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Gandalf Grey
Guest
Health-Care "Demogoguery"?
By RJ Eskow
Created Feb 7 2008 - 3:27pm
The intensity of liberal debate around health care reform shows how agitated
policy addicts can get when their preferred approaches are challenged. The
word "demagogue" is being thrown around a lot by normally mild-mannered
people, over differences that are more technical and tactical than
ideological. It's wonk-on-wonk mayhem -- the Brookings Institution meets the
WWF! I tell ya, it's getting wild out there.
Demagogue (noun) - One who makes impassioned emotional appeals to the voting
public; specifically, in opposition to a policy position you personally
support.
"Mandates" are the provision in insurance-based health reform proposals that
require people to purchase health insurance. They were a key part of the
Massachusetts reform law and are central to the Clinton health proposal.
Obama's reform plan does not include a mandate provision, at least
initially, although he indicated during the early debates that he would
consider adding one later if voluntary programs don't succeed in getting
near-universal coverage.
Clinton has been hammering Obama over this issue for months, saying that her
plan guarantees "universal coverage" and his doesn't. Here's the simple
fact: Mandates do not create universal coverage. When the pundits were
celebrating the "Massachusetts miracle" -- including many of the same
"health wonks" now touting the Clinton plan -- I was one of the few to point
out that the plan was actually more mirage than miracle. It kicked the
unpleasant decisions down the road so that Mitt Romney and his Democratic
and labor collaborators could take an undeserved victory lap at the signing
ceremony.
Sure enough, the legal authority responsible for the Massachusetts plan
eventually acknowledged that the plan will leave 20% of that state's
uninsured without coverage, and the real number may be higher. Why? Because
there is a wide band of people who would suffer financial hardship if
compelled to pay the premiums, and it's financially infeasible to subsidize
them all.
The Clinton plan, should it ever be passed, will suffer the same fate. I
will happily bet Paul Krugman on that point. He should know better than to
claim that the Clinton plan could provide universal coverage [1]. Experience
and political common sense say that just ain't so.
That's not to say there aren't valid arguments in favor of mandates. There
are, which is why they're part of conventional health policy wisdom.
Mandates solve the "selection problem," where insurance costs become too
high because only sicker people buy insurance voluntarily. They also allow
funds that are now used to reimburse providers for treating the uninsured to
be used in better ways. And I think the Obama team is over-optimistic about
voluntary compliance levels.
Krugman and other supporters of the Clinton plan are now pointing to a study
by the respected Urban Institute [2]as a validation of their position. It's
a good study that shows mandates are the only way to achieve something like
"universal coverage" -- if you first exclude single-payer coverage from the
mix. (They also exclude my preferred approach [3] -- core basic coverage
paid from tax revenues, with the ability to "buy up" into private plans
through a subsidy/voucher approach.)
Here's one problem: The paper's authors admit, albeit indirectly, that they
overestimated the ability of Massachusetts to achieve universal coverage.
They make the same mistake here. Here's another: Sen. Clinton and the
supporters of her plan have been evasive about how they would enforce this
mandate, and enforcement is key to the Urban Institute's findings. In a
recent interview she was forced to acknowledge, for example, that she would
consider garnishing wages. And while she has boasted about tying mandate
obligations to personal income, she has been equally vague about what level
of personal income she might allocate for healthcare.
Those provisions are political non-starters. Massachusetts is easy compared
to the country as a whole -- both in terms of political climate and the
scope of the uninsured problem. Yet they had to leave 20% of the uninsured
without coverage. That figure would equate to about 8 million people
nationwide. If we accept Sen. Clinton's figure of "15 million uninsured"
under the Obama plan (and that figure was chosen by a journalist, not a
technical study), that means a difference of seven million -- in return for
a plan that might actually get passed in Congress. (The gap could be filled
in later, after premiums are brought under control and it becomes more
politically feasible.)
And look at what mandates might do to a family of four. While Clinton won't
tell us the percentage of income she'd tie to mandates, many analysts have
been using 10%. If premium assistance is provided up to 300% of the poverty
level, a family of four trying to survive on $75,000 could be forced to pay
$7,500 to insurance companies or in health copayments. The alternative could
be tax penalties or garnished wages. That's profoundly unfair. I also
believe it's a serious misread of American political culture to think that
kind of mandate could ever get through the legislative process.
Krugman and Ezra Klein [4] are both strong advocates for the mandate
position, and they were both outraged by an Obama ad [5] that seemed to
channel "Harry and Louise" from the 1994 anti-reform campaign. (Hey, what
happened to the argument that this primary season's great for "toughening up
a candidate for the general campaign"?)
