Last night after an event, someone asked me and another libertarian if we supported an individual mandate for health insurance.
It's a complicated answer. I think that you can argue that because we cannot, in American society, make a credible commitment not to treat those who choose to go without insurance, the temptation to free ride is too great. So I'm not necessarily opposed on liberty grounds; it may be one of those things, like taxation, that is simply the price of living in society. And, in point of fact, it basically is taxation, so that makes sense.
However. I have practical objections. A mandate to buy insurance comes with a bunch of other things that have to be put into place to make it work. Guaranteed issue, community rating, subsidies, and regulations as to what constitutes basic coverage. These make the individual mandate very, very expensive for both individuals and The American Taxpayer. Before Massachusetts, there was a fair amount of hope that by introducing the healthy youngsters currently foregoing insurance into the pool, the average cost of treatment would actually fall. Massachusetts has fairly conclusively disproved that theory; health insurance premiums in the individual market are going to rise 10% this year, according to the Boston Globe.
There are a lot of reasons for that, but one is mandate creep, something that has particularly bedeviled New York. A mandate essentially becomes an opportunity for various medical service providers groups to pick the pockets of consumers and taxpayers. They lobby to get their service included in the mandatory package. Consumers use it, because hey, it's practically free. Insurance costs go up--but there's no reason not to keep on using podiatrists and massage therapists, because your personal actions will not make a difference in bringing costs down.
Then, as I've earlier discussed, the government's temptation in response to these problems is often price controls. Overall, I'm not a fan.
So while I think there's some theoretical justification for it, in practice, I'm not a big fan.
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Right, the argument is:
1) If you're forced to buy insurance (mandate) and you're uninsurable normally, then someone has to be forced to sell it you (guaranteed issue).
2) If someone has to be forced to sell it to you, then your premiums will be unaffordable unless they poll you with other people. most of whom are healthy. (community rating)
3) Some people are going to be poor and not afford even the pooled price (insurers have to at least stay afloat), so subsidies.
4) If you allow people to get fake policies that aren't really insurance ($0.01 a year for the "never pay" insurance-- a good deal if you don't get sick, viz. Monty Python), then you don't really have a mandate. So if you have a mandate you have to define what's sufficient coverage.
There's a difference between the argument of "if you're going to have guaranteed issue and community rating, you need a mandate or else people won't get insurance until after they get sick," and thinking that the whole package is a good idea.
There's also the separate question of what sufficient coverage would mean. I would be pretty happy if the basic sufficient coverage were a good catastrophic plan with a high deductible and maybe an HSA; that could control costs while still providing coverage in an emergency. But that's not what's on offer; in fact, some versions of the bill have made high deductible plans illegal. And while libertarians could fight to make it catastrophic coverage now, I don't think that the political equilibrium would let it be, for reasons you note. Also that patients hate deductibles. I know people who would rather pay $700/year more every year in premiums than have a $500 higher deductible.
a good catastrophic plan with a high deductible
Which only works if you can save the money to cover the deductible. The poor will need some kind of subsidy.
No. You can make building an escrow account be part of the monthly payments (just as many house payments incorporate property taxes). If we had a privatize Social Security system, the escrow could actually be part of the patient's property. But neither off these things will happen because they don't afford politicians the ability to dole out favors to the well-connected.
No problem wiredog, I'd be on board with that. Give everyone a tax credit of $1000 (or whatever) that gets transferred to their HSA, and make it refundable so the poor get a subsidy.
Universal HSAs (keeping the requirements for the high-deductible catastrophic plans) plus subsidy for the poor would be a net improvement on what we have now from my libertarian perspective.
However, I don't think that the plans would stay high-deductible catastrophic plans for long, which is why I'd be leery of the bargain.
People hate high deductibles because they feel that they are already paying out blood every month for a high premium , so they should be able to walk in and get treatment without shelling out another $150-300 again to the doctor. For most people, it just doesn't feel right, and no chart,argument, or spreadsheet is ever going to make it feel right.
But they're willing to pay a high premium in order to get that?
I have $12.50 taken out of my biweekly paycheck for premiums. People would have $100 taken out of their biweekly paycheck for premiums (and do) rather than have a higher deductible.
They're guaranteed to pay $2275.00 (OK, pretax) extra in premiums per year instead of maybe getting far into their $800 higher deductible.
Strategy 1 to making it feel right:
Compare it to car insurance. People pay car insurance premiums to cover catastrophic events and still pay $100 - $300, or more to get their cars fixed. People don't seem to have a problem with that. The one's that do have a problem can buy extended warranties.
Strategy 2 show them the facts:
I switched to an HSA with high deductible ($5,400) this year. The combined sum of what I deposit into my HSA plus the insurance premium is less than the premium I use to pay on my previous coverage, so your idea of paying a high premium for a high deductible policy is incorrect. Put another way, my premium is about 23% what I paid for the all-in coverage.
More facts: So far this year I've expended 25% of what I've deposited into my HSA. I'll get to carry what I haven't spent over. As I save past my deductible in the HSA, I plan to start lowering the amount I contribute to it.
