start to fall apart. This is the bathtub curve familiar from reliability science. If someone opts out from 20 to 40, he will have saved a lot of money for other purposes, but he will be sucking funds from those contributors who are under 40 when he finally signs up.
2.26.2008 9:28pm
Pyrrhus (mail) (www):
Jvarisco writes:


Not to disagree so much, but does Obama seriously think there is any question there won't be a ton of free riders in the system he is proposing? If you make not getting insurance a rational course of action, of course people will do it. So why wait for them to take advantage rather than fix the system now?



The obvious answer seems to be so that he can pretend to be proposing neither socialized health care nor mandated health care.

Obama's healthcare seems slimier to me the more I think about it. What possible reason could there be to subsidize a system and then give people the "option" of buying into it. Citizens who play fair are punished for dutifully buying health care.

And what about those who feel they cannot afford it? What possible reaction could we have, once they get sick, except to shrug and say "sure" when they ask into the open program? Allowing anyone to buy in after the fact of sickness is an invitation to free ride, not merely a loophole. There is no way, with a straight face, a politician could tell the sick that they ought to volunteer to remain outside of Obama care, and just die (or suffer) from some wasting illness.

I can see why Obama might like his plan: it grants potential access to health care to the poor, without necessarily imposing the cost of mandates on them.

But to the extent that it does this, it is merely socialized health care. It is disingenuous of Obama to pretend otherwise. Or perhaps Obama is merely being disigenuous when he says he won't demand a mandate. Either way he is deceiving people about something.
2.26.2008 9:36pm
Steve2:

Or is this really about being sure that everyone gets exactly the same thing? Even if it means waiting months for emergency surgery, or all the other reasons that Canadians come down here when they can afford it.


I wouldn't object to that. Why do people have a right to deviate from the median quality of life?

One thing that I wonder about is what's the real price of medical anything? After every visit to the doctor, my insurance plan mails me a nice little sheet of paper that has the following numbers on it:

A) How much the doctor said it costed.
B) How much my co-pay was.
C) How much the insurance company will pay for the whatever.
D) How much the insurance company paid the doctor, equal to C.
D) Amount the doctor's still owed, equal to A - B - C
E) How much I still owe the doctor, equal to zero.

So is the price A, or is it B + C, or is it B plus my premiums (adjusted for the time value of money)? And what happens to amount D?

Actually, maybe that dissapearance of amount D, which an uninsured person would have to pay, is what the "free-rider" bit's about.
2.26.2008 9:41pm
Ben P (mail):

I have no confidence that illegal aliens won't get coverage at a tremendous cost to the US taxpayer.


Guess what?

They already do.

Draw from this whatever conclusions you wish, but poor illegal aliens, just like poor Legal Residents and Poor US citizens, will be treated if they show up to a hospital in some state that requires care.
2.26.2008 9:59pm
Toby:
On the lsit of free riders *I* am more concerned about
- Those lard asses who sit next to me on the airplane and seem to require two seats
- Those same behemoths who seem to "acquire diabetes through no fault of their own"
- Those who slack on gymn memberships while whining that others should cover their health care
- Those who demand priapic drugs to compensate for their anerobic lifestyles and diabetes-induced circulatory problems
- Smokers. Of any kind. Of any plant.
- Anyone who took a vacation of any kind while I was putting three kids through private school. THier kids are functional illiterates who my kids will have to support
- Anyone who paid someone else to mow their yard while they watched sports from the Lazy Boy
- Anyone who hikes into the woods, alone, and expects rescue
- Double anyone who hikes into the wod with their kids and expects rescue.
- Anyone who has an STD except by legitimate verified rape.

If and when you propose a society in which someone gets after the above with some sort of experienced professionals with armed with cattle prods all day and every day, then you can come after me for a "subsidy". Until then, it is not a medical subsidy, it is a life-style subsidy.

Don't like that brave new world. Well, then that means you have not confronted the dishonesty of your call for subsidies that protect the innocent. Your call for fairness is merely a dishonest cover for buying votes.
2.26.2008 10:02pm
Ben P (mail):

The rut, who I recall is also a physician, is absolutely right about the best no longer going into medicine. The residents I've worked with recently look at you quizzically when you suggest they might want to do some reading when they get home. Don't they already work 8-6?


