And what are the numbers on individual mandates? Massachusetts was facing some big non-compliance (4% or so of the population, if I recall).

Obviously, auto insurance is mandated. That's the analogy we always hear. It's still not universal.

So Obama's plan sucks. But he's better than Clinton on Iraq. What to do?

And not only does his plan sucks, he's proud of its suckiness. See http://krugman.blogs.nytimes.com/

(stamping my foot) I WANT Health Care for Everyone!

So I can't support Obama.

Why did he have to do this?

As someone who's taught & worked on health policy for over 20 years, its obvious that Obama doesn't understand the intricacies of health care policy. His proposal is a partial step toward the nation's healthcare problem, with many negative side consequences, chief among them being that not seeking to cover everyone leads to a perverse disincentive to not enroll & have the public clean up your misfortune when a serious accident or illness strikes.

You deluded liberals have bought the Edwards-style (Clinton) plan, hook line and sinker.

The distinction between the Obama and Edwards/Clinton plan don't really matter because Obama says there would be carrots or sticks in his plan to encourage people to participate (pretty much the same thing as a mandate). But, more importantly, both plans underestimate extent to which big capital will mobilize to derail any real transformation of the health care system.

We must aim for universal single-payer health insurance in blow or mark my words, we will get nothing at all. And all y'all should read some Michael Harrington.

And what are the numbers on individual mandates? Massachusetts was facing some big non-compliance (4% or so of the population, if I recall).

Massachusetts's program isn't really a universal plan, for the very reason that the state has been issuing exemptions for affordability reasons. Also, the plan only became truly mandatory (for those people who can't get exempted) as of January 1st of 2008. This year the tax penalties increase substantially. I'm not sure if the 4% figure you cite is accurate, but, assuming it is, that's not too bad for a first year performance. I mean, having 96% of a state's residents insured is a lot better than the national average (about 85%).

If the Bay State manages to whittle that 4% uncovered down by another point or two over the course of 2008, I'd say it's pretty good evidence that mandates do work. Just imagine what such a plan could do if they didn't allow exemptions, or if they funding were more robust.

Please, this whole excessive haranguing over what appears to be different versions of the same plan is ridiculous.

You want to cover everyone? Propose single-payer. Too bad Kucinich is out of the race.

I don't remember anyone here showering Kucinich with love.

Your own series on Germany shows they have 99.8% coverage with no mandate for health coverage for people making more than $40,000 per year (figures may be a bit dated). I don't understand why Obama's national pool is much different that a German sickness fund that you praise so highly. You write in 'The Health of Nations' of Germany: "The [German sickness] funds are a mix between private and public entities and are all nonprofit. They can't discriminate, and can't charge customers at different rates corresponding to their health/age/lifestyle. That means no cherry-picking." If 30% of Americans join the Obama national health care pool it's a bigger pool than ALL of Germany. That's quite a negotiating block.

All of the criticism of Obama's plan rest on the idea that his pool will have the bad risk people and private insurance will keep the good. Why is this a given? I'm young and in good health and have had nothing but problems dealing with insurance companies with paperwork for the most mundane procedures like checkups and sprains. I always feel like I'm being cheated and one form away from screwing up and getting a $1,000 bill.

All Obama has to do is outperform the dysfunctional private system with his pool and people will flock to it with no mandate. If Obama can pass a law requiring insurers to insure without regard to pre-condition and convince young people to choose the national pool over private insurance he's going to destroy the health insurance business.

Is this really impossible? How is Obama's credibility with young people? If he says "Sign up for this pool, I'll deduct 8% from your check, and you'll never worry about health care again" he will destroy for-profit insurance overnight.

Without a mandate.

No one else seems to have linked to the following, so I'll do the honors:

http://www.huffingtonpost.com/harold-pollack/universal-coverage-and-t_b_84386.html

So, at the very least, there are a number of experts on the matter who disagree about the importance of mandates. Whatever you ultimately think of their arguments, this makes it clear, I think, that the pro-mandate crowd does not have an obvious knockdown argument against Obama's health plan. We should all settle down, recognize that their plans are both huge leaps forward, and not spend so much time bickering about details that even the experts have not come to a consensus on. As for Obama's "Harry and Louise" project, well, that's politics, people. Don't pretend you're astonished by it.

The problems from not having a mandate only occur if you don't offer a public plan option. If you prevent insurance plans from discriminating based on prior illness or risk factors you have a problem: healthy people don't get healthcare, rates go up, fewer people get healthcare, rates go up further, etc.

But you can break this loop by offering a reasonably priced public option. Now because of the lack of mandate, some healthy people will not get healthcare b/c they don't need it. Now if they get sick they'll sign up and this will cause the plan to cost the taxpayer money. But collectively, we'd be paying for that sick persons coverage one way or another. You might say that the result is unfair because some people who are not paying their way should be, but overall the system doesn't cost anymore and people who need coverage can get it. So its not an ideal solution, but its not nearly as broken as I think people make it out to be.

If there is a public option, that is.

I still believe that mandates will scare off popular support even more than Hillary's 1994 promise to take away people's health care and replace it with an unknown did. Right or wrong, nothing is as popular as Medicare for all -- it eliminates the profits and paperwork costs -- what's the problem?