I think it's also a cash flow thing. People like having a fixed monthly amount that's easy to budget for. It takes time and effort to plan around a variable expense, especially one so variable as health care. That time and effort may be worth hundreds of dollars a year, and it takes a lot of willpower to manage it correctly. Not everyone has that kind of willpower.
"A mandate essentially becomes an opportunity for various medical service providers groups to pick the pockets of consumers and taxpayers. They lobby to get their service included in the mandatory package."
Does taking the decision-making (re: what products and services to include) out of Congress's hands and putting it in the hands of some board of experts (with a straight up and down vote by Congress) solve the problem? I believe that's what Yglesias and others argue. If it does solve the problem, are there other problems it causes (e.g., rationing)?
"A mandate to buy insurance comes with a bunch of other things that have to be put into place to make it work. Guaranteed issue, community rating, subsidies, and regulations as to what constitutes basic coverage."
Is guaranteed issue put into place to make the mandate work, or is the mandate (and community rating) put into place to make guaranteed issue work? I thought it was the latter. That may sound technical and non-substantive, but I think how the question is answered says different things about what is the objective. E.g., if guaranteed issue is put into place to make the mandate work, that implies that the mandate is about lowering costs, and thus the goal is about lowering costs (which Obama/Dems claim is the goal). If the mandate is put into place to make guaranteed issue work, then that suggests that the goal is about universal health care (which many, including myself, believe is what Obama/Dems really care about).
Your last question is interesting, but I'm not sure it has an answer. Certainly, for a lot of liberals, it's the latter, but I'm not sure that's what independents would say. And I'm not sure it makes a difference. You have to lower costs to make the program work; otherwise, as with TennCare and the Oregon program, it ultimately gets defunded.
The idea of putting everything into the hands of "objective" boards is appealing, but it doesn't really work, for a number of reasons. First of all, agencies get lobbied too, and guess where the regulators go to work after they leave the agency? Second, ultimately, they get their authority either from the president or Congress, both of whom can (and do) intervene when an important constituency calls. It might slightly mitigate the problem, but it in no way erodes it--and in fact, every procedure probably benefits someone, so it's hard to control the mandatory inclusions.
"First of all, agencies get lobbied too, and guess where the regulators go to work after they leave the agency?"
Thank you for your response, but as a regulator, I take great offense at that argument. Wait a minute, my recruiter is calling.
OK, I'm back. Next question for the floor. TennCare, Massachusetts, etc, seem like very strong arguments for the GOP to make, yet they rarely do. What does that say about the Republican Party that they go for death panels and keep the government out of Medicare over strong and intellectually serious arguments that, it seems to me, would be even more persuasive (because it's substantive but seems to be easy to make)? Or does it say something about politics in general and not just the Republicans? Does it say something about politics today, or were politics always this way (on the one hand, Lincoln-Douglas seemed a bit more serious, but on the other hand, Thomas Jefferson was treated as badly as William Jefferson Clinton)?
I guess that's several questions.
The GOP still believes Romney is a viable presidential candidate, but if they go off on RomneyCare they lose that. Was TennCare also passed under a Republican governor? To make those criticisms they'd have to acknowledge they weren't being true to their stated beliefs back then. It's tough stuff.
Because it's not more persuasive. Did John Mackey's WSJ op-ed detailing strong and intellectually serious alternatives persuade? What about the serious and intellectual complaints of Rep. Mike Pence? Nope.
But "death panels," bam, instant amendment to the bill. "You lie!" bam, instant amendment to the bill.
We get the politicians we deserve.
Don't forget that some Democrats right now are saying that Republicans want people to die, as they always do.
Politics has always been rough, though. Read this one about the 1868 brawl in the US House that only ended when one Member grabbed the hair of another to hold him to punch, the other member ducked the punch... and his toupee came off. He then put his hairpiece on backwards. Then everyone stopped brawling and started laughing because no one knew he wore a toupee. "The good nature of the House was restored."
Sorry, 1858 brawl.
Janice, the Republican arguments you see in the media are only the tip of the iceberg -- after the media filter has eliminated the 97% of arguments that don't make for sensationalist headlines. Republicans send out detailed, substantive criticisms to the press all the time. The press duly ignores said criticisms. Such analysis is far too dry for their taste -- unlike death panels, which sells advertising space.
The Republicans really don't have substantive arguments to make. Let's face it, the argument for universal health care is overwhelming. There are successful working models all over the world that people can point to. The Republicans can argue that those models don't work perfectly-to which the devastating liberal response is that they work better than what we have now.
The arguments that I have seen on this website are :
1. Government always screws up, so we can't trust government with national health care. Well, government doesn't always screw up, and indeed can work very well, so that argument is an epic fail.
2. Government needs to get out of the health care business altogether, and the free market will solve everything. Nonsense on stilts, but the second most popular argument on this site.
3.Its very, very expensive. Most good things are. Most of the folks making this argument are OK with very expensive unnecessary wars and very expensive unnecessary defense programs. Now, controlling health care costs is a major problem for the future, but its an even bigger problem for private insurers.
