Paul Krugman and Ezra Klein say yes, mandated universal coverage would – and it is also a key part of serious health care reform. Richard Eskow says no; we have to fix the cost problem before we can cover everyone, and mandates won’t achieve universal coverage (actually Richard says 100% effectiveness, which I agree with – but 99.5% is fine with me).
The first part of the question is rather basic – can a mandate, that is, required coverage for all residents, actually cover all residents?
Looking at other countries with mandates, it looks like mandates are an effective means to force universal coverage – Germany is the only EU country that allows people to go bare, or buy insurance from a private carrier. Yet the uninsured population is about .25% of the population – a quarter of a percent (200,000 out of 87.4 million).
Among the French, less than a half-percent don’t have health insurance. Notably, this number, although infinitesimal, appears to be growing – albeit slowly.
I know, there are more than a few differences between the US, Germany and France. But among all members of the OECD, only in Mexico and the US (search for ‘uninsured’) is any substantial portion of the population uninsured. And as I’ve noted previously, the Mexicans are rapidly working to provide coverage for most of their population.
There are other examples of mandated coverage in the US that seem to work pretty well. For employers, workers compensation is required (for all but a very few employers) in all states save one (Texas), and rare is the employer that goes bare. Yes, it does occur, but the premium audit function catches most of the cheaters. Unemployment compensation is another.
People can, and will, argue over whether mandates are consistent with American culture and politically possible. But the argument that we can’t have them because they don’t work doesn’t fly.
Mandates can, and do, result in universal coverage.
But remember, costs are higher here. That’s why the Massachusetts Connector is exempting 20% of the uninsured population there from mandates.
(And if Germany’s figures are better than France’s, what’s the lesson in that?)
We’re really discussing sequencing more than we are the ultimate model, but starting with mandates is going to be problematic.
Joe:
Lets try a few other mandates:
Voting
Citizenship
Healthily Diet
Auto Insurance
Obeying the law
Driving only when sober
Resumes that are accurate
Politicians that tell the truth
For a few.
Doing so we will cut the cost of health care, reduce taxes, empty the jails, save 50,000 plus lives a year, solve illegal immigration, provide a huge boost to the economy and produce an informed electorate.
Mandates on employers are enforced with fines, penalties, and jail time.
How many people are you willing to send to jail for not buying an insurance policy to pay some doctor a half million dollars a year or support profits of drug companies that make billions in the US because other countries regulate their price? How about for paying doctor owned laboratories that knowingly perform unneeded tests to line their doctor owner’s pockets? How about for huge expenditures to prolong the life of someone already brain dead for years because the family can’t let go? How about for liver transplants for alcoholics that knowingly ruined their own? How about for extended AIDS care for drug users? How many are you willing to send to jail, Joe?
Oh, I am so cynical this morning. Must be Monday and I need a cup of coffee.
Get real, Joe. It ain’t gonna happen.
Joe, I know you delete a number of my comments. Probably because my views are widely at variance to yours. But I do want to say that you have really made me think and write out over the last few months my thoughts on those views. I have also made some changes, not many but some towards some of your views. I have also hardened some of my views at wide variance to yours. Keep up the good work. I hope it makes others think as much as it has made me.
One final thing, there is never anything personal in my comments. I have never met you but do look forward to it. Also I found you from the “Lynch Ryan’s weblog about workers’ compensation” so blame them.
Regards,
Charles Read
Richard – one of the great things about discussing this with you is I respect your opinions as they are on point and based on your real world experience, and I know we are both focusing on the same goal – meaningful health reform.
The point I was (and am) addressing is pretty narrow – can mandates realistically get close to 100% coverage. From my examination of other countries, and other ‘mandated’ benefits my conclusion is ‘yes, they can’. There is no question it will cost money to do, but that is a separate, altho tightly linked, issue.
Charles – I delete comments for specific posts that are off-topic or rants – Aubrey from BCBS FL just screams, and that adds nothing to the dialogue. As to my deletions of your posts, I’m fine with disagreements. It is the propensity of some commenters to use labels (eg socialized medicine) as justification for their disagreement that makes me nuts.
Your comment here is helpful, because it illustrates the second part of the issue – cost, and what we pay for. My post is, as noted above, very narrow – and nothing in your comment leads me to question my conclusion.
Charles, how we ‘enforce’ a mandate is a separate question. IN a free society, there are always going to be people who freeload on others. I do not expect, and no one should, that any solution will be perfect. But that does not mean we should not pursue change.
I look forward to your reasoned comments. I learn a lot from commenters – disagreeing intelligently, using logic and facts to back up positions, and respectful dialogue are all very helpful, and make it tough to dismiss one with whom you disagree.
That’s one reason I’ve been thinking a lot about Richard’s Obama perspective.
Regards – Joe
I think the three most important issues related to an individual mandate to purchase health insurance are (1) will it be affordable for most people, even with subsidies based on income, (2) how significant is the penalty for non-compliance, and (3) how rigorously will the penalty be enforced.
Given the high cost of health insurance, especially for family coverage, I think an employer mandate would have far greater appeal than an individual mandate. If all employers must purchase health insurance on behalf of their employees, none would be disadvantaged vs their competitors. It would have to be explicitly included as part of each employee’s total compensation in determining how much the employer could then afford to pay in straight wages, and the cost would have to be built into the price of the employer’s product or service.
An individual mandate would then have to be applied to the unemployed, pre-Medicare eligible retirees and, perhaps, sole proprietors and those who work for very tiny businesses, and they would need subsidies scaled to income to make sure the cost of health insurance did not consume an unacceptably large share of their total compensation. Bottom line: it can be done. That said, the penalty for non-compliance in Massachusetts is woefully inadequate, in my view, as are the resources committed to subsides to make health insurance affordable for the bottom half of the income distribution..
Thanks for the interesting discussion.
With all due respect, I think any discussion of “mandated coverage” is a bit out of focus unless we specify the kind of coverage we’re talking about. After all, mandating a high-deductible plan has dramatically different implications than mandating the $20 copay-type plan I’m lucky enough to have.
I’m not well-educated about the EU mandates you outline; do citizens get robust coverage for the dollars they’re required to invest?
By the way, I don’t see high-deductible plans as “robust” by any stretch. If the average U.S. income is about $50K, and the mandated plan calls for $10K deductibles, there’s a bit of a mismatch there to say the least.
Am I mandated to pay tax? Or is a tax not a “mandate”.
Semantic bullshit aside, the US government can tell people to do what it wants in every other sphere–when it wants to.
To Matthew Holt:
Matthew, if that was really true we would need no prisions, no unisured motorist coverage, No bars on windows, no red light cameras, no security guards, no presidential pardons, no guard dogs, no child support enforcement mechanism and I can go on.
People do what they want for the most part regardless of what the government says.
Charles
PS: There are millions who delibertly pay no tax and many many more millions who delibertly unreport and unpay they taxes every year.
“the US government can tell people to do what it wants”
Henry IV Act III scene i:
GLENDOWER: I can call spirits from the vasty deep.
HOTSPUR: Why, so can I, or so can any man; But will they come when you do call for them?