Why is everybody so afraid of (everyone loves to hate) insurance industry opposition; which industry wont even be around long gets Medicare for all is adopted? Insurance oppo is the only rationale I ever hear offered for our reps not going with Medicare for all.

Remember, $40,000/yr is more like the REAL (just above) poverty line for a family of four (not the official line based on three times the price of an emergency diet) and $55,000/yr is roughly median family income these days. Most families are not far from poverty while med insurance climbs and climbs. (Obama is oh so right in saying that policies with $10,000 deductibles are home insurance, not health insurance.) Forcing growing premiums down the throats of many families with shrinking income is flirting with disaster in many cases -- and could impose disaster in may hanging by a thread families.

So-called subsidies tend to be set by proportion of the in REALITY 50% discounted fed poverty line. I really believe our academic liberals have much trouble envisioning the existences of anyone below 50 percentile income (why you almost never hear Dem candidates so much as mention the average Americans' most desperate economic need, massive re-unionization -- , nor criticism of a ridiculous minimum wage raise that will end up lower than 1956's in REAL buying power) -- and here we go again.

Medicare is what all are waiting trustingly on when they are old and may need lots of even critical care -- no reason any should fear it while still young and healthy.

still believe that mandates will scare off popular support even more than Hillary's 1994 promise to take away people's health care and replace it with an unknown did.

That's exactly right. Everyone says how single payer is unpopular. But forcing poor and working class people to buy health insurance coverage is also unpopular. Complex plans involving health alliances and purchasing pools were also unpopular.

The argument for not doing single payer is entirely pragmatic-- it's a good idea but it won't pass. Well, none of the bad ideas will pass either, in part, because liberals like me will oppose them. There are a lot of us, and demonizing us as the opponents of universal coverage (which we are not) will not sway us.

Ezra,

Some standards, please.

The lead author is a former healthy policy advisor to the last Clinton health reform in 1993 and is releasing their report 4 days before the major primary day.

The piece is called "Do individual mandates matter?" and they provide absolutely zero evidence that they do. The discuss the failings of a voluntary system as well as the mechanics of mandate system. No evidence provided on how and why mandates are effective. Given the title of the piece, that's a joke.

And stamping your foot, or Hillary stamping her foot will not get you there.
If we demand everyone has to buy heath care there will be no health care reform.
I want everyone to have health care, I want a single payer system, but the minute we try to mandate health care we not only lose the debate we lose the GE.

No comment on the strength of this study. Just comments on the posters.

It's funny how the same things are said no matter how much evidence is brought to the subject. You bring out data comparing country to country outcomes. They rant. You bring out data regarding preventable deatsh per year, and it's the brown people's fault. You bring out the fact our system costs twice as much as it's something other than the system. That's really the point. Were this one data point, then you could say the evidence was circumstantial and inconclusive. But it's not. So repeating the same things over and over again really just seems like faith rather than analysis. Again an observations about the usual suspects posting here.

i am tired of the lie that Hillary's health care plan will be Universal, it doesn't cover illegals or Permanent Residents (who are ineligible for low income subsidies) and being that the majority of the uncovered fall into these two categories the universal part is a lie. Beyond that, mandates are bad politically, because they will be distorted by the Republicans to mean that poor will have to buy overpriced insurance which has high deductibles and miserable care (crowded waiting rooms, etc.) when available. And I am afraid that in order for Hillary to get her "universality she will throw the poor under the bus by simply buying out the insurance companies, with the poor essentially buying worthless coverage, in which case they will be worse off then when they started. At least the Seniors get the drugs under Bush. She will triangulate the position so that it becomes a noose around the neck of the Democrats.

And Social Security is financed by taxes, Mandates expect people to buy insurance on their own, middle income young people will simply buy extremely restrictive, high deductible policies but very cheap policies to avoid a fine, but essentially only make the insurance companies rich without providing any kind of long term preventative care.

I share Ezra's concern about Obama's health care plan, but it's not terribly influential in holding back my support of Sen. Obama. Here's why.

There is PLENTY of opportunity to shape the contours of the health care plan before it reaches President Obama's desk. Does anyone seriously think President Obama is going to veto a comprehensive health care plan passed by both houses of Congress?

I know the heat of the campaign magnifies this policy difference on mandates, but in reality the next Congress (with input from the President) will develop the details of a health care plan. I support Obama because he is so much more likely to add Democrats down-ticket that will make real change possible.

akaison - It's a 4-page press release from Blumberg and Holohan's that cites Blumberg and Holohan's earlier work as evidence. It's not exactly a 'running of the numbers'. If 9 out of every 10 hyperlinks in Ezra's posts were to Ezra's earlier posts would you walk away thinking 'Wow, that was well supported!'.