4. The innovation argument has been discussed. Most liberals don't find it persuasive, in the face of the misery caused by the current system.
Those are pretty much the conservative arguments, which is why they resort to fear-mongering
stonetools:
Single-state single payer has been an epic fail everywhere it's been tried-- Oregon, Tennessee.
State mandated insurance has caused Massachusetts' premiums to rise much faster than the national average, as Megan points out.
Guaranteed issue and community rating without a mandate (and creeping requirements on what must be included in insurance) has caused New York's insurance to be far more expensive than other states.
OTOH, consumer-driven health care has a ten-year record of controlling costs, causing people to get more preventative care, and producing better compliance with evidence-based medicine. High quality research supports them. The most successful national health care systems, like in Singapore, use them. It's what the Dutch have been moving to.
The evidence for consumer-driven health care plan is overwhelming, stonetools.
@John Thacker
Actually, consumer-driven health care has been tried for ten years in a small, self-selected, affluent population. I'm sorry, I need more. Let's try it for a more representative population. Let's take it for a spin in rural Tennessee or Compton before we scale it up to a national plan.
Singapore, eh? According to Wikipedia,"Singapore has a universal health care system where government ensures affordability, largely through compulsory savings and price controls, while the private sector provides most care" (Sounds REALLY libertarian).It has public ownership of hospitals, and government pays for 80 Per cent of " basic health care services". HSAs(called MSAS) make up 10% of all health care spending.
http://healthcare-economist.com/2007/04/18/health-care-systems-in-east-asia/
This is what one commenter says about the two systems:
I am Singaporean, and am living in the US now, I have seen first hand on both the healthcare systems in the countries (my grandmother has multiple illnesses and visits the hospital 3 times a month, and my roommate in the US is disabled).
People who say that the healthcare in the US is not atrocious really need to start opening their eyes.
For examply both my grandmother and my roommate have to go through the exact same ailment (Hip replacement surgery). My family paid SGD6000(USD4000) up front for the surgery and a week and a half stay in the hospital, and was reimbursed 60% of that amount by the insurance company. On contrary, my roommate, who owns a painting company paid USD90,000 for the surgery and a 5-day stay in the hospital. He had to declare himself a bankrupt, get on disabled and medicare. But now, SSI and medicare is trying to make him pay XX amount back for what they call "OVERPAYMENT", when they know that he is not able to cough up that money.
There is something really wrong with the health system in the United States. In contrast, Singapore -- which may not be a perfect world, viewed as an equally capitalist country -- at least understands what it means to pay if you have the means to pay.
My grandmother has used both privatised medicine and public healthcare, and the price difference is astonishing, but... this is a choice that our family has made, mainly because we have health insurance, and most of our family members are blood donors (yes, blood donors are given a huge discount on healthcare), and also TTS hospital is one of the most reputable hospital in Singapore.
So for someone who is experiencing both worlds now. I would say I thank the higher beings that I a Singaporean.
http://econlog.econlib.org/archives/2008/01/singapores_heal.html
Yep, thanks for pointing out Singapore.
(actually in reply to MOswingvoter) TennCare was created under a Democrat governor (McWherter) and solid Democrat majorities in both chambers.
this question may also be the key to understanding the political problems with health care reform. there are two natural constituencies for reform: those who feel that they pay too much for medical care and those who think the lack of access is a failure of social justice. most middle-class swing voters fall into the former category and most progressives fall into the latter. there is likely a sizeable population in the overlap, but these are certainly two distinct groups. the democrats have almost refused to admit that there is any difference between the two groups, or even between the two issues. i wonder if this is a calculated case of log rolling or do the democrats really believe that what was essentially a rejection of george bush and the republican party in favor of obama's percieved competence was actually some great electoral move towards embrassing the progressive agenda.
it's likely a little bit of both.
The two best strategies to combat mandate creep are (1) tax employer payments of health benefits, so that consumers see the cost of the mandates, and (2) allow interstate insurance sales of a scaled-down type of coverage and pre-empt states' power to regulate it. In combination, these two steps would go a long way toward ending mandate creep.
I'm not sure I buy the theoretical argument. Why, for example, does that same argument not apply to a mandate for grocery insurance? There are some, who thinking that they don't need grocery insurance, will choose not to get it.
Of course, it's not quite the same in that we don't expect others to pay for our groceries. We expect to pay for that ourselves. But if we remove the assumption that others are going to pay for our health care, then doesn't that destroy the theoretical reasoning behind mandated health insurance?
Am I missing something?
I'm also apparently missing it.
In fact, that was the fastest "theoretical" discussion I've ever seen. Health care is the same as defense, Q.E.D.?
Also, your theoretical reason for going with the mandate IS a practical reason.
Difference: Medical care has the possibility of catastrophic injuries. You don't suddenly develop an absolute need to eat foie gras at every meal.
One theoretical reason: Poor health care can have large externalities; certainly true in the case of vaccines (esp. because of herd immunity.)
The other reason is theoretical in the sense of "If you could ensure that the type of universal insurance would be high-deductible catastrophic coverage with HSAs and subsidies for the poor, and it would never change over the years, I would do it." But the premise is false, so no.
