Obama Says No One Should Be Forced to Sign up For Insurance; Edwards Says If You Don’t, He’ll Garnish Your Wages—Who is Right?

John Edwards’ declaration that under his health reform proposal anyone who refuses to sign up for health insurance will be subject to having their wages garnished has led to a blogstorm of often confusing debates.  Under national health reform, should everyone be required to enroll? The Edwards and Clinton plans have mandates insisting that all Americans purchase insurance; the Obama plan has a mandate for children, but not for adults

New York Times columnist Paul Krugman stirred controversy Friday by defending Edwards, and criticizing Barack Obama: “Under Obama’s health care plan, healthy people could choose not to buy insurance—then sign up for it if they developed health problems later,” Krugman observed. “As a result, people who did the right thing and bought insurance when they were healthy would end up subsidizing those who didn’t sign up for insurance until or unless they needed medical care.”

On Sunday former FCC Commissioner Reed Hundt called Krugman out on TPM Cafe in a post headlined “Ease up, Dr. Krugman.” According to Hundt: “The very idea of government mandates directed to individuals evokes a command-and-control model that disturbs citizens who want to enjoy certain freedoms in choosing health care.” As of yesterday, Hundt’s post had drawn some 60 comments—some on point, others muddying the waters.

Meanwhile, at TNR Jonathan Cohn weighs in with a long discussion of just how many people Obama’s plan might leave uncovered—and suggests that one of Obama’s advisers has information showing that under Edwards’ plan, even more Americans would be left “going naked.”

Because the conversation in the blogosphere has become such a mix of good information, misinformation and false assumptions, I’ve decided to try to spell out, as clearly as possible, why we need a mandate. Very simply, it addresses a serious defect in our health care system:  under existing rules, you don’t have to buy insurance, but you can be priced out of the insurance system if you are sick.

After examining that problem–and looking at how requiring insurance solves it– I’d like to answer a sensible question that observers like the Washington Monthly’s Kevin Drum have raised: Why force people to buy insurance? Why not just tax everyone, put the money in a pool similar to the Medicare Trust Fund, and use it to buy universal insurance?

Begin with one of the most serious inequities in our current system.
Today, laws in many states, including California, allow insurance
companies to refuse to cover anyone applying for an individual policy
who suffers from a “pre-existing condition”–including common
conditions such as asthma or pregnancy. As a result, if a person loses
her group coverage—either because she changes jobs or because her
employer no longer offers health benefits—and then discovers that she’s
pregnant, she may find that she is uninsurable.

Moreover, even if you manage to secure coverage, in many states the
insurer can jack up your premiums if you become sick and actually begin
using your policy. A small business also may find itself penalized if
one or more of its employees become seriously ill; in some cases
employers have had to cancel insurance for the entire group because
they couldn’t afford spiraling premiums.

In addition, the Los Angeles Times reports (see a 1/08/07 story by Lisa
Girion, available by subscription) that in states like California
private insurers can –and do—refuse to insure entire categories of
workers who they deem “too risky” to cover, including roofers, pro
athletes, dockworkers, migrant workers and firefighters , even if they
are in good health and can afford coverage. The LA Times looked at
confidential underwriting guidelines of three health plans: Blue Shield
of California, PacifiCare Health Systems Inc. and Health Net Inc. which
all said that “actuarially speaking,” certain workers pose too big a
risk.

A last resort for people turned away by the private market is a state’s
high-risk pool, in which the state assumes the financial risk while
paying private insurers to administer coverage. But in California,
enrollees must lay out as much as one-third of their income on monthly
premiums that cost up to $796 (see 12/21/06 story by Lisa Girion, also
in the L.A. Times). Meanwhile, annual benefits are capped at just
$75,000. If your child is diagnosed with cancer, it’s likely that
you’ll run through that $75,000 in less than six months.  Then what do
you do?

In each case, insurers are penalizing people for being sick, or because
it seems likely that they might be injured. Those who most need
insurance are excluded.  It is one thing to raise car insurance
premiums if a driver has a series of accidents (suggesting that he
might well be a reckless driver). But most people become sick through
no fault of their own, No matter how careful we are, unless we die in
an accident, each of us is going to become seriously ill at some point
in our lives. We just don’t know when. This is why we all need
insurance.

To prevent insurers from shunning the sick, some states, including New
York, have passed “community rating laws” which say that insurers must
charge everyone in a given community the same price for the same
policy, regardless of age or health status. Moreover, insurers are not
allowed to hike rates because a business or an individual has made
claims.

In states like New York, where community rating applies, no one is left
out in the cold.  If an individual wants to apply for a new insurance
policy, he does not have to report pre-existing conditions. But he does
have to show that he was already insured with another carrier; you
cannot just wait until you’re diagnosed and then decide you want
coverage.

Insurance in New York is much more expensive than it is in California
because the pool includes sick people who would have been excluded in
California. (The percent of premiums that insurers pay out to provide
care is roughly the same in both states. Insurers don’t make higher
profits in New York. If anything, they prefer to operate in states like
California where they can hope to avoid patients suffering from
serious, debilitating diseases).

If you are young and healthy, you might prefer to live in a state like
California, where insurance is cheaper—assuming you don’t mind living
in a state where your mother can’t get insurance because she has had
breast cancer and your best friend can’t afford insurance because she’s
a diabetic.

Progressives believe– rightly, I think– that most of us don’t want to
live in such a society.  So the three leading Democratic candidates,
including Obama, are calling for community rating. Their proposals for
reform offer citizens a choice between public sector insurance (that
would be much like Medicare) and private sector insurance, and under
their plans, both public and private insurers would abide by community
rating, insuring everyone in the community, young or old, sick or
healthy, at the same price. 

And to make sure that everyone can afford the price, the government
would offer subsidies, based on income. Thus, only upper-income
twenty-somethings would wind up paying the full price. The subsidies are key. As The American Prospect’s Paul Starr points out:

“The secret power of the mandate is that it is as much a mandate on government as it is on individuals. It is a mandate on government to make coverage available and affordable. For it would be patently unacceptable to demand that people have coverage and then provide no practical way for many people to get it.” But the government (i.e. taxpayers) will be able to afford those subsidies only if the healthy and wealthy participate in the pool.

Why Insuring Everyone Means That Everyone Must Be Insured

If we want community rating, Edwards and Clinton realize that we also
must mandate that everyone sign up. Otherwise, no one would buy
insurance until they were sick or elderly; then they would enroll,
secure in the knowledge that insurers had to cover them, and couldn’t
charge them more.  Meanwhile, the insurance pool would be comprised
mainly of people who are expensive to insure, and premiums would
skyrocket.

Put simply, mandates are the flip side of community rating. If you want
to say insurance must cover everyone—even if they are suffering from a
slow, progressive disease like Parkinson’s—then you have to insist that
everyone gets into the pool. This is the only way we can afford
universal coverage. If you think about it, this is precisely what
Medicare does: no one over 65 is excluded, but everyone—even the young
and healthy– must pay the same percentage of their paycheck in
Medicare taxes.

In the end, Harvard economist David Cutler, Obama’s health care adviser, agrees that for
national health reform to work, we will need to bring everyone in under
the tent. But he says that, rather than forcing people to buy
insurance, Obama believes “a better approach is to do everything
possible to make it affordable and available. When it is, almost
everyone will have it.”

