04 February 2008

The problem with mandates

Democrat Hillary Rodham Clinton said Sunday she might be willing to garnish the wages of workers who refuse to buy health insurance to achieve coverage for all Americans.

Hillary should be smarter than this. I mean, what a dumb, stupid thing to say, handing opponents of reform a tailor-made talking point to use against the idea.

However, this does illustrate the problem with the whole framing device of a health insurance "mandate." It's a negative frame, describing an obligation and begging the questions, "what if I don't want it?" and "what if I refuse?" The answer to that is that a mandate is not optional, that there needs to be some enforcement, usually punitive or otherwise coercive, and the whole thing winds up looking oppressive and unwelcome.

What proponents of health care reform ought to be advocating is not some idea of compulsory mandates, but "Universal" health care, with "automatic enrollment." People view these as positive features of a health care plan, and while the net effect is similar, the perception is vastly different. I would hold up Sen Wyden's Healthy Americans Act, once again, as an example of how this ought to be designed and marketed. There are no taxes (which people hate) or garnishing wages (ick), but simply "premiums," a funding method most people fundamentally view as fair and reasonable. Enrollment is taken care of when you file your 1040, which effectively captures the vast majority of Americans, and the premiums are withheld from earnings much as they are for the majority of Americans today.

Maybe Obama was wise to avoid the idea of mandates altogether. But he also loses the universality totem as well. Krugman bashes him yet again today, arguing that universality would be more cost-efficient than his half-measures plan. My actuarial chops aren't up to analyzing the argument, but it seems t pass the sniff test. I don't entirely agree with Krugman's anti-Obama rhetoric, neither on the facts nor strategically, but he does summarize it well:
while it’s easy to see how the Clinton plan could end up being eviscerated, it’s hard to see how the hole in the Obama plan can be repaired.

Ezra Klein piles on as well:

There is no doubt in my mind that [Hillary] will do everything in her power to move us towards universal health care, and she will do so having thought long and hard about what went wrong in 1994. By contrast, it is not clear to me that Obama will gamble on health care, and given how he's spoken about it throughout the campaign, it's even less clear to me that he's thought hard about how to enact it.

Though I like Obama and want him to be the nominee, I do agree that his approach to national health reform is probably his weakest point as a candidate.


  1. Much of my wages are already garnished to pay for Social Security and Medicare benefits that I doubt I'll ever personally enjoy, and plenty of my income already helps fund the ever-growing Medicaid program.

    You can call it whatever you want, but these "premiums" or "withholdings" are still taxes, and they are equally unpleasant whether you disguise them with flowery language or not.

    My "withholding premiums" could have bought some nice hardwood floors last month. Or a motorcycle. Or a really nice home theater system. Instead I bought a handful of Medicaid pelvic ultrasounds and a couple of uroseptic nursing home workups. Yay!

  2. Hm. Scalpel said what I was going to say...it's bad to garnish someone's wages to pay for their own health insurance, but it's just peachy keen to keep garnishing mine for other peoples' insurance to the tune of a few thousand bucks a year? I certainly have never been offered the choice to "refuse". I refuse to pay for all non-mentally retarded, non-severely disabled (ie TBI, post-CVA, schizophrenia) peoples' Medicaid insurance. Hm. No one's listening. *sigh*

    Not saying I agree with Hillary's plan at all because any more govt involvement I'm opposed to, but it's just hypocritical to decry garnishing wages to pay for one's own insurance when you're in favor of garnishing wages to pay for others' insurance to any large extent.

    Speaking of Medicaid pelvic ultrasounds, we had a patient come in for her 8th abd pain check up today in the last 1 1/2 months. The first 6 times, she made up abd pain in order to get "free" pregnancy tests and even admitted to exaggerating symptoms to get pregnancy tests. The last 2 times, now that she's REALLY pregnant (3 weeks, only detectable by blood draw) , she's come in with "complications" (read: I want an ultrasound).

  3. Though I like Obama and want him to be the nominee, I do agree that his approach to national health reform is probably his weakest point as a candidate.

    Au contraire, mon frère. His approach to health care reform is his strongest point.

    In the general election, it would be an easy matter to paint Hillary as a scary, big-government liberal who wants to turn our health care system into Walter Reed. But Obama gives the appearance of being much more reasonable on a variety of issues, including mandates, tort reform, and even federalism.

    As a card-carrying knuckle-dragger, I’d much rather run against Hillarycare than Obamacare.

  4. Scalpel,

    Unless you are planning on dying young (which I don't advise), I'll lay odds that the two great entitlements will still be there when you and I retire. Unless some future government decides to start defaulting on Treasury Bonds, Social Security will be there for us. Both may (will, in the case of Medicare) require increased taxes to support them when it comes time for us, but, hey, it'll be our kids paying it, so why should we care?

    (if that sounds callous, I refer you to the last seven years of deficit spending by the GOP, which seems to share the same philosophy.)

    And yes, I'm talking about how we *market* universal health, not about the essence of the plans, per se. "premiums" sounds nicer than "taxes," but they are more or less the same thing. but bear in mind the premium/tax, for you and me, just replaces the premiums we currently pay, so is pretty transparent.

  5. Catron,

    So may I take that as a formal endorsement of Obama?

  6. By the time we retire, Medicare benefits will be only a token supplement to our out-of-pocket healthcare expenses, and the return on our considerable Social Security investments will be negative.

    So pardon me if I'm not as enthusiastic as you about these "benefits."

  7. "Both may...require increased taxes to support them when it comes time for us, but, hey, it'll be our kids paying it, so why should we care?"

    Because some people have heard of that trick before.

  8. Formal endorsement?

    I voted in my state's primary today, and I nearly ID'd myself as a Dem just to vote for Obama.

    It's not that I like him much. He's a nanny-state liberal just like Hillary.

    But at least he's not as corrupt (and unbalanced) as she is. So, he the lesser of 2 evils.

    Is that an endorsement? In the end, I actually pulled the lever for ....

  9. "Enrollment is taken care of when you file your 1040, which effectively captures the vast majority of Americans"

    Does it capture the vast majority of uninsured Americans?


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