Even as an admittedly somewhat flaky libertarian, I'd be fine with (perhaps even actively support) some kind of catastrophic coverage mandate for those who can afford. But somehow health care reform advocates argue out of one side of their mouth that such catastrophes justify the mandate, and out of the other side advocate a mandate that covers vastly more.
Even if we're committed to treat those without insurance, I don't think the free-rider problem really IS that much of a problem, and that's because there are relatively few people with wealth and income who go without insurance. The reason they don't is that even though we are committed not to let you die if you get sick and have no insurance, we're NOT committed to protecting you from bankruptcy. So, generally only those with very little to lose will go without insurance, and those are mostly either poor people or young people (who are rarely wealthy).
What if you're a relatively high-income person who never saves a dime and prefers to spend every cent on fun stuff rather than 'waste' any money on insurance? Again, there really aren't that many people like that (high-earning but without employer provided insurance and unwilling to buy their own). But perhaps we need to make health-care debts incurred by such people non-dischargeable at the discretion of the bankruptcy judge.
One thing to consider is that under the “free rider” problem, while it’s true that the costs are likely either passed along to the taxpayer or to other patients (or their insurance companies) the same is even more true for Medicare and Medicaid patients. Neither of these “public options” pay the full cost of treating their beneficiaries and we as taxpayers and private patients end up having a lot more costs shifted onto us for people on these programs than we do from “free riders” who don’t buy health insurance and get treated at the emergency room.
So if concerns about cost-shifting is one of the drivers of “health care reform,” while it may or may not support an argument for an individual mandate to buy health insurance, it’s a pretty big nail in the coffin of proposals for Medicare For All, the “public option,” or any expansion of existing public programs.
I think Megan's right that it is essentially impossible in current American society to *not* provide some kind of medical care to anyone who gets sick; hysterical proclamations to the contrary, if you show up in an American emergency department with an acute illness, they *will* treat you. As extensively as someone with the ability to pay? Perhaps not, but it's just foolish to claim that there's anyone in this country without the access to *some* safety-net medical care.
That being the case, it may well be the case that it's most efficient to mandate that every American have some form of health insurance - even aside from the moral imperative, since we (society) are going to provide care anyway, we might as well have an explicit mechanism for doing so. Once you reach that conclusion, an individual mandate associated with at least guaranteed issue and probably community rating as well becomes the most obvious policy.
Where this line of thought falls down is the fact that there is almost no understanding among either policymakers or the public about what medical care costs, or what a "basic" policy would look like. We live in a medicolegal - and ethical - environment in which it is extremely difficult if not impossible for a physician to tell a patient, "In a perfect world, you would have treatment A, like the patient down the hall with the private health insurance. However, that's pretty expensive, and your particular insurance won't pay for it. If you'd like to pay for it yourself, I'm happy to go ahead - but if that's too much money, let me recommend treatment B, which is helpful but clearly inferior by such-and-such a margin." Patients go bonkers, doctors feel pressure to fabricate data to get the insurer to pay for treatment A, and everyone starts screaming about how the Evil Health Insurance Company (tm), led by its Dark Lord / Greedy Bastard CEO, is letting patients suffer in order to pay for their private jets.
If, for example, you want a policy that covers:
1. Those preventative services *actually supported by data* (i.e. vaccinations, blood pressure and cholesterol checks by a nurse, mammograms, and maybe colonoscopy, but no routine physical exams or labwork for healthy people, no cardiac stress tests for people without symptoms, etc.)
2. All generic medications.
3. No brand name medications. No, not even if you really, really need them. No, not even if you have a politically favored disease like breast cancer or HIV.
4. All costs of hospitalization for acute illnesses (like pneumonia or getting hit by a car), up to four weeks a year or so.
5. No organ transplants. Not even if it's *not* your fault as a result of substance abuse.
6. No hemodialysis.
7. No chiropractic care, no massage therapy, no in vitro fertilization. No, not even if your lobbyist has a really fat expense account and a really short skirt.
Guess what? I'll write you that policy pretty cheap. Which is to say that the unaffordability of individual health insurance policies in most (not all) states is *entirely* the consequence of decisions made by the state legislature on what constitutes an acceptable policy.
Regardless of the details of payment, amount of socialization of costs, level of deductible, the basic problem in health care costs is that no one wants to be the one to say that simple little word..."No."
Why should we even need insurance for preventive medicine? I'd love to see a wave of doctors starting to publish price lists for uninsured office visits. The cost honestly should not be that high, just 15 min of a doc's time plus overhead. And so many generic drugs are already ridiculously cheap due to Wal-Mart's lead (shocking, I know), so most prescriptions wouldn't require insurance either. That leaves catastrophic & hospital care, perfect candidates for insurance coverage.
You are generally talking $150 and up for doctor's visits. For a poor person, that's a lot of money. Think of your college student days. Did you have $150 lying around for a doctor to take a look at you? Only if you forgo groceries or the rent.
Bottom line-the poor and uninsured don't do preventive medicine. They get sick and go to the emergency room. With a high deductible, they will continue to do so.