Will everyone sign up? Many young people look in the mirror and feel
immortal. Meanwhile, young libertarians just don’t believe that they
have a responsibility to help cover others. In Massachusetts, where
there is no mandate, over 200,000 of the Commonwealth’s uninsured have
refused to sign up. Roughly one-fifth of the refuseniks earn more than
$50,000 a year; many are under 35, but choose not to buy coverage even although under the Massachusetts plan,  a 27-year-old can buy insurance for as little as $176 a month.

Cutler’s idealism is sincere. He, like Obama, would prefer to soft-sell reform. But it’s telling that, in the interview with Sentinel Effect last Friday.
Cutler went on to acknowledge that: “If there are free riders [people
who don’t sign up but expect to receive care if they’re in an
accident], Obama is open to mandates.  . . . He hasn’t ruled anything
out. It’s a matter of priorities. The fact is the policy differences on
the mandate issue aren’t that large at all. Sen. Obama believes they’re
an option down the road, if other approaches don’t work.
”  [emphasis
mine]. In other words it seems that Obama, like Edwards and Clinton,
realizes that in the end mandates may well be needed. But right now,
Obama is targeting younger voters, and this isn’t what they want to
hear.

Edwards, on the other hand, says he wants to be honest: “I’m going to
tell people what I’m going to do and how I’m going to do it.” As a
matter of political strategy, I would say that Edwards may be honest to
a fault. It’s probably not necessary to talk about “enforcement” now.

But if Americans want universal, affordable insurance, they need to
understand that, to achieve that goal, everyone must help. Insurance,
when it works, is all about spreading risks.

Still, when Edwards talks about enforcing the rule that everyone
purchase insurance, people like Reed Hundt become anxious.”Could an
employer fire an employee for not adhering to a mandate?” he asks.
“Could the police arrest those who fail by accident, confusion, or even
negligence not to sign up? Could a hospital decline to treat those who
did not comply with a mandate?”

The answer is ‘No.’ As Paul Krugman explains, “If individuals don’t
have insurance, they won’t be penalized, they’ll be automatically
enrolled in an insurance plan.  That’s actually a terrific idea,” he
adds, “not only would it prevent people from gaming the system [by
becoming “free riders”] it would have the side benefit of enrolling
people who qualify for S-chip and other government programs, but don’t
know it.”

How will the government know whether or not you have insurance? Under
Edwards’ plan, every time you come in contact with the government or a
health care provider (filing income taxes, enrolling your children in a
public school, showing up at an ER or a doctor’s office) you would be
asked for your insurance policy number, just as you are routinely asked
for your social security number. If you didn’t have one, your name and
social security number would be typed into the system, automatically
enrolling you in a public sector plan. 

Then, if your income is too high to qualify for a full subsidy, you
would be billed for your fair share, either as part of the payroll tax
you now pay for Social Security and Medicare, or ( if you are
self-employed) through your income taxes. (There are, of course people
who don’t earn a salary and don’t file income taxes, but the majority
are very poor, and would qualify for the full subsidy anyway).

Forcing Americans to pay their share of health insurance may sound
Draconian, but again, this is exactly what Medicare does, and very few
people object. Yes, the tax takes a chunk out of their paychecks, but
the vast majority feel secure knowing that when they are 65, they can
count on receiving health care no matter how sick they are. And there
is every reason to believe that a public sector program modeled on
Medicare would be just as popular as Medicare itself.

Which brings me to Kevin Drum’s question. In Washington Monthly,
he writes: “a Rube Goldberg enforcement program like [Edwards’] does
nothing except highlight the absurdity of individual mandate healthcare
plans in the first place. If you’re really this serious about getting
every man, woman, and child in the country enrolled, why go through all
this? Why not just do it like Medicare, where the funding mechanism is
the existing tax system and everyone is enrolled automatically? It
amounts to the same thing and it’s cheaper, easier, and less
intrusive.”

There are four reasons: First, in the recession we’ll be facing in
2009,  it will be much harder to persuade Congress to pass a tax
increase than it will be to persuade legislators that everyone should
have  health insurance—just as we now require everyone to sign up for
auto insurance.

The second reason is closely connected to the first: many of the
taxpayers who elect those Congressmen don’t want to pay taxes into a
single Medicare –for-all system. A 2007 poll shows
that while 76 percent of Americans favor offering a government
subsidized plan to Americans who don’t have employer-based insurance,
only 26 percent of favor paying more income taxes to expand either
Medicare or Medicaid. Seventy-four percent are opposed.  In other
words, just as in Massachusetts, everyone favors universal care, but
the majority of voters do not want to pay higher taxes to support it. 

Moreover, as I’ve written recently on this blog,
the polls also reveal that 80 percent of Americans like the private
insurance they have now—or at least they like it better than an unknown
alternative. Their main worry is that they will not be able to afford
what they have in the future.  They do not want to be told that we are
all going to be funneled into a brand new government-funded
Medicare-for-All System.  They want the choice of keeping the devil
they know (i.e. their private-sector insurance).

Finally, in order to afford universal health care, we will have to be
more careful about wasting health care dollars. This means that we
can’t cover every pill or product that someone decides to advertise on
TV. All three Democratic candidates have called for independent
research comparing just how effective new products and procedures are
when tested, head to head, with existing products. (This is something
that we don’t do now. A new product can win FDA approval simply by
showing that it is better than a placebo).

If we have only a public sector plan, everyone will blame “the
government” or “socialized medicine” when they are told “No,” their
insurance won’t cover the pink pill that is twice as expensive as
existing products because medical research says it is no better. If we
have both public sector and private sector insurance, private insurers
will usually follow the public sector’s decisions about what the
cover—if they don’t, private insurers will have a very hard time
competing on price.  Thus, those who fear “socialized medicine” will
begin to understand that even private insurers cannot cover every pill,
product or procedure that comes down the pike—at whatever price the
manufacturer chooses to charge. Premiums would be unaffordable.

Over time, if private insurers are forced to compete with public sector
insurance on a level playing field (which means that all insurers offer
community rating and that all offer benefits that are, at a minimum, as
rich and comprehensive as Medicare), I think that the majority of
Americans will wind up picking the public sector plan.  The public
sector plan should be able to offer better value for our health care
dollars because it doesn’t have as many extra expenses: Medicare
doesn’t have to return profits to investors; it doesn’t have to
advertise and lobby Congress, and it doesn’t pay its executives the
seven-digit salaries that for-profit insurers feel they must pay in
order to compete with each other. 

But right now, many Americans are nervous about health insurance. And
they don’t trust government. They need time to decide whether they feel
more comfortable with for-profit insurance or a public program. In the
meantime, we need to ensure that everyone is covered, and that everyone
helps weave the safety net. That’s why we need community rating and
mandates. It’s all about solidarity. 

23 thoughts on “Obama Says No One Should Be Forced to Sign up For Insurance; Edwards Says If You Don’t, He’ll Garnish Your Wages—Who is Right?