And then there's this from Blumberg & Holohan: "Affordability. No individual mandate would be morally or politically acceptable if required premiums exceed an individual or family’s ability to pay. Defining what is affordable for families of different economic circumstances is inherently a value judgment, however, and as of now, there is no established social consensus on what that should be. None of the candidates has yet to delineate their perspectives on this issue. In our work, we have demonstrated the importance of taking both premiums and out-of pocket liability into account when assessing affordability of health insurance.8 For example, a health insurance plan may have a low premium and seem affordable to a person of modest income; however, if the low premium reflects a deductible of thousands of dollars and limited covered benefits, it would not provide affordable access to medical care for that individual when they needed it."

Contrary to their assertion that "None of the candidates has yet to delineate their perspectives on this issue' -- Obama has been very clear on the issue which is why he opposes mandates. The lack of a political consensus on what level of burden a mandate can impose on people as noted by Blumber and Holohan may be a throwaway line in their press release but it's the nub of the problem in the political debate over mandates. Obama has considered the immorality of imposing a mandate on people who can't pay and the folly of having a mandate of health insurance that doesn't actually provide affordable care (more home insurance than health insurance) and designed his plan accordingly.

Massachusetts cannot achieve universal, or even really, near-universal (the credo now) unless we deal with those who are exempted from the mandate (because any insurance that's available to them costs more than the Commonwealth's Affordability Schedule). These are the working poor and near poor...who have no mandate but can't access care either.

It's important to note that "coverage" means "insurance" in Massachusetts. It does not mean these people have doctor they can go to. This new plan highlights our massive doctor shortage, and I'm not clear we have a plan to deal with that.

Key point for Urban Inst. it when they suggest that :if you are going to make the mistake of leaving the private for-profits in place, well then yeah you need mandates.

Yup I had the Urban Institute stuff yesterday, when I tried to give everybody a heads up about why both Clinton and Obama are both right and both wrong on the mandated health insurance schema in a do your homework before the debate diary on Kos yesterday:

http://www.dailykos.com/story/2008/1/31/123659/474/505/446985

Short version:
Obama is right that it will wind up as unaffordable subsidy to for profit health insurance industry. He is wrong that his plan is better, insofar as it is equally unaffordable and just insures less people as its solution to unaffordability.

Clinton is wrong insofar as it it is a forced subsidy to the private for profits. She is right, that once you have made the mistake of leaving the private for profits in place, that her plan will get more people insured and that without mandates less people get covered and the folks who are betting they are healthy and stay healthy will opt out making it more expensive for everybody else.

Which is why we need single payer, the only way to get to Universal coverage (everybody), Comprhensive coverage (covers everything needed) and Cost-control (affordable for individual and country).

Still supporting HR-676!

Key point for Urban Inst. it when they suggest that :if you are going to make the mistake of leaving the private for-profits in place, well then yeah you need mandates.

Yup I had the Urban Institute stuff yesterday, when I tried to give everybody a heads up about why both Clinton and Obama are both right and both wrong on the mandated health insurance schema in a do your homework before the debate diary on Kos yesterday:

http://www.dailykos.com/story/2008/1/31/123659/474/505/446985

Short version:
Obama is right that it will wind up as unaffordable subsidy to for profit health insurance industry. He is wrong that his plan is better, insofar as it is equally unaffordable and just insures less people as its solution to unaffordability.

Clinton is wrong insofar as it it is a forced subsidy to the private for profits. She is right, that once you have made the mistake of leaving the private for profits in place, that her plan will get more people insured and that without mandates less people get covered and the folks who are betting they are healthy and stay healthy will opt out making it more expensive for everybody else.

Which is why we need single payer, the only way to get to Universal coverage (everybody), Comprhensive coverage (covers everything needed) and Cost-control (affordable for individual and country).

Still supporting HR-676!

The Urban Institute was a key player in Massachusetts' health reform plan...which includes mandates. They, with the Blue Cross Blue Shield of Massachusetts Foundation, created the 2005 Roadmap to Coverage.

DR STEVE B's comment gets to the heart of the matter with a point so nice he posted twice.

The mandates are necessary if for-profit insurers are going to remain a part of the landscape for sometime in the future...but that doesn't mean they don't suck, and that doesn't mean we can't come up with a better plan.

Edwards was my fave candidate, but his health care proposal was so-so.

Robert Reich, former Secretary of Labor under Bill Clinton, has some excellent insight on this issue. Basically, he supports Obama's position, but says that the debate over mandates is overblown and unnecessary. See his blog at:
http://robertreich.blogspot.com/2008/01/democrats-should-stop-squabbling-over.html

Imagine a future in which families are mandated to buy a health plan with a $10,000 deductible (the cheapest legal option?) -- okay, they obeyed the law -- but now they end in the emergency room MORE OFTEN because they have even LESS money left over for family doctor visits.

Again and again: Medicare for all ought to be the easiest program in the world to sell: Medicare is the plan most folks happily look forward to relying on when they are older and perhaps much more in need of even critical care -- why in the world should they hesitate to rely on it now while they are young and usually healthy?

Eh, for the most part, I think an individual mandate should be part of any health reform.

That said, mandates in Massachusetts are only sort of working--older, low-mid income people can't afford coverage and end up paying penalties for the fact that they can't afford coverage.

In terms of the mandate, you have to make the penalties substantial enough that it becomes a really bad decision to not buy insurance. And since insurance costs are rising, you need stiff penalties--which HRC's plan completely lacks. Otherwise, the mandates don't do a whole lot.