So do you support the retail clinics that have nurse practitioners do routine preventative care and checkups, and are much cheaper than a doctor's visits?
Preventative care is free in my high deductible plan, including a yearly checkup.
They get sick and go to the emergency room.
In our health utopia, that is the only thing you can do. It is very difficult to get a primary care physician in many places, and by the time you can see them you may be forced to emergency anyways. There are very few walk in clinics.
So your fear of the horrible inefficiency of emergency room centered medicine is fully realized in a top to bottom socialized system.
Odd that.
Derek
Call ahead and ask if they'll give a cash discount. My hospital's clinics for the poor charge $55 for a regular adult visit. That's two weeks of cigarettes if you have a pack-a-day habit.
The ER has to take you, but they also send you a payable-in-full bill.
doctor's visits are not 150+ unless you only go to specialists, and are not necessarily that high even then. a more typical range is 50-100, closer to the 50 than the 100 in many locales.
the poor often don't realise that many doctors will not charge much to poor people if they but ask. they are afraid to ask and so they don't go to the doctor. there is also a cultural difference in some cultures of american poor in which going to the doctor is a sign of weakness, that one should be able to get over any ailment without doctors/hospitals/modern medicine.
there is a lot more to the poor not going to doctors than fear of being charged an imaginary 150$.
@Derek
Acording to this article, you are mostly a purveor of myths about the Canadian system.
http://www.pnhp.org/news/2008/february/10_myths_about_canad.php
The writer is " both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I’m in a unique position to address the pros and cons of both systems first-hand. "
You claim to be a Canadian. Have you had any experience as an uninsured US citizen? I have, and I assure you that there is a major difference between having to wait to see a physician and not being able to see any physician unless you go to the emergency room. Unlike you and most commenters here, I've lived it, not just imagined it.
The arguments for a mandate usually seem to center around saying that if we could bring all of the young, healthy people into the system it would make health insurance cheaper for everyone. This sounds fine, until you realize what you've done: you've created a special tax for young people, who generally are at a stage in their life when they make less money. I'm not concerned about affordability here, but about the creation of a gigantic regressive tax.
And even worse, some of the young people will die in accidents and won't get to be old, whereas all the old people, by definition, were young once and for a long time. Young people who live to be old may get their money back, but the net effect is to tax people who die young to give it to the people who live long.
Young people-if they are lucky-get old, at which point the young will take care of them. It's part of the age old compact between generations.
Heck, for the first 18 years of their life, the young benefit from an enormous regressive tax paid by their parents, if you want to look at it that way.
So the unlucky ones should subsidize the lucky ones, stonetools? That seems harsh. I thought most people on the left thought that the lucky should subsidize the unlucky? The "age old compact between generations" didn't have government providing the services or money, so that's a strange argument.
Huh? Do you know what regressive means? Parents are generally wealthier than babies. Also, parents have lived longer than babies.
Not to mention that parents chose to have babies. Young people are not given the option to opt out of this ponzi scheme.
here's a question that only seems to be getting minimal play: is it even legal for the government to force us to buy health insurance?
this is a stretch for even the interstate commerce clause. the mandate to by auto insurance is not federal, is it? the only analagous federal mandate i can think of is social security, in which we are forcible enrolled through a payroll tax. obama seems unwilling to call this a tax, so by what mechanism will this health care mandate be enforced? and, if this passes, how long before we see a test case come before the courts?
Yep!. Never in the history of the country has the government tried to force people to buy something from other private entities. SS cannot be compared because its a tax that goes to the government and the government pays the benefits.
Another problem, constitutionally, would be the vast divergence in premiums among various states and localities. Should an individual in new York City be forced to pay about $25,000 per year while an individual in another state might pay $6000? Does that somehow violate something like Equal Protection?
I wonder about that, too. Isn't having a payment to the IRS that you are required to pay just for being alive, and that is a flat dollar amount, a new form of poll tax, and therefore unconstitutional according to a Supreme Court decision a few decades back?
It seems to me that the first question is whether Congress is authorized to impose individual mandates. I would say Congress is under the interstate commerce clause: The selling, marketing, and administering of health insurance, as well as the provision of health care services and products (which, at a minimum, probably almost always requires the use of tools and products that travel in interstate commerce, whether you're talking about a doctor or a large hospital), are economic activities involving interstate commerce. As I recall, the cases that have found that the interstate commerce clause was not sufficient were based on legislation targeting activities (violence against women, gun possession, etc) that were not economic activities at all.
The next issue is whether any constitutional provision protects consumers from having a mandate imposed on them. The only one I can think of is the due process clause, but I believe that the justices most likely to forbid imposition of a mandate (the conservatives) don't believe in a substantive due process clause (i.e., a due process clause that provides substantive rights like a right to privacy or abortion, as opposed to just mandating certain procedural requirements).
My guess is that Thomas is the only one who would seriously consider striking down individual mandates. He has actually suggested revisiting the entire body of case law regarding the interstate commerce clause. Other than him, I doubt that even Scalia would go there.