I'm rather dubious of this claim. Going to an undergrad institution that had a very large percentage of "pre-med" students, only the best had a significant chance of getting into med school. There's a few places where people who were otherwise can get in, but not many. The rest of them were fighting for tenths of a point between 3.8 and 4.0.
2.26.2008 10:06pm
Pyrrhus (mail) (www):
Thats a pretty rambling list that is at one moment redundant with health care free riding, at another trivial (fat people on airplanes?), and at another divorced from government policy.
2.26.2008 10:09pm
Pyrrhus (mail) (www):
Oh and some of it isn't even free riding.

(- Anyone who paid someone else to mow their yard while they watched sports from the Lazy Boy )
2.26.2008 10:11pm
therut:
It will be interesting to see how they try to control cost. Medicare is going to bankrupt the country as it is. I can not imagine putting everyone into that system. I remember several years back the State of Arkansas tried two tricks to control Medicaid costs. One was to make a 50cent to 1.50 cent co-pay thinking the poor would not overuse the system. Did not work. They still went to the physician anytime they wanted and just did not pay the co-pay so in reality the physicians were making less. Next they tried to limit visits to 12 a year. They still over used and physician just got paid nothing for the extra visit. Until the government can somehow limit the over use it will be a complete failure. I guess they will just pay physicians less. You have no idea what FREE health care does. Parents bring in children with a runny nose that just started that morning and since they are coming they bring in the 2 other children just to have them checked. All a total waste of time and money. How will the governemt stop that? They can't anymore that they can make someone lose weight. There is another big problem in the making. The high rate of Diabetes in the Mexican population is going to be very expensive. Plus obesity is rampant in this group even the very young children. The government will not change that I can guarantee it. The parents get mad if you even bring the subject up.
2.26.2008 10:35pm
dew:
Russell Korobkin: Massachusetts mandates that individuals buy health insurance and even threatens fines if they do not, but 20% of that state's citizens still remain uninsured.

Considering that MA was at around 10% uninsured before the insurance mandate, and has gone down from there, you might want to check your facts.
2.26.2008 10:39pm
Toby:
Well, as yard work is considered a good mode of exercise, than failing to avail oneself of it, and actually paying someone else to do it for you, should mean that your lesser health is now your own responsibility. (I was reaching for someone who "couldn't afford to work out")

Yes it is rambling - but every one of them is arguably choosing poor health over better health. If there costs are covered by society, every one of them is choosing to rely on someone else paying for their life-style choices. THsi means every one of them is free-riding.

I do not think society should require each of them to reform. I want to be able to eat a stick of butter stright from the fridge every day if I wish (although I don't wish).

I just think that those who take the rare case and use it to talk about fate and unfairness are making a dishonest argument. Most of the people who die early die early for one of two reasons: bad decisions or bad genes.And we won't do much for them anyway if they have bad genes. (Jim Fixx outlived his father and grandfather, but still died in his 40's).

If you want to argue that society should cover the unusual cost of the run-away steam roller, so be it. But if I have to pay for your health care, I should be able to snatch that cigarett from your mouth and grind it into the ground, and take away your Krispy Kremes as well. From there it is a short step to regulating sexual behavior and french dinners with reduced cream sauces.
2.26.2008 10:42pm
CEpperson:
In a free society the government should not be mandating things like Health Insurance. The same goes for Auto Insurance. Things like that make one less free and more a subject and less a citizen.

The more the government stays out of peoples lives the better they are.

How long before they mandate physical fitnes( if you don't you are wrong and wasteing tax money in fitur healt costs) or strict government approved diets. Thats the kind of tyrany I cannot abide.
2.26.2008 11:05pm
Jmaie (mail):
Re: Going to a Canadian system would likely ultimately remove that option from both countries.

Yes, but then public demand would force both systems to behave themselves better.


Aleks get my "optimist of the year" award
2.26.2008 11:14pm
Jmaie (mail):
"From there it is a short step to regulating...french dinners with reduced cream sauces."

Sir, you go too far.
2.26.2008 11:18pm
glangston (mail):
The claim of 45 million uninsured has a strong link to the claims of global warming ....or as we're wont to say "climate change"..... Mostly it's utter BS once you account for those who could afford heath insurance and don't buy and those who are not citizens. Leaving around 9 million to affect a sea change of federal bureaucracy is ludicrous.