You can also cut costs, but as I understand it, HRC and Obama are pretty much the same on that.

I still say the 'Medicare for all' model is the only one that makes sense. I know people don't feel passing that is possible, but I really wonder if we have reached a threshold where another Hillarycare-type defeat of such a plan wouldn't just turn more people towards voting for Democrats who are for single-payer rather than running to the Repugs.

I worry a half-assed system that includes private insurers in a primary role will only create problems either because the govt is unable to effect positive change due to limitations put in by the private insurers or the private insurers corrupt the plan and sabotage it, which might instead backfire and lead to a resurgence of conservatives promising to return us to the old status quo and save us from the brink of 'socialism'.

You ask: Do individual mandates matter? I answer: not so much.

You base you conclusion on a non-peer-reviewed article signed by 2 people, both economists, one of which was a Health Policy Advisor for Bill C linton during the failed universal health care attempt at the beginning of his presidency.

I base my opinion on the following letter signed by 80 distinguished professors of medicine, law, health policy and economics at top universities, plus a peer-reviewed article in the leading journal of health policy.

Details here:
http://www.huffingtonpost.com/harold-pollack/universal-coverage-and-t_b_84386.html

Most are missing the point. Obama has a decent health care plan. It is not ideal to many people. If that were it, this would be a non-issue.

The issue is him putting out a hit piece on Paul Krugman and reviving the ghost of republican smears past to defend his (again, very similar) plan. That is the real problem, not his lack of a mandate.

Carping over 'teh mandates' now is just silly. A solution will be arrived at legislatively, regardless of who is President.

My thoughts: Hillary sez she will cover those who can't afford the mandate with tax credits. That's just BS. If you aren't paying taxes because of low income (or aren't filing tax returns at all), there's no subsidy.

Short of single payer, I'd eliminate MedicAid (no Virginia, not Medicare) because of widely varying state support for it through state taxes, and use that money to put them in Medicare Parts A, B and D, without cost to the insurered.

Make it like 'motor-voter'. You show up at a medical facility without insurance, and they create the paperwork to start qualification for Medicare. You get a card automatically. A person can opt out only by showing current private insurance coverage before Medicare stops paying (but why would they opt out?)

As Atrios has said on several occasions, just mail them the card. Or give it to them when being treated.

Basically, he supports Obama's position, but says that the debate over mandates is overblown and unnecessary.

Bull!!

It may be economically overblown and unnecessary but from a "liberty" point of view it is neither - there is a HUGE difference between an approach based on attracting people to choose coverage and one based on forcing people to have it by threatening them with legal punishment.

"liberal fascism" may be a figment in the mind of the Doughy Pantload, but "Progressive Authoritarianism" is alive and well.

The issue is him putting out a hit piece on Paul Krugman

Right, because Krugman has always been so kind to Obama...

I think this is wrong, but Krugman is about as objective about Obama as Sullivan seems to be on Clinton.

Malarky Ezra.

The problem with *experts* is that they are looking at the situation on paper only.

Mandates make perfect sense on paper. They placate the insurance industry because healthier people even out the risk pool of less healthy people.

The problem is no one has shown any way to enforce mandates making them moot.

Proponents point to car insurance.

We still have uninsured drivers, otherwise there would be no uninsured/underinsured attachments to our policies. The second problem is the monthly cost difference in the two products. Health insurance cost, by any standard, is FAR more expensive, cuts much farther into a monthly budget than car insurance. The third problem is levels of insurance. Mandatory car insurance is something like 10,000 in most states...costs little and covers less. That level of coverage wouldn't get you in the door of a hospital these days.

Mandates are unenforceable and therefore moot.

Ezra,

The Urban Institute report looks at how coverage would have been impacted in the absence of an individual mandate for two state level policies much less ambitious in reach than either the Obama or Clinton proposals. Unfortunately, the authors fail to provide the assumptions for those policies in terms of either the breadth of public program expansions or the scope of the employer requirements.

The vast majority of the uninsured are either low-income or in a family with a workforce connection. Others are unable to purchase coverage on the individual market due to preexisting conditions, or are priced out of the market due to demographic factors. Each of these groups could be reached by a policy along the lines proposed by Obama. It would be useful to have an analysis of who would remain. Unfortunately, the Urban Institute study does not provide it.

"The argument for not doing single payer is entirely pragmatic-- it's a good idea but it won't pass."

Not entirely. There's another argument against it: rationing.

A fair number of health experts I know have moved away from single-payer and towards individual mandates out of precisely that concern.

libarbarian: so I assume you want to do away with every existing social insurance program offered by the government, as well abolish taxation? After all, why force people to pay taxes when it would be so much less "anti-liberty" to give them an incentive, like a national lottery or something....