Simply living is NOT and economic activity. Any mandate would be on individuals, not providers of medical services so your defense of more government control of individuals should not apply.
Yes it is. You have to get food somehow. Either you work for it yourself or others do the work for you.
@Nelson - you seem to be suggesting that "regulate commerce...among the several states" means Congress has the power to regulate *any* economic activity, at any level. I think that's overly broad.
There are a couple of ways I can see...
1) Make health insurance a tax credit up to a certain dollar amount for approved plans. Raise the general tax rate to make it revenue neutral. It doesn't force you to buy it, but as long as at least one of those plans is under the limit, you'd be foolish not to.
2) Just call it a tax.
Whatever you call it, it is certainly constitutional. Sorry.
Many people have tried to argue that taxes aren't constitutional over the years. They've all failed.
Another problem is that Americans have come to view insurance in the abstract as a method to get medical treatment more cheaply than they could if they paid for it directly.
$75 for a visit to the doctor? Who can afford that? An extra $50 for a blood test? I have a chronic illness causing a lot of expensive medical treatments; You mean an insurance company can refuse to cover me at a rate I consider "affordable" (ie less than my medical costs actually are)?
This is the result of 60 years of separation between the patient and the payment system.
Yes. As I said above, I have co-workers (all presumably quite intelligent) would prefer to pay $1000 or more in higher premiums and forego $1000 a year in an HSA in order to have a deductible that is on net $800 smaller. (If you count the HSA money against the deductible; you could otherwise express it as $1800. I checked the numbers on my benefits website.)
I too would be happy if everyone had catastrophic coverage or true insurance, even if such coverage were mandated. I am completely against community rating and guaranteed issue. The combination of the two is a hidden tax - everyone's premiums go up by some unisolatable amount. It would be far preferable to subsidize those who need it because those amounts would be measurable and the true costs of the plan would be seen.
Also, even though I am no big fan of Medicaid, ordinary people who could not afford a basic plan would still be covered.
Why not just cut the crap and go whole-hog with single-payer? Enough of this dancing around the fact that we're socializing the entire thing anyways. At least cut out the bureaucracy! I think we can fast-track our way to Britainistan if we install cameras everywhere and nanny-state every last detail of our lives.
For the first and perhaps only time, I am fully in agreement with you.
I just don't want to fight it anymore - the American people have spoken.
Then why is making the free riders pay more expensive then letting them free ride on the private system?
Imagine free riders as just another expense of the system, no different from any other. From that perspective, the American system provides quite a lot to everyone even with the riders.
Yet now we are being told getting rid of the free riders means everyone needs to pay more for less services.
Friends don't let friends get fooled by reds.
Is there any data from the places that have mandates whether the free rider problem, or the uninsured problem is eliminated? Do the insurance companies actually collect more money proportionate to the supposed numbers?
It seems that this would provide an excellent imperative to go underground. If filing taxes then forces you to pay for insurance, why file taxes?
And if you show up at a hospital without, how would it be any different than now?
All this would do is raise the cost of law compliance.
If you don't think that is an issue, in the largest Canadian municipality, a trade association estimated that fully 20% of all the construction projects fulfill all their regulatory and legislative obligations.
Derek
Do you have a link to the news story?
I really dislike the whole logic of the argument from emergency care.
It starts out with, "We don't want you to die from a medical emergency, so we're going to give you medical care, even if you can't pay for it."
Then the next step is, "Giving you free medical care costs us more than we want to spend, so we're going to force you to pay for medical insurance."
And the third step is, "You didn't pay for medical insurance, so we're going to punish you by taking your money."
It all reminds me of the Inuit man who told Peter Freuchen, "With gifts you make slaves just as with whips you make dogs" (quoted by Erich Fromm in The Anatomy of Human Destructiveness).
Young women going off to the big city used to be warned about accepting expensive gifts from men. First the man will give you an emerald bracelet, the story went; then he'll starting asking you to have sex with him, and say he deserves it because you took his emerald bracelet; and in the end he'll force himself on you. Well, the Democratic Party seems to be taking the role of the big city seducer . . . except that we don't even have the option of refusing the bracelet: people who have never used medical services without paying for them, who have funds set aside for emergencies, or who have catastrophic coverage policies, are still subject to the mandate and the penalties.
I find the logic of this argument morally contemptible. If you can't stand the thought of my dying, and want to pay for my health care emergencies should I be unable to, that's generous; but if you turn it into an excuse to force me into a "responsibility" I can't afford or wouldn't choose to undertake, that's no longer generosity but manipulation. What comes next: Taking mothers who are getting government money to help support their small children and forcing them to accept menial jobs at low pay? No, wait. . . .
Here's my ideal insurance plan:
1> Guarantee issue with a mandate. Yeah, I know the libertarian side of me screams at this, but in a country that everybody receives treatment -- everybody in the pool.
2> Get back to the idea of insurance not insulation. People want insulation from healthcare prices, not insurance. Insurance is what kicks in for those bad years. Therefore the basic policy should have a family $5,000 deductible with a $10,000 out of pocket. High deductible with HSA is the basic package for everybody.