Krugman, who has been arguing that Obama's position is "less progressive"
(which as I explain here [6]isn't true), goes positively reactionary in his
response [7]: Mandates are to "prevent some people from gaming the system,"
he writes, as if that family of four could just write out that $7,500 check
if they weren't so dishonest. That check would be a financial hardship, and
I think Obama's right to point that out -- although to Krugman that's
"unscrupulous demagoguery [8]."
The "gaming the system" language, like John Edwards' "shared responsibility"
phrase, is a right-wing frame that demonizes people who make tough choices
with their personal budgets every day. We already have a mechanism for
"shared responsibility," and it's called taxation. Adding 10% to struggling
families' financial burdens is nothing more than a highly regressive tax to
be paid to wealthy insurance companies, which is why insurance companies
prefer the Clinton plan. [9]
Ezra Klein's a reasoned and articulate advocate for mandates, and we've
disagreed on this topic in a courteous way for months. But he was furious at
those ads, too [10]. Yet neither Klein nor Krugman voiced outrage over
Clinton's many boasts that her plan will achieve "universal coverage" -
although they must know Clinton keeps dodging the tough questions, and that
even Massachusetts couldn't get to "universal." Those "universal coverage"
taunts have sounded as demagogic to me as Obama's ads do for Klein and
Krugman. That leads me to what might be the only statement we can all agree
on during this campaign:
Demagoguery is in the eye of the beholder.
--
NOTICE: This post contains copyrighted material the use of which has not
always been authorized by the copyright owner. I am making such material
available to advance understanding of
political, human rights, democracy, scientific, and social justice issues. I
believe this constitutes a 'fair use' of such copyrighted material as
provided for in section 107 of the US Copyright
Law. In accordance with Title 17 U.S.C. Section 107
"A little patience and we shall see the reign of witches pass over, their
spells dissolve, and the people recovering their true sight, restore their
government to its true principles. It is true that in the meantime we are
suffering deeply in spirit,
and incurring the horrors of a war and long oppressions of enormous public
debt. But if the game runs sometimes against us at home we must have
patience till luck turns, and then we shall have an opportunity of winning
back the principles we have lost, for this is a game where principles are at
stake."
-Thomas Jefferson
By RJ Eskow
Created Feb 7 2008 - 3:27pm
The intensity of liberal debate around health care reform shows how agitated
policy addicts can get when their preferred approaches are challenged. The
word "demagogue" is being thrown around a lot by normally mild-mannered
people, over differences that are more technical and tactical than
ideological. It's wonk-on-wonk mayhem -- the Brookings Institution meets the
WWF! I tell ya, it's getting wild out there.
Demagogue (noun) - One who makes impassioned emotional appeals to the voting
public; specifically, in opposition to a policy position you personally
support.
"Mandates" are the provision in insurance-based health reform proposals that
require people to purchase health insurance. They were a key part of the
Massachusetts reform law and are central to the Clinton health proposal.
Obama's reform plan does not include a mandate provision, at least
initially, although he indicated during the early debates that he would
consider adding one later if voluntary programs don't succeed in getting
near-universal coverage.
Clinton has been hammering Obama over this issue for months, saying that her
plan guarantees "universal coverage" and his doesn't. Here's the simple
fact: Mandates do not create universal coverage. When the pundits were
celebrating the "Massachusetts miracle" -- including many of the same
"health wonks" now touting the Clinton plan -- I was one of the few to point
out that the plan was actually more mirage than miracle. It kicked the
unpleasant decisions down the road so that Mitt Romney and his Democratic
and labor collaborators could take an undeserved victory lap at the signing
ceremony.
Sure enough, the legal authority responsible for the Massachusetts plan
eventually acknowledged that the plan will leave 20% of that state's
uninsured without coverage, and the real number may be higher. Why? Because
there is a wide band of people who would suffer financial hardship if
compelled to pay the premiums, and it's financially infeasible to subsidize
them all.
The Clinton plan, should it ever be passed, will suffer the same fate. I
will happily bet Paul Krugman on that point. He should know better than to
claim that the Clinton plan could provide universal coverage [1]. Experience
and political common sense say that just ain't so.
That's not to say there aren't valid arguments in favor of mandates. There
are, which is why they're part of conventional health policy wisdom.
Mandates solve the "selection problem," where insurance costs become too
high because only sicker people buy insurance voluntarily. They also allow
funds that are now used to reimburse providers for treating the uninsured to
be used in better ways. And I think the Obama team is over-optimistic about
voluntary compliance levels.