Mandates don't work, with or without them, if people can't afford health care, or don't think they can, they will not get coverage. Even if people get the tax credits from these plans, if at the end of the day they still have to struggle to pay rent, utilities, other bills, food, etc, do you really think they are going to buy into an insurance plan that has absolutely no enforcement? How naive are you people? The government has mandated car insurance for a long long time, wanna guess how "universal" that coverage is? Not very, millions of drivers take to the roads every day without insurance, and they DO have penalties if they are pulled over and don't have any. Are you going to require people to show proof of medical insurance at traffic stops? No. There is no enforcement, so people who don't want it aren't going to get it. I don't have health insurance now, I can't afford health insurance now, and under these plans health insurance would still be too expensive, so they can mandate all they want, I'm not going to do it unless I can actually afford it. Obama realizes that these mandates aren't some magic bullet like Clinton wants to make them out to be, all they do is put the burden onto low income people. Krugman is a tool, he is a Hillary supporter and he spends half of his time going after Obama for Hillary, on everything from Health Care to Reagan, he will say anything and distort anything to make Obama look bad. How can anyone take him seriously anymore?

We really need a not-for-profit single payer system, and until we get that any system is going to be flawed, but pretending that Obama's plan is so bad and Hillary's is so good is ridiculous. They have a policy difference on one point, and Obama has very good reasons for this difference. MANDATES DON'T WORK.

If Billary can't sell mandates to a Democratic primary audience, do you think they will sell it to the country?

Isn't this just good political practice for Billary...ready on day one?

I'm disappointed in Ezra for posting on this total crap. I really like most of his blogs, but this whole mandate thing is a fantasy. Everyone who really knows about these issues knows full well that these mandates aren't going to force people to do anything, and at best they are just going to hurt the people who need the most help. Anyway, I saw the headline and I was hoping that you were going to point out how bad of an idea mandates are, but I was sadly mistaken.

joejoejoe,

Germany does in fact have a mandate system. It's just that the mandates are for employers and taxpayers, rather than individuals as premium buyers. That's why having the option of not being covered above $40,000 income only results in 0.2% uninsured in Germany....well, that and the fact that German health care costs almost half as much as American health care. Our system costs so much that we would have much more uninsured with an employer-only mandate. And good luck getting that passed. With no mandate at all, good luck making much of a dent in the uninsured at all.

All a mandate is, basically, is a fine for not getting insurance, probably paid at the end of the year when you pay your taxes (presumably the IRS would have a system in place to encourage you to pay on an ongoing basis rather than all in April).

Bottom line: there is going to be a mandate in the system somewhere if we are going to have truly universal health care. The mandate will be for employers and/or individuals and/or taxpayers to cover those who don't make enough to pay for their own care. This is why it is so foul for someone who supposedly supports universal health care to decry mandates.

There is no way to universal coverage with out some type of mandate. All current UHC systems have mandates -
the differences are who the mandate applies to and who pays. The much beloved single payer system also has a mandate in the form of compulsory taxation.

UHC will require some portion of the population subsidizing another portion of the population whether it is the rich/poor or healthy/unhealthy.

Ezra -- Looks like about a 100 healthcare experts disagree with your claim about mandates and that hack job by the Urban Institute/Clinton healthcare team. Here's their sign-on letter.

The leading Democratic and Republican candidates for president have proposed major changes to our health care system. These proposals are worthy of serious consideration. Rising medical costs threaten our country's long-term fiscal stability. And our failure to provide health insurance to 47 million Americans is cause for shame.

As this year's competitive primary election season builds to a climax, arguments within each party are bound to become heated. As candidates seek a competitive edge, it is natural to magnify small differences. But if the political debate over health reform is to inform Americans about the choices we face, it should be grounded on facts.

The remarkably similar health plans proposed by Senators Clinton and Obama have the potential to reduce the number of uninsured Americans (citizens, permanent residents, and others lawfully present in the U.S.) to two percent or less of the population. Achieving this goal would require full implementation of these plans' subsidies and insurance market reforms, plus robust outreach efforts to get everyone to sign up for coverage.

The necessary outreach will not be easy, and it will be fruitless unless health insurance is made affordable and accessible to all. Some believe that an individual mandate to buy health insurance should be part of this effort; others hold that a mandate would be paternalistic or too onerous for families at the margins of affordability. Regardless of our feelings on this issue, what is clear from the evidence is that mandates alone, without strong incentives to comply and harsh punishments for violation, will have little impact on the number of uninsured Americans.1 Indeed, as the Massachusetts experience illustrates, non-compliance with mandates is a large problem, absent harsh sanctions. There is simply no factual basis for the assertion that an individual mandate, by itself, would result in coverage for 15 million more Americans than would robust efforts to make health care more affordable and accessible.

The inaccurate claim that an individual mandate alone would reduce the ranks of the uninsured by 15 million draws attention away from the challenges we must surmount to make good medical care available to all. These challenges include adequate public subsidies, insurance market reform, outreach to people at the margins of American life, and long-term control of medical costs. Individual mandates may have a role in health care reform, but there is risk of a specious "Mission Accomplished" moment. It is a time for rolling up our sleeves and addressing the hard work required to get everyone care. The central challenge is to make health insurance affordable and accessible, and to reach out to all Americans to help them obtain coverage. Voters should insist that candidates for president address these very real issues.