3> Subsidies for low income. The premium paid + deductible paid in any given year should stay below 15% of AGI. Total out of pocket below 22%. Tax credit to make up the difference. Exact % negotiable, but you get the idea.
4> All employer provided plans that cost in excess of the package described in point 2 taxed on that excess. Why should one form of compensation be favored over another. I'd actually like to see all employer provided care taxed, but this proves my ability to compromise.
5> Insurance sales across state lines. Actually I don't think this would be necessary. When the basic package is catastrophic insurance then the instate rates will plummet. But this does make a good backup plan to keep politicians in line.
6> Expanded services to be offered by nurse practitioners, physician assistants, midwives, pharmacists, and other trained medical professionals. Does anybody really believe that a modern nurse practitioner, with today's information technology at his fingertips, is LESS skilled than a doctor turned out even 15 years ago? The AMA monopoly keeps prices high by restricting who can provide services. This is usually not at all necessary.
7> Speaking of the AMA -- Also break their monopoly on medical school slots. Today a university cannot create or expand a medical school without AMA permission. This is nothing more than a medieval style guild working to restrain entrants to the profession. Kill it. If BackWater U. wants to start turning out doctors so be it. Rely on basic curriculum standards and licensing tests to keep out the riffraff like all other professions, not the AMA guild.
8> Oh, yeah, malpractice reform. Limit awards to economic loss + limited $ pain and suffering.
But since I'm not likely to be appointed dictator in the foreseeable future the chance of these reforms being adopted is nil. I probably should come up with a couple of other points just because a 10 point plan just seems so much smarter than an 8 point plan.
Actually, The Baucus plan has pretty much all of that. It has insurance exchanges, which achieves interstate competition without the race to the bottom of just allowing interstate competition. Doesn't have AMA deregulation(which I would agree to).
You don't have anything about preventive care, which is severely discouraged by high deductible plans.
Subsidize that, and have the FTC oversee the insurance companies for collusion and price fixing, and you may have something.
The most important of his points is #2, which the Baucus plan completely and utterly fails to cover. Indeed it does the exact opposite by forcing a minimum standard package that will drastically increase costs - as occurred in Massachusetts.
The only points the Baucus plan covers are 1 and 3, notably the only two points in his list of 8 that serve to increase Health Care costs in this country rather than reduce them - the stated objective of Obama, though not his true goal.
As for your argument about insurance exchanges, they have managed to come up with a plan to spend large sums of money on their exchange rather than simply allowing intrastate competition which would be cheaper, but this point is arguably somewhat covered at least.
Too bad none of the substatial ones that would actually make things better aren't.
Agreed for the most part, with a couple of exceptions.
With number 6, I think there are services that can be expanded to an extent, but I absolutely believe a just graduated nurse practitioner or physician's assistant is certainly less knowledgeable than a doctor turned out 20 years ago. The difference in education is much, much different. Experience and technology may make up for it, but the truth is that these days medical school's main goal is to expose you to everything in the first 2 years so you can use technology to look it up, then spend 2 more years of rotations to expose students to what crops up in this country. Then, they send you to a minimum of 3 years residency. That's a minimum of 7 years, whereas physician's assistants graduate in 2 or 3.
There is also Osteopathy school, which is geared toward providing primary care physicians, which are in short supply.
I would also disagree that the AMA "monopoly" keeps prices high. It used to, but considering the training and commitment that goes into being a physician, not to mention the loans, physicians are mostly underpaid. There are surgeons that make a LOT of money (insert $30,000 amputation joke here), but most people overlook a surgeons work week, which often ranges from 50-70 hours a week. In most cases, I would argue physicians make a reasonably high salary, but rarely excessive, and certainly not on average.
With 7, medical school slots don't affect the number of physicians. This is an often misinterpreted representation of the process of becoming a doctor. While they do present the MD's, only residencies actually allow you to practice. I'm not positive who sets the number of residencies, but I do know they are primarily funded by Medicaid or Medicare, and I'm pretty sure it's set by the government.
As far as I'm aware, nearly everyone who gets through medical school gets a residency. That makes medical school the bottleneck.
As for Nurse Practitioners/PAs, the question is not whether they are better than a doctor. The question is whether they are good enough most of the time. Walmart clinics seem to have shown that the answer is yes.
With DO School, Caribbean Medical Schools (and their US rotations), and foreign medical schools, there are always more applications for most residencies than there are spots available. Unfilled residencies occur, but because they are unattractive residencies (geriatrician), not because there aren't enough applicants.
I understand the argument, but when do you draw the line? The problem with most of the time is determining where it ends, and I think this is a much more difficult problem than it seems.
Well, I did some research on high deductible plans that people here like so much and I discovered this, according to one article:
High deductibles, though, can pose problems for people who cannot afford the out-of-pocket costs associated with the plans. For a low-income family earning $25,000 a year, for example, the out-of-pocket costs of a high-deductible plan would eat up an estimated 15 percent of the annual household budget, according to a Kaiser Family Foundation report.
