Tyler wonders what will be done with people who are required to by health insurance, but don't. The answer, I think, is "they'll get treated". The object is not to play chicken with people; we can't make a credible committment not to treat people without insurance (and thank god for that.) The object, as I see it, is to force the people who care about things like legality to get insurance rather than rolling the dice. The people who don't care about such things will continue costing us some fraction of the small amount that caring for the uninsured currently costs us now. It may only be a slight improvement, but it's still an improvement.
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Something I've wondered about is this -- exactly who are these people going to see for treatment? Presumably insuring the people who are currently uninsured will cause them to start seeing doctors a lot more often.
But if there are doctors out there with a lot of spare time that needs filling up, I haven't seen them. Doctors, in general, seem to be carrying pretty full patient loads. Yeah, I know that over time we'll see more people become doctors to handle the extra patient load, but there will be almost a decade of lag time before those doctors enter the market. Aren't prices going to go through the roof in the meanwhile, from the shock of dumping tens of millions of new consumers into a market where supply is highly inelastic?
It would be easier to think of possible solutions if there were any reliable estimates of how many people actually are uninsured. Most of the estimates floating around are all over the place.
I don’t know about that, anytime you create a “mandatory” system there is going to have to be some mechanism of enforcement. In the case of the Massachusetts system, if you don’t comply, their Department of Revenue (or whoever it is that is in charge of tax collections) revokes your personal exemption and/or fines you every month. Someone has to pay for the cost of enforcement whether it’s passed directly onto the taxpayer or passed indirectly by mandating that employers handle all or part of it.
Also if you’re going to bring employers into the mix with mandated universal coverage, they’re going to have to hire and/or train people to comply with the new rules which is rather expensive. And if you try to exempt small businesses (Massachusetts set the bar at 10 or 11 employees) you’ve just created an incentive not to hire the eleventh or twelfth employee that would make the difference in having to comply with a costly new mandate.
In which case whatever marginal benefit you get from forcing people who can afford health insurance but choose not to buy it but would if you made them could very well be swallowed up by the costs that come every time someone who says “there ought to be a law” gets their wish.
I say we beat 'em with 2x4s.
If we're going to have mandatory insurance, then it should be . . . mandatory. I really dislike laws that are written but that are unenforceable or have no enforcement mechanism. Why bother?
EI
"In which case whatever marginal benefit you get from forcing people who can afford health insurance but choose not to buy it but would if you made them could very well be swallowed up by the costs that come every time someone who says “there ought to be a law” gets their wish."
-Thorley Winston
TW, no doubt.
Or, harking back to an earlier post, we can make it 10 for 10, and 'quarter' a bureaucrat in every household. You know, to ensure compliance.
I was thinking about this and I think I may have come up with a solution (btw...please let it be known that I don't like the forced component of these types of plans, but I digress).
If you have health insurance you get treatment. If you don't have health insurance you get billed. They can take everything you own. And, one final thought, it'll be like Student Loans. Banckruptsy doesn't erase it or even make the amount less. Your wages get garnished. It becomes hell on earth. And if you don't pay it after you die the debt gets transferred to your immediate family.
All of that is an exceptional incentive to get insurance, especially if it's "affordable".
Now that is not to say that people won't still skip town and change their names, but it gives added incentives to people who would otherwise not have gotten insurance. I know people who pay their student loans before their rent for exactly this reason.
It's just a thought.
"...we can't make a credible committment not to treat people without insurance (and thank god for that.) The object, as I see it, is to force the people who care about things like legality to get insurance rather than rolling the dice."-MM
Who really cares about legality for its own sake? If there is no penalty associated with illegality, the law is no law at all. Look at jaywalking in New York. Is anyone really concerned about the "illegality" of crossing the street. I never once saw someone waiting on the sidewalk there for the light to change when the street was clear. The law on the books was clear and everyone knew about it; but everyone also knew that the police didn't enforce it and so everyone disobeyed the law.
If the government passed a law requiring me to get out of bed at 6AM every morning, I would just disobey it unless there were some penalty and enforcement mechanism.
Just where in the Constitution does it provide that the federal government can force citizens to buy health insurance? Is this somehow subsumed under "General Welfare" or the right to regulate "Commerce"? Before we worry about those who won't do what Big Brother dictates, perhaps we should worry [funny how those who howl the loudest about the Bushies trashing the Constitution have never raised this issue] about what gives Big Brother the power to so order in the first place.