  1. The trick is to find the appropriate method of taxation. Funding it “like Medicare”, primarily with payroll taxes as Dennis Kucinich has suggested, would be a disaster and would be a windfall to the upper middle class not yet old enough for Medicare.
    If the method is “like Medicare” — that is, financed with payroll taxes — then you may see a lot of people who are close to early retirement but “only working for the health insurance” suddenly leave the work force in droves.
    And that would cause a big problem: many of today’s top wage earners (and taxpayers) at their peak earning years would
    I’m 42 years old now, and my wife is 39. We’re in a financial position where, if universal health coverage was financed by payroll taxes like Medicare and Social Security, we could retire by the time I was 50, live off of income from our retirement savings, and become massive tax consumers instead of tax payers. But if we had to pay for our own individual health insurance, 50 would be a pipe dream by quite a few years.
    So if I viewed this from a selfish standpoint, I’d say “bring it on” where funding through payroll taxes is concerned. But making the working class pay the freight for idle upper middle class early retirees like me would be silly, unfair, regressive and just plain bad policy.
    Presumably, though, early retirees would be treated as the self-employed for these purposes — and required to add their “health taxes” into their income tax return and remit it as part of their quarterly estimated payments. However, this could cause other inequities as the self-employed could probably write off their medical insurance premiums, while the early retirees couldn’t.
    The tax system is very nearly as screwed up as the health care delivery system.

  2. I believe the we have to make tough decisions, both as society but even more importantly as individuals. We are spoilt by abundance. Rather than take steps to enhance our health ourselves, we look to others for solutions.

  3. Tim–
    I’m impressed that you are willing to look at this problem with an eye to what is best for all of us–and not just what is best for me. (This is what I mean by “solidarity”–at the very end of my post.)
    But I’m not quite following the logic when you write: “I’m 42 years old now, and my wife is 39. We’re in a financial position where, if universal health coverage was financed by payroll taxes like Medicare and Social Security, we could retire by the time I was 50, live off of income from our retirement savings, and become massive tax consumers instead of tax payers. But if we had to pay for our own individual health insurance, 50 would be a pipe dream.”
    It seems that you are suggesting that, under health care reform, the amount that you would have to pay for insurance would be significantly less than what you now pay.
    But assuming that you are in a “upper-middle-class” tax bracket (which I’m assuming because you have enough retirement savings to think about retiring at 50) I doubt that would be true
    Your income from your savings (capital gains, dividends, and anything that you drew out of 401ks and other tax-deferred retirement accouts) would be included in your income when the govt figured how much you should pay toward health insurance. So it’s very unlikely that you would be eligible for subsidies.
    And tax deductions (mortgage payments, property taxs, etc.) would not be subtracted from your income before your payment for universal health care would be assessed. (Just as, today, these deductions are not subtracted before calculating how much you owe in Medicare and Social Security taxes.)
    In other words, the fact that you would make your health care payments through your income taxes does not mean that they woudl be calculated the way income taxes are (anymore than Medicare payments that self-employed people make on their income taxes are calcualted the same way their income taxes are . . )

  4. Maggie,
    I’m not speaking of all such proposals but only of the ones where almost all of the funding comes from payroll taxes. If you’re talking about a plan where much of the funding comes in the form of higher income taxes, including investment income, it’s another story.
    My point was that SOME of the suggestions I’ve heard would primarily fund health care by creating a *payroll* tax. If you aren’t on a payroll or self-employed — in other words, if you have only investment income — there is no payroll tax, so you get health care for almost nothing, funded by people who still have to work. Seems like a fantastic giveaway for people who can afford to not work, doesn’t it?
    So some of the plans such as Kucinich et al are proposing — which are funded predominantly by a payroll tax — would be a fantastic giveaway for the people who could afford to retire early and stop working. Also, your reference to Kevin Drum’s article mentioned funding it through existing taxes “like Medicare” makes me wonder how hard he may be pushing the payroll tax idea as well.
    I’m just saying we need to think the funding mechanism through really carefully. I don’t think a payroll tax is a good way to fund the bulk of it unless there was a way to also get to those who have mostly investment income through the income tax. And even that would open a Pandora’s Box — would people over 65 be exempt from it? You know AARP would push for that.
    In reality I think a payroll tax is only a good idea for benefits that strictly apply to workers (state unemployment benefits and disability come to mind). If you give broad-based benefits to everyone which is funded by a payroll tax, those who can afford not to work benefit most. If it’s something that benefits everyone — not just workers — it’s probably best to fund it with a broad-based tax.
    Some of those plans also have a large amount of funding from other sources besides the payroll tax, but if it’s almost all funded by a payroll tax, congratulations — they just convinced a lot of well-off 50-somethings and early 60-somethings to stop working. I don’t think it’s good public policy to encourage me (or anyone else) to stop paying taxes in their peak earning years and get “almost free” health care because working stiffs are paying for almost all of it. And I’ll probably be one of them within a decade. I don’t think coal miners and teachers and farmers need to be subsidizing my health care in early retirement.

  5. Doc and Tim–
    Doc, I agree: we have been spoiled by abundance.
    And achieving health care for everyone will mean focusing more on preventive care and cost contaiment and learning that the newests, most aggressive “quick fix” is not necessarily better care. Often it is worse–as is overtreatment.
    Tim–
    I agree, a payroll tax is not the way to assess taxes for heatlhcare.
    I tend to think people over 65 should be exempted, though, because they have paid their full share into Medicare and wouldn’t be benefiting particularly from the new program.
    I do think that we need to tax wealth (unearned income as well as earned income) in order to afford national health care. And I agree with you: we do not want to encourage people to stop working and begin clipping coupons. For one thing, then we’d have to deal with a slew of depressed people!

  6. Doc and Tim–
    Doc, I agree: we have been spoiled by abundance.
    And achieving health care for everyone will mean focusing more on preventive care and cost contaiment and learning that the newests, most aggressive “quick fix” is not necessarily better care. Often it is worse–as is overtreatment.
    Tim–
    I agree, a payroll tax is not the way to assess taxes for heatlhcare.
    I tend to think people over 65 should be exempted, though, because they have paid their full share into Medicare and wouldn’t be benefiting particularly from the new program.
    I do think that we need to tax wealth (unearned income as well as earned income) in order to afford national health care. And I agree with you: we do not want to encourage people to stop working and begin clipping coupons. For one thing, then we’d have to deal with a slew of depressed people!