Less ludicrous than universal legal representation but only slightly.

All the programs that infect people with the idea that they are subsidized, or even worse, free. are destined for the ash heap of things over-valued or under-used.
2.26.2008 11:36pm
David Schwartz (mail):
Our current health care system is currently so screwed up in so many ways for so many reasons that there really are three separate problems. One is figuring out where we want our health care industry to get to. The next is figuring out how to eventually get there. The last is figuring out how to deal with all the problems the kinds of major changes we need will cause.

Our biggest problem is that we are committed to trying to provide only a single tier of service. Imagine if we decided that all car owners had to have the very safest cars. Every new safety feature would be a threat to the economy and the average person would spend a lot more on cars than they do now.
2.27.2008 12:57am
A. Zarkov (mail):
Ben P.

"They already do.

Draw from this whatever conclusions you wish, but poor illegal aliens, just like poor Legal Residents and Poor US citizens, will be treated if they show up to a hospital in some state that requires care."


I already said that anyone with an emergency or an infectious disease should receive treatment.

Do you assert that anyone, including illegal aliens, can simply show up at the ER or the hospital and get procedures like bypass surgery, transplants, cataract surgery, hip replacements etc? If such is the case then we already have universal coverage and we don't need new programs.

As Milton Friedman said you can have either open borders or a welfare state, but not both.
2.27.2008 1:51am
Justin Bowen (mail):
Boy am I sorry that I missed this discussion.


Clinton has refused to propose a penalty and enforcement structure for the mandate that she trumpets so loudly, and she has dodged the question of whether she would exempt the poor from the requirement. This makes her call for mandates meaningless rhetoric, and the claim that her plan would cover everyone false.


Now, I know that this only a proposed solution, but here is what ABC reported her as saying:


Sen. Hillary Clinton, D-N.Y., this morning left open the possibility that, if elected, her government would garnish the wages of people who didn't comply with her health care plan. "We will have an enforcement mechanism, whether it's that or it's some other mechanism through the tax system or automatic enrollments," Clinton said in an appearance on "This Week with George Stephanopoulos".

Clinton went on to say, though, that such mechanisms would not include penalties. "They don't have to pay fines … We want them to have insurance. We want it to be affordable. And what I have said is that there are a number of ways of doing that. Now, there's not just one way of getting to that."


I'm surprised that the people who read this blog missed that. While that does not mean that she will push for wage garnishment, she has certainly led people to believe that it's a possibility. As a matter of course, I refuse to support anyone who propose economic tyranny, which is exactly what that is.


Auto insurance mandates are good for the people who might be hit by an uninsured motorist, but they are hardly welcomed by the uninsured who feel, rightly or wrongly, that they can't afford coverage.


I can't stand it when people use auto insurance analogies as proof that health insurance mandates will be a good idea. They pass right over the issue of whether a person can opt out of buying health insurance like they can with auto insurance. They also pass right over the fact that people can, in many, if not most, states, choose to decline uninsured motorist coverage.


Massachusetts mandates that individuals buy health insurance and even threatens fines if they do not, but 20% of that state's citizens still remain uninsured.


As Dew has noted, your facts are wrong. Here's some interesting commentary on the effects of RomneyCare: http://www.cato.org/pub_display.php?pub_id=9127.

Is Mr. Tanner wrong in his conclusions? If not, why would anyone in their right mind use the MA model as a model for what should be done on a national level?

What I want to know is what either of the socialists plan to do about the over-regulation. Mandates on the insurance companies themselves at the state level are large contributors towards the rising prices. As states continue to mandate that insurance companies cover more procedures and illnesses, the companies raise prices to cover the increased expenses that come with paying for those procedures and illness. Do Clinton and Obama plan on forcing insurance companies to cover everything under the sun, thereby causing prices to skyrocket, or do they plan on deregulating the insurance industry and allowing insurance companies to provide customers with the option of picking and choosing what procedures they want coverage for and what procedures they don't want coverage for (e.g. allowing me to decline coverage for cancer, HIV/AIDS, paralysis, obesity-related illnesses, and other conditions that are catastrophic or chronic in nature)? I imagine that they aren't in favor of that since they want to socialize the costs of health insurance (to include socializing the costs of care for people who make atrociously bad lifestyle choices) but it's worth asking since we have an adviser for one of the candidates here.
2.27.2008 2:10am
Thorley Winston (mail) (www):
Regarding the issue of mandates, from "Barack Obama's Plan for a Healthy America":