Krugman and other supporters of the Clinton plan are now pointing to a study
by the respected Urban Institute [2]as a validation of their position. It's
a good study that shows mandates are the only way to achieve something like
"universal coverage" -- if you first exclude single-payer coverage from the
mix. (They also exclude my preferred approach [3] -- core basic coverage
paid from tax revenues, with the ability to "buy up" into private plans
through a subsidy/voucher approach.)
Here's one problem: The paper's authors admit, albeit indirectly, that they
overestimated the ability of Massachusetts to achieve universal coverage.
They make the same mistake here. Here's another: Sen. Clinton and the
supporters of her plan have been evasive about how they would enforce this
mandate, and enforcement is key to the Urban Institute's findings. In a
recent interview she was forced to acknowledge, for example, that she would
consider garnishing wages. And while she has boasted about tying mandate
obligations to personal income, she has been equally vague about what level
of personal income she might allocate for healthcare.
Those provisions are political non-starters. Massachusetts is easy compared
to the country as a whole -- both in terms of political climate and the
scope of the uninsured problem. Yet they had to leave 20% of the uninsured
without coverage. That figure would equate to about 8 million people
nationwide. If we accept Sen. Clinton's figure of "15 million uninsured"
under the Obama plan (and that figure was chosen by a journalist, not a
technical study), that means a difference of seven million -- in return for
a plan that might actually get passed in Congress. (The gap could be filled
in later, after premiums are brought under control and it becomes more
politically feasible.)
And look at what mandates might do to a family of four. While Clinton won't
tell us the percentage of income she'd tie to mandates, many analysts have
been using 10%. If premium assistance is provided up to 300% of the poverty
level, a family of four trying to survive on $75,000 could be forced to pay
$7,500 to insurance companies or in health copayments. The alternative could
be tax penalties or garnished wages. That's profoundly unfair. I also
believe it's a serious misread of American political culture to think that
kind of mandate could ever get through the legislative process.
Krugman and Ezra Klein [4] are both strong advocates for the mandate
position, and they were both outraged by an Obama ad [5] that seemed to
channel "Harry and Louise" from the 1994 anti-reform campaign. (Hey, what
happened to the argument that this primary season's great for "toughening up
a candidate for the general campaign"?)
Krugman, who has been arguing that Obama's position is "less progressive"
(which as I explain here [6]isn't true), goes positively reactionary in his
response [7]: Mandates are to "prevent some people from gaming the system,"
he writes, as if that family of four could just write out that $7,500 check
if they weren't so dishonest. That check would be a financial hardship, and
I think Obama's right to point that out -- although to Krugman that's
"unscrupulous demagoguery [8]."
The "gaming the system" language, like John Edwards' "shared responsibility"
phrase, is a right-wing frame that demonizes people who make tough choices
with their personal budgets every day. We already have a mechanism for
"shared responsibility," and it's called taxation. Adding 10% to struggling
families' financial burdens is nothing more than a highly regressive tax to
be paid to wealthy insurance companies, which is why insurance companies
prefer the Clinton plan. [9]
Ezra Klein's a reasoned and articulate advocate for mandates, and we've
disagreed on this topic in a courteous way for months. But he was furious at
those ads, too [10]. Yet neither Klein nor Krugman voiced outrage over
Clinton's many boasts that her plan will achieve "universal coverage" -
although they must know Clinton keeps dodging the tough questions, and that
even Massachusetts couldn't get to "universal." Those "universal coverage"
taunts have sounded as demagogic to me as Obama's ads do for Klein and
Krugman. That leads me to what might be the only statement we can all agree
on during this campaign:
Demagoguery is in the eye of the beholder.
--
NOTICE: This post contains copyrighted material the use of which has not
always been authorized by the copyright owner. I am making such material
available to advance understanding of
political, human rights, democracy, scientific, and social justice issues. I
believe this constitutes a 'fair use' of such copyrighted material as
provided for in section 107 of the US Copyright
Law. In accordance with Title 17 U.S.C. Section 107
"A little patience and we shall see the reign of witches pass over, their
spells dissolve, and the people recovering their true sight, restore their
government to its true principles. It is true that in the meantime we are
suffering deeply in spirit,
and incurring the horrors of a war and long oppressions of enormous public
debt. But if the game runs sometimes against us at home we must have
patience till luck turns, and then we shall have an opportunity of winning
back the principles we have lost, for this is a game where principles are at
stake."
-Thomas Jefferson