  7. The #1 cause of injury, disability, and DEATH in America is, Health Care. More people die now from contact with the American Medical Health Care system than from any other cause of death. More than from Cancer, Heart disease, or Stroke. More than any other country in the world. Many times more than any other people in the world. This fact is a catastrophic indictment of the entire US Health Care System.
    Driven by greed. And a rush to profit. Thousands of Americans are killed, and injured daily in America. By compromised health care. Cutting corners. Over, and under treatments. And poisonings with all manor of toxic, poisonous pharmaceuticals. Especially the children. America only makes up 2-4% of the world population. But Americans buy, and consume 50% of all pharmaceuticals world wide.
    But the tide has turned. I can see it. Hear it. And feel it. The message is getting out. And taking hold about the fact that we have a very serious, and major health care crisis going on in America. Hurting everyone. Especially our precious little children. Rich, and poor alike. And most all Americans seem to understand now that “HR 676 Not For Profit Single Payer Universal National Health Care For All (Medicare For All)” is the way to go. Like all the other developed countries have done. I have seen numbers as high as 90% of Americans want government managed health care Now. Medicare for all. Like other developed countries have. And like older Americans have now.
    BRAVO!!! America. YOU GET IT! YOU REALLY GET IT! See sickocure.org.
    It’s NOW TIME to bring out the BIG GUNS!! The BIG GUNS!! are you. The American people. And anyone else that wants to help. From now until HR 676 is passed into law. I want every person to reach out and touch their fellow Americans every day if you can. I want you to take a phone book. And call at least one of your fellow Americans every day. And ask them to pickup the sword of HR 676 Single Payer Not For Profit Universal Health Care For All (Medicare For All).
    Call more than one each day if you can. And ask them to do the same as you are doing if they can. And also to put maximum pressure on their politicians to get HR 676 done. And to make sure their politicians support HR 676. Accept no substitute. HR 676 is a no-brainer. It’s the best way to go on health care. It’s the only moral, and ethical way to go. That is why every other developed country has done it. Most did it years ago.
    I know that many of you have been doing a fabulous job of spreading the word by talking it up with family, friends, and co-workers. And putting pressure on the politicians to get HR 676 done ASAP. The phone calls to your fellow Americans will increase the pressure. And grow the movement at an astonishing, and exponential rate. And I know many of you have been wanting to do something more to help. The phone calls to your fellow Americans is something you can do every day to help.
    Trust me. It will be something to see. But you have to keep the focus, and pressure on getting HR 676 passed pronto. They will try to distract you. With all manor of other crises, and catastrophes. And other plans. Don’t be distracted. HR 676 Single Payer Not For Profit Universal Health Care is the #1 concern of the American people. Thousands of Americans are dieing daily now. And you or your loved ones could be next.
    There is no good reason HR 676 cannot be passed into law well before the coming elections. Do not tolerate delays. If it is not passed before the coming elections. All America will know which politicians are on the side of the American people. And which are not when they vote. Well before the elections.
    Everyone can do this. Most of you are well informed about HR 676. This truly is one of those no-brainers. Be considerate of your fellow Americans when you call. But be comfortable about calling. These are your fellow Americans. Some will be receptive. And some will not be. Some maybe rude, and mean. Just thank them, and move on to the next. Most will be with you. And if you get a call from one of your fellow Americans about HR 676. Let them know you are already on board. And thank them for calling. Build them up. And keep them strong. They are fighting for all of us.
    I will try to make a second post with just a few of the reasons everyone with 2 working brain cells agrees HR 676 is the best way to go. But you can also look them up for your-self. And read some of the positive informed post on many of the message boards too.
    Lastly, I am sick and tired of hearing how the candidates, and politicians health care plans are going to protect, and preserve the private for profit health insurance companies that have been killing, and ripping off the American people. And now the politicians want to mandate (require) that every American has to support the private for profit insurance company’s that have been killing, and ripping you off. Or you will be fined, and PENALIZED. Thats right. PENALIZED. Ridiculous! The politicians really think you are all detached idiots. CASH COWS! To lead to the slaughter. Don’t put up with that.
    So get on it America. Get those phones going. Chat it up! Save some lives. You want all of America talking about HR 676 becoming law, Now! Before more die needlessly. Make it happen. And to my fellow cyber warriors. You have been doing great! I see it! Keep it up. 1 of 2 post…
    Below are a few reasons why “HR 676 Single Payer Not For Profit Universal Health Care For All (Medicare For All) is a no-brainer. And some reasons why private for profit health insurance is a stupid idea, and injuring, and killing you and your loved ones.
    Medicare cost 2-3% to administer. Private insurance cost 30% to administer.
    Under HR 676 everyone would be covered from birth to death. No co-pays. No-deductible. No out of pocket cost. Plus Dental. And Vision. For less cost than we pay now under private health insurance.
    With private insurance. You have 47 million Americans with no insurance.
    And 89 million Americans that had no insurance part of the time from 2006-2007.
    And over a 100 million that are under insured.
    18-30 thousand Americans that die each year from lack of health care.
    Health Care bills as the #1 cause of personal bankruptcy. And loss of homes.
    Under HR 676 health care is moral, and ethical.
    Private for profit insurance is immoral. And unethical.
    Profit is the primary motive of the private insurance companies.
    They make profit by charging needy, vulnerable, sick Americans as much as they can charge them.
    Then they make more profit by denying them care when they most need it. And are most vulnerable and unable to fight back. When they are sick. Or trying to recover from major illness.
    Yep! I know you are getting angry. I’m sorry. But I have to continue.
    Under HR 676: we will save 300 billion dollars in administrative cost each year.
    With private insurance: we spent more per capita on health care than any other country in the world. Over twice as much as most other developed country’s. Yet we have 47 million with no health care.
    We rank at the bottom in quality of health care #37.
    Americans have a shorter life expectancy than people from all other developed countries. We rank # 42 in life expectancy. Down from #1.
    For the first time in American history. The life expectancy of American children is less than that of their parents. American children are dieing at a record rate. And are in terrible health generally.
    People from other country’s enjoy a much higher level of general health than the best privately insured Americans.
    Americans are also shrinking. We used to be the tallest people in the world. Now we are down to # 10.
    People from other country’s never have to worry about going bankrupt, or loosing their homes over medical bills if they get sick.
    Maybe you should go take a break for a while before I go on. I know this must be upsetting. But this is just a small part of the sad truth about private health insurance that HR 676 can fix.
    Under HR 676: Health care will be based on need. Not on profit. And high standards, and quality will be enforced, and patients protected by the Government through a dedicated civil service. With the power, and resources to rain in abuses of patient care. Like they do with Medicare now.
    With private insurance: Medical care is base on ability to pay. And profit. Tens of thousands of patient are killed, and millions are injure, crippled, and mutilated each year under private for profit health care, and insurance.
    By insurance companies denying needed care to increase their profits.
    By hospitals cutting corners. And using the cheapest least experienced personnel, equipment, and standards they can get away with.
    By doctors that over treat, and under treat. Who injure, mutilate, and kill patients with unnecessary test, procedures, surgery, and invasive diagnostic test for profit. Who poison, kill, and injure millions of Americans with all manor of unnecessary pharmaceuticals for profit. Men, Women, Children, and babies.
    Americans makeup 2-4 % of the world population. But Americans buy, and consume 50% of all pharmaceuticals world wide. This is a monstrous evil. And immorality.
    And lastly, by politicians that take blood money from all these despicable groups and turn blind eye’s to this slaughter of the American people. And the slaughter of their own loved ones. And them-self.
    Well I could go on. And on. But I think this is enough to get you started making your daily phone calls to your fellow Americans to support HR 676. And to help them understand how important it is that each of them join the fight. And bring the MAXIMUM pressure to bear on all individuals, parties, and especially your politicians, and Representatives. To get HR 676 passed into law immediately.
    This is an emergency. America is in a crisis. More Americans have died from this health care crisis than have died in all the wars in US history. Do your best. Millions of Americans lives are counting on each of you. Including your own life. Remember, you are Americans. You know how to fight for your country when you have too. The whole world is in your blood. I’m with you.
    All the best… 2 of 2

  8. HR 676 (as referenced in the comment below) is basically the Kucinich plan I mentioned earlier. It draws virtually all of its funding from payroll taxes (NOT broad-based income taxes, but *payroll* taxes levied on employer and employee) and some income tax surcharges on the top 5% of income earners. It does not tax investment income except with respect to the top 5% of income earners and a relatively puny 0.25% tax on stock and bond transactions.
    In other words, I could retire a decade from now in my early 50s and (barring a long-term bear market) live comfortably on investment income probably in the $60-80K range per year — solidly middle class (at least in terms of income if not net worth) and well below the levels targeted by the income tax hikes.
    How much tax would I pay to support the health care system under HR 676? Almost nothing — just 0.25% of the proceeds of stock and bond sales in my portfolio. How much would people who work and bring in a lower income than me pay in? A LOT more — 5% of their income plus 5% from the employer (which will eat into their future raises and bonuses).
    I’m not saying everything about HR 676 is bad, but the funding mechanism is fatally flawed as it makes the working class pay a lot more than many early retirees who can afford to not work. Indeed, I think this bill would encourage a lot of higher-income taxpayers to stop working by their 50s.
    If those of you who support HR 676 want to pay for my health care while you continue to work, that’s up to you. But if I were in your shoes, I wouldn’t be wanting to give me a free ride. It would personally benefit me greatly, but that doesn’t make it the right thing to do.
    HR 676 is, as funded, a colossal giveaway to people under 65 who can afford not to work.