1 S.A. Glied, J. Hartz, and G. Giorgi, "Consider It Done? The Likely Efficacy Of Mandates For Health Insurance," Health Affairs 26 (2007): 1612-1621.

Signers:

Stuart Altman
Dean and Sol C. Chaikin Professor of National Health Policy
Heller School for Social Policy and Management
Brandeis University

M. Gregg Bloche, MD, JD
Professor of Law
Georgetown University
Non-Resident Senior Fellow
The Brookings Institution
Adjunct Professor
Bloomberg School of Public Health
Johns Hopkins University

Nicholas A. Christakis, MD, PhD, MPH
Professor
Department of Health Care Policy
Harvard Medical School
Department of Sociology
Faculty of Arts and Sciences
Harvard University

David Matchar, MD
Professor of Medicine
Director, Center for Clinical Health Policy Research
Duke University Medical Center

E. Richard Brown, PhD
Professor of Health Policy
UCLA School of Public Health

Henry J. Aaron
Senior Fellow, Economic Studies
The Bruce and Virginia MacLaury Chair
The Brookings Institution
Paul Weiler
Emeritus Professor of Law
Harvard Law School

Elliott S. Fisher, MD, MPH
Professor of Medicine and Community and Family Medicine
Director, Center for Health Policy Research
Dartmouth Institute for Health Policy and Clinical Practice.

Harold Pollack, MPP, PhD
Faculty Chair, Center for Health Administration Studies
Associate Professor
School of Social Service Administration
University of Chicago

Lainie Friedman Ross, MD, PhD
Carolyn and Matthew Bucksbaum Professor of Clinical Ethics
Professor, Departments of Pediatrics, Medicine, and Surgery
Associate Director, MacLean Center for Clinical Medical Ethics
University of Chicago

David Blumenthal, MD, MPP
Director, Institute for Health Policy
Physician, Massachusetts General Hospital
Samuel O. Thier Professor of Medicine
Harvard Medical School
Professor of Health Care Policy
Harvard Medical School

Theodore Marmor, PhD
Professor Emeritus of Public Policy and Management
Professor Emeritus of Political Science
Yale School of Management

Barbara Starfield, MD, MPH
University Distinguished Professor
Johns Hopkins University

Paula Lantz, PhD
Professor and Chair
Department of Health Management and Policy
University of Michigan

Mark Schlesinger, PhD
Professor of Health Policy
Yale University

Nancy L. Keating, MD, MPH
Associate Professor of Medicine and Health Care Policy
Harvard Medical School

Gerald F. Kominski, PhD
Associate Dean for Academic Programs
Professor, Department of Health Services
UCLA School of Public Health

Diane S. Lauderdale
Associate Professor
Department of Health Studies
University of Chicago

David Cutler
Otto Eckstein Professor of Applied Economics
Harvard University

Einer Elhauge
Petrie Professor of Law
Director, Petrie-Flom Center in Health Law Policy
Harvard Law School

Kathleen A Cagney
Associate Professor
Department of Health Studies
University of Chicago

Ronald S. Sullivan Jr.
Clinical Professor of Law
Director, Harvard Criminal Justice Institute
Harvard Law School

Henry J. Steiner
Jeremiah Smith, Jr. Professor Emeritus
Harvard Law School

Martha Minow
Jeremiah Smith, Jr. Professor
Harvard Law School

Jerry Mashaw, PhD
Sterling Professor of Law and Management
Yale University

Laurie Zoloth, PhD
Director, Center for Bioethics, Science and Society
Director, Brady Program in Ethics and Leadership
Professor of Medical Humanities and Bioethics
Feinberg School of Medicine
Northwestern University

Dayna Bowen Matthew
Associate Dean of Academic Affairs
Professor of Law
University of Colorado School of Law

Elizabeth Bartholet
Morris Wasserstein Professor of Law
Faculty Director, Child Advocacy Program
Harvard Law School

Ellen Meara, PhD
Department of Health Care Policy
Harvard Medical School

Donald E. Fry, MD, FACS
Professor Emeritus
Department of Surgery
University of New Mexico School of Medicine

Mark E. Courtney
Ballmer Endowed Chair for Child Well-Being
School of Social Work
University of Washington

Jacqueline Fox
Assistant Professor
School of Law
University of South Carolina

Oliver Oldman
Learned Hand Professor of Law, Emeritus
Harvard Law School

Jane Loewenson
Partner
Nueva Vista Group LLC

Laurence H. Tribe
Carl M. Loeb University Professor
Harvard Law School

Thaddeus Mason Pope, JD, PhD
Visiting Professor, Widener University School of Law
Senior Scholar, Thomas Jefferson University Medical College
Assistant Professor of Law
University of Memphis School of Law

Mervin Shalowitz, MD Visiting Scholar
Kellogg School of Management
Northwestern University

Barbara A. Noah
Associate Professor
Western New England College School of Law

William Pitsenberger
Adjunct Professor, Health Law and Policy
Washburn University School of Law

Philip J. Rosenthal
Professor
Department of Medicine
University of California, San Francisco

Sarah-Anne Schumann, MD
Clinical Associate
Department of Family Medicine
University of Chicago Pritzker School of Medicine
Chicago Family Health Center