What’s more, low-income families don’t benefit from the tax breaks associated with health savings accounts the way middle- and high-income earners do.
Even if you can afford the costs, the loopholes that insurers often weave into these plans to reduce premiums can mean that even after your deductible is met, you may not have the coverage you need to handle a serious illness or accident.
“For most people, a high-deductible plan is basically a bet against yourself,” said Ms. Stoll. “You’re betting that you won’t get sick and you won’t have an accident. But isn’t that exactly what insurance is supposed to be? A bet that something might happen, and if it does you’ll be protected?”
http://www.nytimes.com/2009/05/30/health/30patient.html
Another article says :
High Deductible Health Plans Would Be Good For Individuals and Families Who Can:
Afford High Out-of-Pocket Expenses (deductibles on high deductible health insurance plans are generally $1000-$2000)
Are in Good Health
Generally Never Need Prescription Drugs
Don't Plan to Get Pregnant (some plans have a one year wait before they cover maternity care)
Don't Have Pre-Existing Conditions (again, there may be a waiting period)
http://personalinsure.about.com/od/health/a/aa071208a.htm
That sure doesn't sound like everyone. Indeed, it doesn't sound like most people.
Here is another study that pretty much says that these plans are a disaster for lower income people.
http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2005/Apr/How-High-Is-Too-High--Implications-of-High-Deductible-Health-Plans.aspx
I think people who like these plans have to answer these objections, before blithely recommending high deductible plans.
Easily done. The high out of pocket expenses are usually offset by the cost savings of the plan. I have a $5,000 deductible. If I recall correctly, to lower that to $500 would have raised the price of my insurance by over $3500/year. (The only explanation I have for this is that some consumers are irrational.) If I stick the money I save by buying cheaper insurance into an HSA, I have enough to pay for the deductible.
Pregnancy is a choice. If you can't afford it, don't do it. Health insurance should not pay for pregnancy, just as car insurance should not pay when you want to buy a new car.
As for people in good health and who don't need drugs, those are the people Obama wants to force to buy health insurance.
High deductible insurance doesn't make other people buy you medical procedures or drugs, nor is it meant to. It's sole purpose is to protect you from large, unexpected events. Handling the small stuff is just part of being a responsible adult.
High deductible insurance has an additional benefit: people with such a plan spend 30% less on medicine than others but are equally healthy (according to the RAND experiment).
The paper was published in 2005, and consists of predictions about consumer driven health care plans, based on a survey in 2003. Here's a more recent summary of research from 2009 which reviews various high quality studies completed in 2008. It finds that those fears from 2003 did not come true. I trust empirical research over predictions based on surveys.
The articles on about.com and the New York Times are silly, because it completely ignores that people would have to pay more in premiums for a low deductible plan. At my workplace, the difference in annual premiums paid by employee for a low deductible plan is greater than the difference in the deductible from a high deductible plan. When to add to that that my company grants $1000 a year towards the deductible from its cost savings from the plan, it seems rather obvious.
If you have pre-existing conditions, then you're not going to be able to afford a low-deductible plan at all, so those aren't "right for you" either.
I agree that poor people would need support to afford plans. I don't have a problem with that. I'm arguing that these plans are a superior form of insurance and should be encouraged by the government, instead of being discouraged.
The Baucus bill increase the point at which you can deduct medical expenses from your income from 7.5% to 10% of your income. This is done to raise money to make up for the fact that the bill requires low-deductible plans in its mandates.
That's a terrible idea. It's making things considerably harder on people who have catastrophic medical problems or very high expenses, in exchange for encouraging people to pay less out of pocket (but more in premiums) during relatively health years.
My experience. I have a consumer driven health plan. Now I find out how much my drugs cost at different pharmacies and go to the cheaper one. CostCo membership costs $50 a year, but I save well over that per year by getting drugs at CostCo.
One drug costs $19.27 for a month's supply at CVS, but $5.69 at CostCo.
Another costs $52.57 for a month at CVS, but $28.51 at CostCo.
I haven't paid anything out of pocket yet, since it comes out of my company funded HRA (which rolls over year to year). But I definitely pay more attention to price, since it does save me money if anything worse happens. With a traditional insurance plan, I would pay the same co-pay at CVS and CostCo, even though I'm getting generic drugs. I would have no incentive to get the medicine that costs my insurance company less.
I live in California; between the San Andreas and the Hayward faults, closest to the Loma Prieta fault.
I enjoy wine.
I buy "bladder in a box" wine regularly. I fill empty bladders with water and stack them in the back yard.
None of my neighbors have lived here as long as I (since '65). I don't believe any of them stockpile water.
When "The Big One" hits, will I share?
Do I think my neighbors (some with children) should "Act Responsibly"?
Do I want Government to make them "Act Responsibly"?
Thank God I can afford wine.
Thank God for wine.
I will stockpile every ounce of water I can.
I will share freely.
Government is our common enemy. They should be hanged, set on fire chopped into small pieces, drowned, then buried alive.
Some may disagree with me, perhaps from considered and heartfelt moral objection. They should refuse me and wait for the Government.
Still, I will share. I will never sic government on anyone.