  9. Maggie and Tim,
    With all due respect, a payroll tax is a good way to pay for a taxpayer financed health insurance system because it offers the virtue of clear cost transparency which contributes significantly to efficient resource allocation.
    By contrast, the 0.25% tax on stock transactions is a terrible idea. That opinion has nothing to do with the fact that I work for a (tax exempt) pension fund or that I buy and sell stocks for my personal account. With electronic trading today, a six figure electronic stock transaction can be done for a brokerage commission of $9.95. A 0.25% tax on a $100K transaction would be $250 which would raise the effective transaction cost by 25 fold! I can assure you that such a tax would either cause trading to decline dramatically or it would drive much of it offshore where it would be beyond the jurisdiction of U.S. tax authorities.
    To replace the private insurance system with taxpayer financing plus cover the cost of health insurance for the 47 million people who currently lack it would probably cost about $1 trillion. The current 2.9% payroll tax dedicated to Medicare covers about 55% of the cost of the overall Medicare program (Parts A, B and D) or roughly $80 billion for each percentage point of tax. That implies we would need a payroll tax of 12% to provide Medicare for All. The administrative savings that advocates think can be achieved are highly likely to be wildly overstated. If we’re lucky, we might be able to achieve $30-$40 billion of savings at most.
    The way to deal with the differential tax burden between wages and investment income is an approach that tax policy types call integration of payroll and income taxes. For example, you could apply a flat tax rate of, say, 30% to all income above a standard deduction equal to the Federal Poverty Level (FPL). All payroll taxes whether paid nominally by the employer or actually by the employee would count toward the individual’s tax liability, though any tax paid by the employer would also count as income. If you added a 12% payroll tax for health care to the current 15.3% tax for Social Security and Medicare, that’s 27.3% combined. With the proposed standard deduction, anyone who made up to about $100K from wages would probably owe no income taxes. By contrast, a family with a similar income, all from interest, dividends, capital gains, rent and other investments would pay 30% of income above the standard deduction for income taxes but would owe no payroll taxes. Warren Buffett, who paid 17% of his income in federal taxes last year while his receptionist paid 30% would, under this approach, also pay 30%. Presto, a flat tax!
    If the federal tax rate on investment income moves much beyond 30%, to which state income taxes must be added in most states, there would probably be material adverse effects on investment and risk taking. A flat overall tax burden, while exempting the poorest among us, is probably about the best we could prudently do and would be considerably fairer than the system we have now which taxes investment income (notably capital gains and dividends) way too lightly, in my opinion.

  10. Jack, Tim and Barry–
    Thank you all for your comments.
    First Jack–it’s impressive to see that someone can write a comment as long as some of my posts!
    Seriously much of what you say is true. But the solution is not quite as simple as you suggests. (And I have the greatest admiration for Conyers and his bill.)
    First, if you’ve been reading this blog for a while (or if you have read my posts and responses to comments on TPM Cafe) you know that I think that, ultimately, a single-payer “Medicare-for-All” system could be the most efficent solution to health care reform.
    (Though I have to say, I do worry a bit about who might be running Medicare in future administrations. What if the American people elect another George W. Bush and the people running “Medicare For All” are political appointees like the people who failed to respond to Katrina?
    IF you look back at Ameriocan history, GWB is not a complete anomaly. From time to time we elect truly disasterous presidents.
    That said, “Medicare -for All” seems a simple solution.
    Except . . . most Americans do not want to be forced into a a single-public-sector system. They want choices.
    How do I know this? See an earlier post on this blog about what Americans Want (or think they want)
    Poll after poll shows that, yes, Americans want universal health care and they are happy to have a public sector program (like Medicare for all) as an option.
    But only as an option.
    These polls show that 80 percent of Americans are satisfied with the healthcare insurance they now have. (Usually employer-based insurance.)
    Their greatest fear is that they may not be able to afford it in the future.
    But if they can hang onto what they have, this is what they want. It’s familiar. It’s a known.
    If national health reform gives them a choice between private insurance and buying into Medicare for all, I believe that, over time, many (most) would choose Medicare- for-all (after realizing that their brother-in-law had better, more affordable insurance than they do.)
    But public sector insurance will not automatically be that much more affordable. You write “Medicare cost 2-3% to administer. Private insurance cost 30% to administer.”
    I’m afraid this just isn’t true. See my post on this blog today on Health CAre BAsics– How much does private insurance cost us?
    Tim and Barry–my husband has dinner ready. He is Italian, and therefore a much, much better cook than I am.
    (The Irish write great poetry and plays, but cuisine is not our specialty.)
    So I’ll respond to your very interesitng comments later–probably tomorrow.

  11. Maggie:
    I was directed to your blog by Joe Paduda’s.
    I found it interesting though not convincing. The comments by Jackstraw were so outrageous and internally conflicted as to be absurd. i.e.: The American health care system is killing Americans so lets make everybody sign up, and that we are 37th in quality of health care (I assume among developed countries) which is ludicrous on the face (unless you have never left the country).
    But the whole argument of universal mandated care needs to be looked at from a more fundamental basis. Are we a free society of individuals or are to a socialist state? Is the government to care for us from womb to tomb and we exist only to fill its coffers? Is the government is in the best position to make all of our decisions at all times. Should the government, as in many developed countries, will decide who gets higher education and who picks up the garbage? Should the local mayor hold our passport and decide if we are allowed to travel out of the country. Is this the Matrix?
    Or are we individuals that are free to go our own way. Free to make our own decisions and live with the consequences of them. Should we be free to choose our course in life? Should we be allowed to exercise our talents and abilities to the extent we possess them. Choose our own spouses, careers, number of children, religion, place to live, lifestyle and so on. Free to go to hell if we choose.
    The second country is the one I fought for as a US Marine.
    Freedom is what has made us great. Combine that with the rule of law and wealth previously unknown and undreamed of has been created. Wealth, luxury, old age, conveniences all the things we take for granted.
    Now we want to give up that life style for one that is organized. Everyone will comply. Everyone will do what the government says. Everyone will march in lockstep. Everyone will be equal in all ways. I for one do not. Freedom is messy. Individuals are different. People want different things. Ugly things happen.
    People need to be responsible for their decisions and actions. Most uninsured people choose that. Even then in most communities there is a safety net for the uninsured in crisis.
    If you want the government to do something about health care reopen the H1A program for nurses. Increase the number of medical schools. Force the drug companies to charge US citizens what the rest of the world does. That will lower cost reducing the excuse for not having insurance. And for those who choose not to have it that is their decision and they will have to live with the consequences. I assume that as a “Progressive” that is not the kind of world you want to live in. I think you have the wrong label for yourselves, I think you need to think of yourselves as “true” communists like the Onieda communities.
    It is not a lifestyle I want to subscribe to, nor one I fought for.
    Regards,
    Charles Read