(1) OBAMA'S PLAN TO COVER THE UNINSURED. Obama will make available a new national health plan which will give individuals the choice to buy affordable health coverage that is similar to the plan available to federal employees. The new public plan will be open to individuals without access to group coverage through their workplace or current public programs. It will also be available to people who are self-employed and small businesses that want to offer insurance to their employees.

The plan will have the following features:

. . . .

Comprehensive benefits. The benefit package will be similar to that offered through the Federal Employees Health Benefits Program (FEHBP), the program through which Members of Congress get their own health care. The new public
plan will include coverage of all essential medical services, including preventive, maternity and mental health care. Coverage will include disease management programs, self management training and care coordination for appropriate individuals.


So what Obama is promising to do (and its virtually identical to the Clinton proposal in this regard) is to allow people to basically opt into a plan comparable to the plan offered to federal employees. Note that government health benefits are some of the most generous in the nation and usually include prepaid health care (as opposed to actual health insurance) at low deductibles and copays because the cost of which is being born by the taxpayer. Keep in mind that the new participants won't actually be working for the government and many in fact will be having their premiums subsidized even further (thereby creating a new class of dependents). But here's the part that ought to scare the s*** out of anyone who already has coverage either on their own or through their employer:

(2) NATIONAL HEALTH INSURANCE EXCHANGE. To provide Americans with additional options, the Obama plan will make available a National Health Insurance Exchange to help individuals who wish to purchase a private insurance plan. The Exchange will act as a watchdog and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible. Through the Exchange, any American will have the opportunity to enroll in the new public plan or purchase an approved private plan, and income-based sliding scale subsidies will be provided for people and families who need it. Insurers would have to issue every applicant a policy, and charge fair and stable premiums that will not depend upon health status. The Exchange will require that all the plans offered are at least as generous as the new public plan and meet the same standards for quality and efficiency. Insurers would be required to justify an above-average premium increase to the Exchange. The Exchange would evaluate plans and make the differences among the plans, including cost of services, transparent.


What Obama's proposed here (and again this is virtually identical to the proposal offered by Clinton) is to "allow" people to continue to buy private insurance BUT now the insurance plan will be required to be "at least as generous as the new public plan" which means that in ADDITION to the already existing mandates which the States have imposed (and which Obama explicitly promises to allow to continue so long as they're "as generous" as his plan), there will be a NEW set of mandates which will make private insurance even more expensive than before (plus the cost of regulatory compliance for his new "watchdog").

So basically what Obama (and Clinton) has proposed is to (a) make it more expensive for people to get insurance on their own or through their employers by requiring private insurance plans to carry the same or comparable mandated benefits as are covered under health plans for federal employees and (b) to subsidize people who enroll into a new government-run plan paid for by the taxpayer. The logical outcome would be to displace people who have existing coverage and moving more people onto the dole.
2.27.2008 4:42am
PersonFromPorlock:
Aleks:

We have all of these things right now, except instead of a government bureaucrat it's an insurance bureaucrat.

If I understand mandated health care correctly, it'll still be an insurance bureaucrat, just one the government's compelling you to do business with. Somehow, I don't think the latter fact will improve the situation much.
2.27.2008 7:42am
Dan Weber (www):


Economically, how come health care for-profit is preferable to "socialized" government-run health care?

I realize both systems have problems, but the current status quo does not seem to work, where the "socialized" approach seems to work modestly in other countries (judging simply by life expectancy and quality of life).


Our status quo could probably be called capitalist on paper, but it's a pretty messed up version of that.

The law strongly encourages people to have insurance through their employer. This sets up two levels of insulation between the consumer and the bill.

It's like going out to eat with your friends, and you decide up front that you will all split the bill evenly. Maybe the filet mignon wasn't worth pay $10 extra, but when split it'll only be $1 extra. Sounds good, except for the fact that everyone else is getting filet mignon, too.