Daniel H. Lowenstein, MD
Professor of Neurology
Director, Physician-Scientist Education and Training Programs
University of California, San Francisco

Jonathan Skinner, PhD
Professor
Dartmouth College & Medical School

Robin Henry Dretler MD, FIDSA
President
Infectious Disease Specialists of Atlanta

Laurel Coleman, MD, CMD, FACP
Physician
Augusta, Maine

Ann M Labriola, MD
Associate Professor of Medicine
Division of Infectious Diseases
Department of Medicine
George Washington University Medical Center

Jens Ludwig
Professor of Social Service Administration, Law, and Public Policy
University of Chicago

Norman Daniels
Professor of Ethics and Population Health
Harvard School of Public Health

Donald H. Taylor, Jr. Ph.D.
Assistant Professor of Public Policy
Duke University

Colleen Grogan
Faculty Director, Graduate Program on Health Administration and Policy
Associate Professor
School of Social Service Administration
University of Chicago

Leon Wyszewianski, PhD
Associate Professor
Director, Executive Master's Program
Department of Health Management and Policy
University of Michigan School of Public Health

John Henning Schumann, MD
Section of General Internal Medicine
MacLean Center for Clinical Medical Ethics
Human Rights Program
University of Chicago

Michael Pine
Lecturer in Medicine
University of Chicago

Wade S. Smith, MD, PhD
Professor of Neurology
University of California, San Francisco

Keith W.L. Rafal, MD, MPH
Assistant Clinical Professor
Brown University Medical School

Bob Arnold
Professor of Medicine
Leo H Criep Chair in Patient Care
Chief, Section of Palliative care and Medical Ethics
University of Pittsburgh

James Tulsky, MD
Professor of Medicine and Nursing
Duke University

William M. Altman, JD, MA
Senior Vice President of Strategy and Public Policy
Kindred Healthcare, Inc.

Rebekah E. Gee, MD, MPH
Robert Wood Johnson Clinical Scholar
University of Pennsylvania

Clarissa K. Wittenberg
Health Education Consultant

Jason Block, MD
Physician
Brigham and Women's Hospital

Harlan M. Krumholz, MD SM
Harold H. Hines, Jr. Professor of Medicine
Yale University

S. Claiborne Johnston, MD, PhD
Professor of Neurology and Epidemiology
Director, Stroke Service
University of California, San Francisco

Richard Kronick
Professor
Department of Family and Preventive Medicine
University of California, San Diego

Maggie Czarnogorski, MD
George Washington University
Carl Vogel Center, Medical Director

Howard P. Forman MD, MBA
Professor of Diagnostic Radiology, Management, and Public Health
Lecturer, Economics
Director, Yale MD/MBA Program and Yale MBA for Executives: Leadership In Healthcare
Yale University

William Terry, MD
Brigham and Women's Hospital

Rahul Rajkumar, MD, JD
Physician
Brigham and Women's Hospital

Frederick A Masoudi, MD, MSPH
Associate Professor of Medicine (Cardiology)
Denver Health Medical Center
University

David A. Richardson
Health Care Consultant

Helen Levy, PhD
Research Assistant Professor
University of Michigan

Robert Burt, JD, MA
Professor
Yale Law School

David B. Wilkins
Kirkland & Ellis Professor of Law
Director Program on the Legal Profession
Harvard Law School

Gene Webb, PhD
Manager of Planning
Biological Sciences Division
Pritzker School of Medicine
University of Chicago

Nikhil Wagle, MD
Physician
Brigham and Women's Hospital

Clifford E. Douglas, JD
Executive Director, University of Michigan Tobacco Research Network
Adjunct Lecturer, University of Michigan School of Public Health
Senior Policy Fellow, Michigan Public Health Institute

Thomas G. McGuire
Professor of Health Economics
Department of Health Care Policy
Harvard Medical School

Robert A. Berenson, MD
Senior Fellow
The Urban Institute

Stanley S. Wallack
Professor
Heller School for Social Policy and Management
Brandeis University

Charles J. Ogletree, Jr.
Jesse Climenko Professor of Law,
Harvard Law School

Jon Klein, MD, PhD
James Graham Brown Foundation Endowed Chair in Proteomics
University of Louisville

Sara Rosenbaum
Chair, Department of Health Policy
Harold and Jane Hirsh Professor of Health Law and Policy
Professor of Health Care Sciences
George Washington University

John C. Coates IV
John F. Cogan, Jr. Professor of Law and Economics
Harvard Law School

Peter J. Hammer
Professor of Law
Wayne State University Law School

Meredith B. Rosenthal, PhD
Associate Professor of Health Economics and Policy
Department of Health Policy and Management
Harvard School of Public Health

Barron H. Lerner, MD, PhD
Professor of Medicine and Public Health
Columbia University

Lucian L. Leape, MD Harvard School of Public Health

Kasturi Haldar
Charles E. and Emma H. Morrison Professor
Department of Pathology
Northwestern University

"There is simply no factual basis for the assertion that an individual mandate, by itself, would result in coverage for 15 million more Americans than would robust efforts to make health care more affordable and accessible."