  12. Charles:
    You write: “Is the government in the best position to make all of our decisions at all times. Should the government, as in many developed countries, decide who gets higher education and who picks up the garbage? Should the local mayor hold our passport and decide if we are allowed to travel out of the country.”
    This all suggests that you have never lived in any European country–or in Canada, Australia or New Zealand as none of these restrictions apply there.
    My husband’s son has lived in Germany for many years. My daughter lived in Canada for four years. My oldest friend from childhood has lived in Canada for more than ten years. My husband’s best friend lived in Italy all of his life. One of my closest friends has lived in France for a number of years.
    So I’m pretty famliar with these countries in terms of education, freedom to travel, health care, etc.
    On healthcare– Everyone I’ve had contact with in these countries is happy with their health care system, and would never trade it for ours.
    Put it this way: my husband’s son has been in the U.S. army for more than 15 years, stationed in Germany for the last 7 or 8 years. He and his wife are about to have their first baby this spring.
    Unfortuately, the army is sending him back to the U.S. this spring for 3 years. (They wanted him to recruit; he refused.He sees the kids going to Iraq though Germany–and coming back, often with severe mental problems, only to be sent back once again.)
    But they’re sending him to the U.S. anyway.
    He is going to leave his wife in Germany with their newborn. She went to college in the U.S. speaks 5 languages fluently, and could easily get work and a visa to come here. But as he puts it:
    “I know she and the baby will get much better healthcare in Germany than they will in the U.S.”
    So he and his wife and newborn child will be separated for three years–though they will, of course, travel back and forth whenver they can.
    She has been living in Germany for about 15 years, getting the heatlhcare that Germans get and since she has been quite sick and hospitalized a couple of times, she knows what that care is like.
    You describe the U.S. as a Utopia:
    “wealth, luxury, old age, conveniences all the things we take for granted.”
    Except of course for the people who don’t belong to your “we”–the poor, the disenfrancised, those who are born into communities where the public schools are so under-funded that first-grade teachers don’t have books to teach arithmetic; where conditions are so bad that few teachers will stay for more than 2 or 3 years; where kids come to school who clearly have been abused (cigarette burns on their necks and backs) and if teachers call the people who are supposed to protect kids, no one returns their calls. As for healthcare: one child has holes in his face where there should be a nose.
    Medicaid pays so little for heatlhcare for the poor that that’s all the plastic surgeon would do when he was born. Many kids have repiratory problems because of environmental problems; there are no neighborhood health clinics.
    (My daughter taught in such a school for the past four years. She came back here from Canada because in Candada “there aren’t that many kids who need my help.” The Canadians take care of their poor; we don’t.
    Many of the six-year-olds she has taught will not grow old enough to enjoy the wealth and conveniences that you envision–even if they had the education needed to get good jobs. Even if they had the health care they need in order to flourish.
    No doubt you would put this down to “diversity” in our society.
    As you put it:
    “People want different things. Ugly things happen.”
    You’re right, I’m a progressive. I believe that we will progress past the point where we look at these kids and say “ugly things happen.”
    After all, we finally gave up slavery, didn’t we? And then we even passed some civil rights legislation. Progress is possible.

  13. Maggie-
    I can only hope you were not literal in your use of the term ‘refuseniks’.
    To remind you, refuseniks were Russian Jews who were denied individual rights by the Soviet Communist dictatorship.
    Please clarify– are you drawing the parallel between those who have not signed on to the government mandates and the oppressed Soviet Jewry or between the actions of the legislature (and former Governor Romney) of the Commonwealth and the actions of the Kremlin?
    Also- since I believe words matter– how does one become an “idle upper middle class retiree”? Is it possible they could have worked and earned and been successful? You use ‘idle’ as a pejorative.
    Also– to quote ” we can’t cover every pill or product that someone decides to advertise on TV.” Who is the ‘we’? Should ‘we’ prohibit individuals from spending their own money for health care services that they believe will benefit themselves or their families?
    I look forward to your responses.

  14. Eric–
    You are absolutely right; I shouldn’t have used the word “refuseniks.”
    I know who refuseniks were –brave people who stood up for values that matter. By contrast, young healthy people who refuse to sign up for healthcare in Massachusetts are, I think, foolish (insofar as they are putting themselves at risk–you never know when you will be in a terrible accident), and fail to appreciate that insurance is all about spreading risk.
    I, too, believe that words matter, and as I typed refusenik, I thought–t wait a minute, refusniks were . . But I was in a hurry–I’m writing all of the time, seven days a weeks.
    This of course, isn’t an excuse, merely an explanation; it was a very sloppy and insenstive choice of words.
    On “idle upper-middle class retirees,” on the other hand, I can’t plead guilty. I searched the post, and it turns out that Tim used the phrase.
    And since he used it to apply to himself and his wife (if they decided to retire early because taxes for health care made it foolish to work) I really don’t think you can accuse him of class bias.
    He used “idle” as a pejorative becuase he felt that if he and his wife retired at 50, they would be retiring while they still had many proudctive years ahead of them.
    As for people spending their own money on whatever they feel they want or need. I have absolutely no problem.
    When I speak of “we” spending on health care I am speaking of “we” taxpayers–the people who pay into Medicare and would pay into Medicare for all.
    Because “our” resources are limited, I think we need to look for value for our health care dollars, which means covering treatments that are backed by medical evidence –while also putting “our” tax dollars into randomized clinical trials of treatments that look hopeful.
    But if any individual wants to buy an experimental treatment, or something that Medicare deems over-priced or not necessary, that, quite clearly, is fine.

  15. The argument can be summed by a simple analogy:
    If car insurance companies could not refuse to insure any car, then no one would buy auto insurance until after their car was damaged in an accident.
    Obama is wrong. If we mandate that health insurance companies cannot refuse any patient, then we must mandate that everyone have coverage. Otherwise the risk pool would have only sick patients, as no one would buy insurance until they were sick.

  16. Ms. Mahar, where did you get such inaccurate and grossly misleading info about the MA plan? We DO HAVE A MANDATE LAW IN EFFECT. And the monthly premium price of $176 that you quote is so misleading (that’s a “YAP” plan-for those 27 or younger that has a $50k lifetime benefits cap!! Many call this “stripped down insurance” and rightly so (with YAP just pray you don’t get cancer, a serious injury that needs treatment and rehab., or something like that.)
    The reality in MA is that there are hundreds of thousands of people who fall outside the “affordability definition”, will not be granted a mandate waiver (state permission to remain uninsured) but who still cannot afford the insurance products! Add together the premiums, deductibles, the co-pays (not to mention the co-insurance that some plans have) and this is quite evident.
    You write: “In Massachusetts, where there is no mandate, over 200,000 of the Commonwealth’s uninsured have refused to sign up. Roughly one-fifth of the refuseniks earn more than $50,000 a year; many are under 35, but choose not to buy coverage even although under the Massachusetts plan, a 27-year-old can buy insurance for as little as $176 a month.”
    Ms. Mahar, please state your sources for this info. I live in MA, have been closely following and participating in health policymaking in the state for over 20 years as a nurse and citizen activist. What you say about the MA plan and the situation here does not accurately inform your readers. I ask that you clarify your statements about MA.
    Those of us on the front-lines of healthcare delivery know that mandates will do a lot of harm. It is our obligation to try and stop them as well as to advocate for more effective, humane, and cost effective solutions to the health system crisis.
    Health professionals from all disciplines and folks from all walks of life see clearly that a mandate to purchase private insurance that is sold at a profit (and at a price that pays for and sustains the layers and layers of wasteful bureaucracy) WILL NOT WORK.
    I am alarmed to see you, Ms Mahar, whom I respect, writing things about the MA situation that are so far off the mark. Please cite sources for your MA stats. The official word here in MA is that 20% of the uninsured will not be covered due to being exempted from the mandate b/c there is no insurance that is officially “affordable” for them.
    The affordability definition is misleading (really it’s bogus) b/c it does not factor in deductibles, co-pays, or the 35% co-insurance that exists in some of the “low cost” plans.
    While here in MA we might have so-called “community rating” we also allow age discrimination in premium pricing. That stinks. Also there’s a big problem with the state mandating that citizens purchase a private product. Period.
    Add to the mandate to purchase private insurance the fact that here in MA our “not-for-profit” insurers like Blue Cross and Blue Shield divert healthcare dollars to payout over $19Mil in a retirement package to a CEO while also paying him over $1Mil the year AFTER he retired (pay was for being on the board!).
    Government mandates to purchase private insurance products for healthcare are wrong and take us in the opposite direction needed to get to cost effective sustainable universal healthcare. Plus mandates won’t work.
    I went to the link you provided for the MA stats data (“Health Care in Three Acts” article by Eric Cohen and Yuval Levin)but do not see any MA stats data there. Please clarify the sources for your MA stats and other MA generalizations in this post. Thank you.