Correct me if I'm wrong, but doesn't the "problem" with uninsured middle class types lie not in their inability to pay for treatment, but the fact that young, healthy types opting out of coverage skews the risk pool for those remaining?
I think the point of the mandate is to try to lower the cost of health insurance for those who require care by subsidizing their premiums with premiums from those who are unlikely to require care, i.e., the class insurance model.
"The object is not to play chicken with people; we can't make a credible committment not to treat people without insurance (and thank god for that.)"
Are you out of your mind? You just advocated a tax on people who like to obey laws (as there does not seem to be any punishment for flouting them). When you tax something, you get less of it.
As I see it, your choices are
1). Repeal the mandate to buy insurance
2). Bring back debtors' prisons for people who do not
3). Let the uninsured die in the streets
4). Recognize that law-abiding behavior will decrease
As rule of law is one of the major diferences between the US/UK/Japan and parts of Africa (to answer your previous blog post) it would seem that #4 is actually the worst of all choices.
No that’s about it in a nutshell. While there certainly are some case of the uninsured having uncompensated medical expenses which get passed along to the rest of us*, the main concern is that because they’re not buying health insurance and paying premiums, they’re not subsidizing the generally older and more expensive to insure people who are.
IMO what we ought to do before we even consider creating an individual mandate is to get rid of the unfunded mandates on insurance (mostly at the State level) which raise the cost of health insurance premiums between 20-25% and limit consumer choices to only those policies which carry things other than catastrophic illnesses or things that people could probably afford to pay for themselves (in which case it shouldn’t be a matter for insurance). Also we ought to let people by policies from anywhere in the country just like they can for pretty much every other product except for health insurance. Generally we have done best as a nation when the United States is a “free trade zone” and goods, services, and people flow freely between the 50 States (in fact it’s one of the primary reasons why we have a Commerce Clause in the Constitution). Unfortunately under the current system, each State got to create its own patchwork of individual mandates (something like 1900 of them IIRC) which lead to each State becoming dominated by a few companies selling to a captive audience.
* Of course the uninsured and/or their employers also don’t get the tax deduction for health insurance and pay more in taxes as a result. The problem is that the uncompensated care they get is usually paid for at the State, county and municipal level whereas the extra taxes they pay go to the federal and State government.
"As rule of law is one of the major differences between the US/UK/Japan and parts of Africa (to answer your previous blog post) it would seem that #4 is actually the worst of all choices."
"And, could I get an extra order of "Western exceptionalism" to go with that?"
Like Arnold Kling, I am for mandatory health insurance in theory, but not in practice. As he points out, here in Massachusetts, "the mandates in mandatory coverage were so broad that 600,000 people who had health insurance before the law was passed were told that their plans no longer qualified as health insurance in the state of Massachusetts."
In other words, because of all the coverage minimums and mandates, more people are "uninsured" after the law than before it.
Jim
This isn't rocket science:
1) Create a health insurance surtax and withhold it from the employee portion of payroll, like we already do with FICA taxes.
2) Set the tax high enough so that it will roughly equal the health insurance premiums paid by a median-income, median-wage worker.
3) Rebate this amount back when workers demonstrate proof of health insurance coverage over the previous year when filing their taxes.
4) Require proof of family health insurance before allowing parents to qualify for child tax credits as well.
5) Use the un-refunded/forfeited health insurance/child tax credit monies to subsidize health care for the uninsured.
In a nutshell, young people should pay for unneeded health insurance so that old people can reduce their own insurance costs. Sounds fair.
First IMHO middleclass people can aford to pay a $100,000 hospital bill these days they live in $200,000 homes and the hospital will give them terms.
Here is my idea for positive change, I think it would be good but maybe not:
Provide universal coverage with low deductibles for the poor and very high deductibles for the middle class and the rich. By high deductibles I mean like $100,000/year but based on one's last year's adjusted income. The tax any gap insurance heavily. The middle class and rich are almost all capable people and thus would not be likely to skip helpful preventive care even in the face of very high deductibles. My hope would be that this plan would drive prices down in response to the high deductibles faced by the rich and middle class, but the poor who might be inclined to not use sufficient preventive care in face of deductibles would be encouraged by the low deductibles to use preventive care.