As I've said before in this thread, there are certain parts of the health care system that can't and shouldn't be made free market. However, that doesn't mean we should throw the free market entirely out the window.

Take a look at LASIK, for example. It's gotten a hell of a lot better and a hell of a lot cheaper over the past 10 years. Note that the insurance companies are generally totally uninvolved in it. That's not a coincidence. Taking the insurance industry out behind the barn and shooting it in the head isn't a bad way to start reform.

How can we capture the benefits of the free market while still allowing for emergency service and care for the poor? That's the question to be looking at.
2.27.2008 10:27am
Dan Weber (www):

Wouldn't it make more sense long-term to provide preventive care via offering a health insurance plan available to anyone regardless of immigration status rather than forcing the uninsured to tie up the ER?

"More preventive care will actually lower costs" is a common rallying cry, but it's not really true.

There are indeed a few preventative steps that lower long-term costs. And most of these are already encouraged.

But if one could magically lower medical costs by throwing money at "prevention" then it would've been done already. Look at all the states with budget crises. If all this money is sitting on the table to be saved if they just shoveled more onto the "prevention" pile, we'd see one of them doing it already.

I'll admit that the insurance companies don't always have incentive to promote prevention when it would save money; if it stops someone from getting sick ten years down the road, well, the patient will likely be on someone else's insurance plan at the time. That's why I'd really like to see insurance become more personal rather than employer-based. (I don't lose my house insurance if I lose my job.)

I suppose the government would have more force to encourage people to stop bad behavior than an insurance company would. That's not a re-assuring thought, though.
2.27.2008 10:49am
Mark Buehner (mail):
Oh the law of unintended consequences is sharpening its knives.

Either of these schemes will inevitably lead to single payer 'HillaryCare'. That is no accident. If the government rigs the system to give the young and healthy (the vast majority of the uninsured... economics at work) a simple way to get catastrophic insurance cheap... the entire private system will collapse in heap. Open secret- our current ponzi scheme like system is built on tricking the young and healthy into subsidizing everyone else with insurance they dont need.

Now, as someone said, neither Dem is actually interested in universal insurance coverage. They are interested in universal healthcare, run as a command economy. These plans are simply trojan horses to destroy the private industry. Granted our insurance industry is messed up and disfunctional, but NOTHING like the tragedy that will become when the people that brought you the IRS and the DMV run your health.
2.27.2008 11:07am
Thorley Winston (mail) (www):
I'll admit that the insurance companies don't always have incentive to promote prevention when it would save money; if it stops someone from getting sick ten years down the road, well, the patient will likely be on someone else's insurance plan at the time. That's why I'd really like to see insurance become more personal rather than employer-based. (I don't lose my house insurance if I lose my job.)


Agreed, we ought to get rid of the distortion in the tax code that favors employer-based insurance. Ideally I think we should give people who buy their own insurance the same tax benefits that employers get and put a cap on how much of the employer-based insurance is deductible to discourage the gold-plated policies with little or no deductibles and copays.

In addition Obama's proposal would not only continue to favor employer-based insurance he would MANDATE it under a "pay or play" provision which would end up being just another tax on employment. Ironically enough while he would exempt some smaller businesses from this new mandate, those would most likely be the very people who are currently going without health insurance and not eligible for already existing programs like Medicaid.

So with Obamacare we have (a) a new tax on employment targeted at those who have health insurance now and (b) mandates that will make private insurance even more expensive with (c) subsidies for people who sign up for his new government-run system.
2.27.2008 11:49am
Joe Bingham (mail):
From OP:

she is trying to market mandates

That's ironic.
2.27.2008 12:17pm
Tony Tutins (mail):

Granted our insurance industry is messed up and disfunctional, but NOTHING like the tragedy that will become when the people that brought you the IRS and the DMV run your health.

I never thought I'd see a time when a volokh poster implicitly conceded that the French are superior to Americans: The French healthcare system runs wonderfully well; we have no hope of emulating it.
2.27.2008 1:38pm
The Unbeliever (mail):
Thorley: I'm no fan of Obama or his proposed health care policy. But I think I saw something interesting; if I'm reading that excerpt right, it looks like those restrictions are only applicable to plans trying to get listed on his Exchange? Selected quotes plus emphasis:

the Obama plan will make available a National Health Insurance Exchange... The Exchange will act as a watchdog and help reform the private insurance market by creating rules and standards for participating insurance plans... any American will have the opportunity to enroll in the new public plan or purchase an approved private plan... The Exchange will require that all the plans offered are at least as generous as the new public plan and meet the same standards for quality and efficiency. Insurers would be required to justify an above-average premium increase to the Exchange.