  17. Ms. Mahar, where did you get such inaccurate and grossly misleading info about the MA plan? We DO HAVE A MANDATE LAW IN EFFECT. And the monthly premium price of $176 that you quote is so misleading (that’s a “YAP” plan-for those 27 or younger that has a $50k lifetime benefits cap!! Many call this “stripped down insurance” and rightly so (with YAP just pray you don’t get cancer, a serious injury that needs treatment and rehab., or something like that.)
    The reality in MA is that there are hundreds of thousands of people who fall outside the “affordability definition”, will not be granted a mandate waiver (state permission to remain uninsured) but who still cannot afford the insurance products! Add together the premiums, deductibles, the co-pays (not to mention the co-insurance that some plans have) and this is quite evident.
    You write: “In Massachusetts, where there is no mandate, over 200,000 of the Commonwealth’s uninsured have refused to sign up. Roughly one-fifth of the refuseniks earn more than $50,000 a year; many are under 35, but choose not to buy coverage even although under the Massachusetts plan, a 27-year-old can buy insurance for as little as $176 a month.”
    Ms. Mahar, please state your sources for this info. I live in MA, have been closely following and participating in health policymaking in the state for over 20 years as a nurse and citizen activist. What you say about the MA plan and the situation here does not accurately inform your readers. I ask that you clarify your statements about MA.
    Those of us on the front-lines of healthcare delivery know that mandates will do a lot of harm. It is our obligation to try and stop them as well as to advocate for more effective, humane, and cost effective solutions to the health system crisis.
    Health professionals from all disciplines and folks from all walks of life see clearly that a mandate to purchase private insurance that is sold at a profit (and at a price that pays for and sustains the layers and layers of wasteful bureaucracy) WILL NOT WORK.
    I am alarmed to see you, Ms Mahar, whom I respect, writing things about the MA situation that are so far off the mark. Please cite sources for your MA stats. The official word here in MA is that 20% of the uninsured will not be covered due to being exempted from the mandate b/c there is no insurance that is officially “affordable” for them.
    The affordability definition is misleading (really it’s bogus) b/c it does not factor in deductibles, co-pays, or the 35% co-insurance that exists in some of the “low cost” plans.
    While here in MA we might have so-called “community rating” we also allow age discrimination in premium pricing. That stinks. Also there’s a big problem with the state mandating that citizens purchase a private product. Period.
    Add to the mandate to purchase private insurance the fact that here in MA our “not-for-profit” insurers like Blue Cross and Blue Shield divert healthcare dollars to payout over $19Mil in a retirement package to a CEO while also paying him over $1Mil the year AFTER he retired (pay was for being on the board!).
    Government mandates to purchase private insurance products for healthcare are wrong and take us in the opposite direction needed to get to cost effective sustainable universal healthcare. Plus mandates won’t work.
    I went to the link you provided for the MA stats data (“Health Care in Three Acts” article by Eric Cohen and Yuval Levin)but do not see any MA stats data there. Please clarify the sources for your MA stats and other MA generalizations in this post. Thank you.

  18. Anne E. Malone–
    Thanks for your passionate comment. It’s clear that you really care, and that’s great.
    First, I completely agree with you that the “stripped down” cheap insurance that Mass is offering to its youngest citizens shouldn’t even be called insurance..
    Secondly. on whether Mass. really has a “mandate” –
    Much of my information on Masschusett’s health care plan comes from the Mass. Medical Association.
    I was one of four speakers at their recent “Leadership Forum” and there I heard leading Mass. physicians and health policy experts (who had all backed Mass. reofrm) talk about what has happend with the Mass. health care plan.
    Massachusetts gave up on the original “mandate” that everyone must sign up for insurance when it decided to “exempt” thousands of Mass. citizens from the mandate becuase they really can’t afford the insurance Mass. is offering to them.
    So much for universal coverage.
    The reason that Mass. had to give up on a real mandate (which would make sure that everyone is covered) is:
    a) because, in Mass., insurers are allowed to charge older citizens twice what they charge younger citizens (making coverage unaffordable for many in their 50s and early 60s, and
    b) because in Mass. if you are young, healthy and wealthy and decide you don’t need insurance, the fine that you pay is very small. . .
    The mandate had no teeth. And so now, the mandate is no more.
    Some are ignoring it, others are exempted from it.
    I’ve written about all of this in earlier posts on this blog (search “Massachusetts” and you’ll find them.
    Probably you weren’t reading the blog then–but welcome, I’m glad you’re reading it (and commenting on it) now.