The good news on healthcare is that things can't continue going in the direction that they are going. I see in this the good news that if Government does nothing people will more and more start to solve the problem in creative ways. If things can't remain this way they won't.
IMHO the biggest problems are over insurance, law suits and licensing. Also people who opt for less care or cheaper care should gain by it. E.G. people with living wills should gain by it.
Way to think outside the box, Floccina. I agree that high-deductible, catastrophic policies should be an option, but I honestly never considered that a deductible could be that high. Certainly, once the deductible gets into the five figures (say, $20,000) premiums are going to be extremely low. And by paying for routine medical care with their own money, middle class insureds will become cost-conscious health care consumers. At the same time, they will be covered if they get cancer, need a transplant, etc.
Forcing people to buy into a broken system is not going to magically fix the system. Hillary's compromise to offer a plan of "mandatory insurance" rather than single payer is simply kicking the can down the road. Insurance companies are part and parcel of the problem, not the solution, and until we get them out of the insurance racket the system will remain broken.
All that will happen with mandatory insurance is the uninsured will remain uninsured, they will just be illegally uninsured rather than legally uninsured. Maybe we can throw them all in jail and forget about them.
Certainly, once the deductible gets into the five figures (say, $20,000) premiums are going to be extremely low.
Brilliant. So given my annual salary of $20,000, how do I pay for the $19,999.99 bill that is not covered, Einstein? Get a loan that I can't repay? Put in on a credit card?
You guys aren't thinking this through.
And by paying for routine medical care with their own money, middle class insureds will become cost-conscious health care consumers.
Brilliant again. Now everyone will learn whether they ought to pay for that T5 thyroid panel due to their own risk factors. Everyone will become so educated about medicine, they'll hardly need a doctor to tell them what is necessary and what is not. Unbelievable.
Kate:If you have health insurance you get treatment. If you don't have health insurance you get billed. They can take everything you own.
This is different from the current system in what significant ways?
If we're going to have mandatory insurance, then it should be . . . mandatory. I really dislike laws that are written but that are unenforceable or have no enforcement mechanism. Why bother?
Because it feels SOOOOO good! See, we Did Something!
One thing I've mused over is a universal government provided catastrophic plan, but any benefits paid become a future tax liability. The tax liability gets carried over from year-to-year, paid off as a person's income (or estate) allows.
Now of course some people will consume more health care than they can ever pay back, but in those cases the debt is wiped out after their estate is settled. But everyone is covered and in principle everyone is responsible for their own bill.
Every person has (effectively) deep pockets, yet to the extent that a person is capable, everyone pays for services received so there's incentive to use health care wisely.
"Brilliant. So given my annual salary of $20,000, how do I pay for the $19,999.99 bill that is not covered, Einstein?"
You wouldn't be a candidate for a policy with such a high deductible, genius. So you would have a more traditional health insurance policy, with no deductible and $10 co-pays. Mandating health insurance coverage for everyone doesn't mean everyone needs to have the exact same policy.
"Brilliant again. Now everyone will learn whether they ought to pay for that T5 thyroid panel due to their own risk factors. Everyone will become so educated about medicine, they'll hardly need a doctor to tell them what is necessary and what is not. Unbelievable."
Just like no one questions car repair estimates because every consumer is an expert on computerized fuel injection systems -- wait, that's not what happens in the real world, right? In the real world, when their own money is at stake, intelligent non-specialists tend to shop... intelligently. Certainly, when it comes to health care money isn't the most important consideration, but if you are paying out of pocket, it at least becomes a consideration.
This sort of consideration of cost has led to lower prices for medical procedures when patients haven't had third-party insurance, e.g., private-paying consumers have driven down the prices of laser eye surgery; there has been a boom in medical tourism, where private-paying Americans (often those without health insurance and ten years-or-so too young to qualify for Medicare) travel overseas for low-cost operations performed by first world-trained physicians in their home countries.
The bottom line is that price is a factor in health care and will be taken in consideration by someone, whether that someone is an HMO, an individual patient, or, in the case of socialized medicine, the government. With high-deductible, catastrophic insurance policies, patients get to be the ones considering cost for procedures that cost less than their deductible.
I beleave that everyone in the United States should be insured no matter what. Weather they have a job, house, kids or not everybody should be insured no matter what the cost. Most people that are not insured are poor people that get cancer or get very ill from not being able to eat, shower, or dress properly. No matter what the problem no matter what the cost everyone should be insured expectially children.