So could an insurer theoretically get away with not trying to list anything on the Exchange, and offer whatever the heck they want? Could they get away with submitting a laughably bad plan as a token gesture, then walk away when nothing gets approved? Does Obama really mean to establish an "exchange" in the truest sense of a location conducive to free transacting (subsidies notwithstanding), or is there a hidden "all insurance plans must conform" requirement that I'm simply not seeing?

Obviously there would be problems trying to exploit this loophole; competition vs federally subsidized products, selling into a newly saturated market, bad PR for refusing to help socialize the industry "for the good of everyone", etc. Plus if enough insurers take this tact and the Exchange starts looking a little barren, I'm sure the law will be changed to force insurers to offer a plan if they want to do business in the US.

My theory is that this distinction was intentionally placed there for reasons of plausible deniability. Between now and implementation time, Obama et al can claim that the Exchange would be optional, allowing insurers to choose to participate or stay wholly private. In reality those claims would be maliciously facetious, as basic economics would turn participation in the Exchange into a de facto mandate.
2.27.2008 1:40pm
The Unbeliever (mail):
I never thought I'd see a time when a volokh poster implicitly conceded that the French are superior to Americans:


Somehow I doubt the majority of VC commenters view "Largest Government Bureaucracy" as an award worth pursuing. I would argue winning such an award hardly makes one country "superior" to another; quite the opposite, in fact.

Expenditures by the French governement account for 54% of their GDP; about 25% of French workers are employed by the state (link here). If that's what it takes to win a Golden Form 538-B in the International Bureaucracy Awards, then I take it as a point of national pride that the US lost in that race.

I could go on about your notion that "the French healthcare system runs wonderfully well", but I don't feel like copy/pasting an argument has been made so many times in so many other places.
2.27.2008 1:49pm
dew:
Dan Weber: On preventative care - talk to any state legislator why preventative care is not funded well. I believe a lot has to do with mandates from the feds: provide a certain level of Medicaid coverage the way we tell you to, or you lose your matching funds. Preventative care is generally optional for states to provide under Medicaid (or just not funded at all by the feds), so in bad budget times it is some of the only health costs that can get reasonably cut from that huge line item. Of course, they could just lose the federal match for Medicaid by cutting mandated coverage...

But, you ask, wouldn't it be wise to fund preventative care anyway, for the long term savings? Most states are under state constitutional balanced budget requirements (unlike the feds), and most of their budgets are effectively mandated (legally or practically) in one way or another - required by the feds, required for federal matching funds, contractual obligations, debt service, local aid, etc. Any cuts usually come from the bits that are left, and usually involve balancing tough choices (and of course, competition with the pet projects of legislators, the governor, and so on). Many can be tradeoffs of deferring future costs: do we fund dental cleanings for the poor, or do we fix some crumbling bridges before they fall down? Of course, you can just raise taxes to create or keep that preventative care, but that idea is usually a non-starter, even in Massachusetts.
2.27.2008 2:14pm
Dan Weber (www):
If throwing money at prevention is such an obvious money saver, then surely some state somewhere would've tried it and been successful.

People cite make up statements like "a 10 to 1 savings from prevention!" but even the most strapped state government would be nuts to pass that up. They would have no trouble selling bonds to raise the money.

If the emergency rooms were paying millions of dollars to deal with rickets, whoever pays the bills would be crazy to not send free vitamin-D tablets to everyone in the community.

There are very specific cases where "prevention" is a significant cost saver. We should learn what those cases are and apply them. We shouldn't just think that "prevention" is a CD we can blindly dump money into and get huge returns later.


Or maybe it's culture. The French prenatal care system is pretty cool. They send vans out to visit expectant mothers. It's "better than free." But I'm not sure it would work in this country, given the fact that, as part of the deal, they cajole women into participating, and you get a visit from a version of Child Protective Services if you don't. I'm not sure that would fly in the States.
2.27.2008 3:29pm
dew:
If throwing money at prevention is such an obvious money saver, then surely some state somewhere would've tried it and been successful.