  19. Maggie – Thanks for responding; you cannot imagine how much it means to me. I want to make a positive difference and have worked alongside others who do too, but we don’t seem to make much progress, instead we end up with crappy plans like the one in MA. The MA plan tinkers and uses wasteful financing to cover poor of the poor but the MA mandate policy actually worsens some of the underlying causes of the crises in access, cost and quality.
    Now on to the fundamental disagreement we still seem to have — Does MA have a mandate law or not? This merits discussion b/c our state “test case” of mandates is looked to, as you know, by other states and on the national policymaking arena.
    I argue that MA does have a mandate law in effect.
    Even though the MA mandate does indeed exclude ~20% of the uninsured (and this figure varies widely – ~370k vs 650k – depending on whose #s you believe, the US Census vs the state of MA) as you point out, I argue that it is still very much a mandate.
    The state has granted itself legal authority to use the MA Dept of Revenue to fine taxpayers if they do not purchase insurance. How is that not a mandate?
    The first year, for 2007 tax returns, you lose your individual tax exemption if you are not insured and have not been granted a state waiver giving you permission to remain uninsured.
    Starting in January 2008 the DOR-levied fines will be calculated on a monthly basis and the fines will increase to 50% of the cost of the least expensive insurance premium for the individual. As you point out, there is gross age discrimination in the premium prices. A 57 yo I know who cannot afford any plan was told by her state senator’s staff “Too bad, it’s the law. Why don’t you get another job a Starbucks, they have insurance plus you’ll get a free bag of coffee every month”. Unbelievable.
    The cabal of power brokers who devised this largely fake reform MA plan are so out of touch with ordinary people’s lives it is tragic. The fact that the power brokers have bought off many of the so-called “health advocacy” groups with insurance co. “grants” is also tragic.
    Another element of this law that is both tragic and should cause public outrage is the amount of new state budget money we are now paying to cover additional poor and low income (yes, it’s good to cover more people with quality benefits) with private HMO insurance (but it’s irresponsible to build on wasteful financing for that coverage/care) under the MA law. Good grief, we have over a $1.2Bil budget deficit already and the public school that my 2nd grader is in has to hold a fundraiser every other week for an art teacher, phys ed activities, etc.
    There is a shameful lack of fiscal stewardship in the MA plan and the mandate concept punishes people for that sorry fact.
    Maggie, it’s interesting that your main source on the MA plan is from the MMS’ “Leadership Forum”… I usually attend that annual event and very much wanted to hear you at it this year but my work schedule prevented me from going (plus, to be honest, it’s increasingly hard to stomach the self-congratulatory tone that pervades that event while our healthcare system continues to implode).
    I’m glad to know you have this blog and will try to look at it regularly. But I wonder how much of this discussion and the many others (on mandates and other health policy elements) are actually useful and will make a difference in making progress? It seems to me that the huge sums of money involved in this HC reform issue is what is blocking needed reforms. When I care for patients who are suffering terribly from preventable illnesses and still don’t have adequate care all because of our screwed up healthcare system it makes me so very angry, but I try to direct that anger into constructive action. (You wouldn’t believe how many groups I am a part of that are tackling this issue.)
    Would you agree that big money’s influence in our politics and policymaking as well as in the health advocacy arena makes it darn near impossible for ordinary people’s needs or concerns to really be heard or to be acted upon? And if you agree, what can be done about it? I don’t want to sound (nor feel) horribly discouraged but after 20 years of my own activism (alongside many others) that’s built on decades of earnest activism that came before, to be where we are now arguing about mandates is really discouraging.
    We’ve got to collectively ask questions and generate public dialogue about “What on earth has a chance of breaking through the moneyed interest barriers that stand in the way of achieving urgently needed health system reforms?” Will showing SiCKO at every State House for legislators and Governors make a difference? Will holding “Truth Hearings” across the country to educate voters about the reality of the crisis make a difference? Will convening forums, writing articles or holding press conferences make a difference? Is all that needed, and more (such as far-reaching campaign finance reform)? What else, then?
    Any thoughts that you and others have on these questions will be most appreciated.

  20. Sorry for the typo- the first paragraph sentence of my prior comment that reads:
    “The MA plan tinkers and uses wasteful financing to cover poor of the poor”
    should read: “…to cover more of the poor”

  21. Maggie:
    My eldest son lived in Germany for 20 years and married a German girl, in fact two (not at the same time). The local “mayor” held the ladies passports. Without his permission they could not leave the country.
    One reason they moved back to this country was my granddaughter, a difficult artistic student, was slated in the German school system to be sent in to a work apprenticeship program at age 14 and not be allowed to go on to University.
    They would not trade healthcare they have from the US Civil Service on a bet. Particularly since the German system never wanted to help my son as an American at all.
    Ask your daughter-in-law about owning a house in Germany. Not the three room flat provided by the government or her employer but a real house that she would own. Like you probably have and your parents had. That is a whole discussion about private property ownership outside of this scope.
    I lived in the orient for two years and have traveled extensively over Asia and Europe. You would be surprised at what I have seen and experienced abroad.
    I advise my clients who travel overseas to by an emergency evacuation policy. If they can’t solve a medical problem with simple remedies available a private jet will pick them up and return them to the American hospital of their choice. Only an idiot would go overseas for an extended period without one. I would not allow a child of mine to be operated on in a hospital in Asia or most of Europe. Maybe in Australia or New Zealand but not in India, Afghanistan, Bangladesh etc. etc. etc. Maybe five or six countries out of 200 plus. And France is not one of them
    I have not seen a hospital in Asia, outside of “old” British Hong Kong that I would want to be caught dead in.
    I don’t describe the US as a utopia. But you have to admit it is the wealthiest country in the world. Everybody around the world bitches about it. That wealth and power were achieved at a cost. The cost was forgoing socialism and letting the individual seek their own level of success. Yes, there are problems. Yes, we have created a second class citizenry for our black citizens, which is intolerable. We are creating another one for our “illegal alien” Mexican population which is just as bad and even less conceivable because we already screwed up once.
    I am a Rotarian. I contribute time and money to help solve problems around the world. Polio eradication is one. The next big push is clean water. How many of our citizens don’t have a clean municipal system to drink from? Not many. There are whole countries where there is no potable water. By the way in Germany don’t drink the tap water, it will make you sick.
    Our poor live in conditions that are the envy of much of the world. They have running water, indoor toilets, TV, public schools (some not that great) and the right to move to a better community if they choose. If you want a three room flat in a German government high rise fine, not me. Everybody who wants a job in the US can have one or two. You want a better life for you and your kids work your ass off, get ahead. If you want it go get it. That is your right. Life Liberty the Pursuit of Happiness. Not universal tax supported healthcare. Not a minimum dole for life for everybody. But a maximum life if you want it, and our willing to work for it.
    Maggie, I could go on and on. I am not blind to the problems. I am not deaf to the cries. I am not hardened to the suffering. I have traveled much of the world and know how blessed we are in this country and I think I have figured out why we are blessed. I really feel that if “Progressives” have their way it will all be destroyed. Not in my lifetime but in the lifetime of my grandchildren. I have earned my lifestyle I want them to have the chance to earn the lifestyle they want, as everyone here in the US currently can.
    We will just have to disagree, sorry.
    Regards,
    Charles

  22. Hi Maggie,
    since long I made no comment, what doesn’t mean I was not online.
    First of all private healthcare insurers work like banks:They give you free of charge umbrella as long as the the sun shines, what they want to take back immediately as the the first drop of rain falls.
    With European way of thinking it is hard to understand American problems, but I try to do my best.
    First of all I fully agree with you.(as before)
    One of the main problems I see – following what other websites communicate as well – is that most the Americans scramble SOCIALIST healthcare and SOCIALIZED healthcare. They don’t have even the faintest idea about the differences between the the two.
    The socialist way of healthcare-health insurance is that everybody who has any kind of income has to pay for others, and nobody knows what they are paying for. (That is what most of the Americans do now – via their employers,or by regular taxing – no matter they acknowledge it or not.)
    The socialized version is when everybody who has any kind of income pays a certain – known – percentage of his or her income for health insurance, and gets a well known service against it.
    Assuming three things:
    1) All those having no income at all – needy – will be covered by the state up to a certain state. (Up to recovery,or stabilizing their state! The rest is the the job of social welfare!) Covered by certain – well defined part – of taxes. Children by THEIR PARENTS INSURANCE.
    2) All those having any kind of income by paying allowances of a certain percentage of income – subject of negotiating between employee and employer within a minimum limit – get another, higher level of package. (You call it policy, and you are right doing so, because that is what politicians are not ready to take any responsibility for.) No matter it is given by the state or any kind of private insurer, the thing is that it is a kind of insurance.
    3) All those having extra wishes can approach their private insurer for extra services, FOR EXTRA MONEY!
    IF you make this three legs of your chair you’ll
    sit safe.

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