States often do various kinds of prevention programs. The feds too - WIC, early intervention. But the savings are often over decades, not necessarily "this year".

For the "this year", we have set up a medical system where many poor people go to the emergency room for every little thing, don't pay, and those big costs must be paid for by the state. Medicaid costs must be paid for by the state. There is only so much discretionary money to go around after the "must be paids". When times are bad, the optional programs, like prevention, get cut - people (reasonably) say "No new taxes!" so cuts have to come from somewhere.
When times are good, you (the wise legislator advocating prevention programs) will be fighting for limited new money against the state employees wanting good raises (reasonably, because you shafted them for a couple of years with 0% pay increases when times were bad), the need for new prisons, the governor's new "job creation" program, the "crumbling infrastructure" problems that got put off for years, the municipalities who are screaming for big school funding increases (despite the fact the school money didn't get cut when times were bad), and so on. That is if the "good times" tax revenue even keeps ahead of all of the normally high health &welfare cost increases, so you have any extra money to spend.

Of course, I don't think it is always as bad as all that, but my memory (having worked once in a legislature, and several friends/relatives who are/were legislators) was that just because you have a good idea that should save money does not mean that (a) others will think it is such a good idea at all, (b) others will think it is a better idea than their idea to spend money elsewhere, or (c) that there is any available money to spend at all on something new, even if others agree.
2.27.2008 5:56pm
chief:
wow, somebody working for obama doesnt like clinton. huge news.
2.27.2008 7:53pm
Victor D (mail) (www):
Why would an individual or small employer buy insurance under Obama's plan? One benefit of mandates is to prevent an *increase* in uninsured rates that is likely to occur when you shift to a guaranteed issue environment. Guaranteed issue + no pre-ex greatly increases the benefits of free-riding.
2.27.2008 10:46pm
Richard Aubrey (mail):
As has been said before, between workers compensation and auto insurance-allied health insurance, practically everybody is covered at some time during his or her week for one or two venues where injury may be expected.

Prevention doesn't do much. That was the thought behind the original HMOs. Free check-ups, get it while it's cheap.
The original targets were unionized groups who had reasonable wages. IOW, they were already in a position to afford check-ups below their deductible. In fact, their recreational budget probably exceeded the potential check-up budget by ten times.
Problem is, checkups are a pain in the butt, figuratively or literally, are generally only available during working hours, take too long, and might provide bad news, which, if the doc doesn't shove in your face, can be denied.
Funding them doesn't get it.
Most milk already has Vit. D in it.
Ditto salt with iodine.
Getting people who are already taking vitamins to take vitamins is unnecessary and those who aren't won't.
In any event, the free-checkup schtick with HMOs didn't help anywhere near as much as proponents thought it would.
Thing is, like any government Big Idea, they didn't bother trying to figure out how real people act. Next step is to force people to act as they would not normally.
2.28.2008 4:12pm
gil (mail):

" but if the two Dems want to play footsie with the HMO's,.."

Obama has a public plan and an option to buy private plan.

Hillary has a HMO type private plan where you can opt for a Medicare like plan..

That is why I like Obama's plan. HMO's scandal ridden Industry have been very profitable - adversely affecting personal health and wealth of Americans.
2.28.2008 5:30pm
gil (mail):
Lively predicts: "I predict some doctors will set up a "self-pay" practice and only accept patients who pay cash.

Then wealthy people who do not want to wait for their health care ration, will go to the cash only doctors."

Many uninsured who don't buy-in into HMO plan right now are likely not buy into The Universal Health Care as proposed by DEMs. Obama's plan doesn't mandate or force adult into the plan. Hillary's plan mandates everyone to buy into the plan, ergo rake in more money. Private HMO's involvement here would be make profit. Do I need a middle man (aside from the government)for a contract between me and my doctor? The middle man who will review the bills, pad the bills pay kicback to the doctor and the government? The health care insurance is corrupt right now. Google the HMO scandals and schemes - skimming $millions from the gov't. America wants to nationalize and legalize it's corruption?
2.28.2008 6:33pm