This is the study? This is the work of 100 experts? Did they do an analysis?

Note that the study that did the analysis is dated January 28, 2008, the 100 experts claiming there is no factual analysis signed the document 2007, before there was an analysis.

The issue is him putting out a hit piece on Paul Krugman

This is the issue? The relationship between a leading candidate and a New York Times columnist? Seriously?

This is also an interesting understanding of the phrase "hit piece."

Hey Healthcare Expert
Just post the damn link asshat.

Did you notice that your experts signed a letter refuting a claim that critics of the Obama plan are not making?
"The inaccurate claim that an individual mandate alone would reduce the ranks of the uninsured by 15 million"

Multiple posts, and still nothing to refute my point that the problem many of you face is that it's not about any one bit of information but the totality. You are all good at arguing the trees , it's the forrest thats the problem.

JimPortlandOR gets to the real issue: "Carping over 'the mandates' now is just silly. A solution will be may arrived at legislatively."

nothing remotely acceptible will pass unless dems pick up ~5 seats in the senate
therefore unless you believe 'no plan' is better than 'not you plan' the real path to healthcare reform of any kind is to nominate the one who will bring in or at least not prevent such a senate pick up
i zm inclined to think Obama wins on that score

McCain will pummel Clinton on mandates. It will be easy for him to make the case that mandates are an example of an intrusive coercive federal government, especially given the imposition of penalities. And would any Congress we are likely to have be able to impose them against the forces of private interest and a united disciplined Republican Party?

Thanks for having this discussion and for providing a platform for arguments that very effectively smack down the concept of an individual mandate.

"Running the numbers" to justify using an individual mandate is absurd. Real life is a lot more complex than that.

I don't want to repeat the points made above but I'll add a few that have developed over 20 years. This perspective comes from having a chronically ill sister whose suffering was made much worse by our "non-system", and from being as a nurse and health reform activist for 15 years.

Observation 1: Years of settling for piecemeal incremental reform bills passed on both the state and national levels have perpetuated the country's health care crisis by leaving our hugely dysfunctional wasteful greed-infested non-system in place and unreformed.

Observation 2: Commercial insurance products = need for profits = care denied.
Market-driven provider services = provision of unnecessary care that wastes resources and carries avoidable risk and drives down quality. These are the hallmarks of U.S. healthcare and it's disgusting, immoral and a disgrace.

Observation 3: Incremental reforms have their place but only if they are part of a broader vision of fundamental system reform that is clearly articulated, on track, and actively worked toward.

Observation 4: Incremental reforms make sense and are often widely supported (here in MA, CA, Federal level such as SCHIP) if they help position further reform instead of heading us in the opposite direction.

Observation 5: Piecemeal changes should be stopped if they will actively harm many in need and will make it harder to achieve the other reforms required to address and remedy the causes of our badly broken system. Cases in point:

- An individual mandate law that forces people of modest means to purchase expensive crappy insurance with high deductibles and co-pays. (see the Mass. Plan for more details)

-- A health law with a funding mechanism that willfully chooses to not address the pervasive waste and profiteering in the health care industry. This worsens the high costs that are already breaking the budgets of countless individuals, families, small and large businesses, and public budgets at all levels of government. (see Mass. Plan for more details)

Observation 6: As you all know, health system reform is a life and death issue for many. Life, and prevention of seriously disabling illness, should trump political expediency and political payoff.

Observation 8: Principles matter. Right and wrong matter when it affects whether thousands each year will live well or will suffer and die. It is not a matter of "the perfect being the enemy of the good". That's cowardly and defeatist. Not everything should be open to "compromise". Compromise is wrong if it enables the cause of such enormous and preventable suffering, if it enables what is bankrupting our families, our businesses, our public budgets, and if it enables the cause of what is immoral.

My activism on this issue began 25 years ago when my sister developed schizophrenia. She became horribly ill and needed to be hospitalized. On the day her private insurance coverage ran out McLean Hospital discharged her, still actively psychotic, undergoing medication adjustments, and in need of their services and care. That event was just the beginning of her "troubles with the system" and our family's long fight to get her needed care and medication.

Our mother depleted every cent of her savings to try and pay for care that was needed but that "the system" denied. This same kind of thing happens every day to countless patients and families.

Individuals mandates won't help and in fact they would make prospects for real reform a lot worse. Let's put our collective focus and energy where it will make a major impact. Let's empower Obama - or whomever is the Democratic Nominee - to fight for Improved Medicare For All.

McCain will pummel Clinton on mandates. It will be easy for him to make the case that mandates are an example of an intrusive coercive federal government, especially given the imposition of penalities.

And he would be correct. If he were not, McCain would not get any traction and you would not be afraid of McCain's response.

The mandate is not working in Massachusetts. It is, however, traumatizing many working families and increasing resetment against government. The Bay State's "health reform law" has done nothing to control rising medical costs. The program is already $400 million over budget. Additionally, we are seeing increasing cost shifts and dilution of insurance coverage. Taxes to support Chapter 58 are already on the rise. The California legislature was prudent in rejecting a similar fiasco. It is only a matter of time before the Massachusetts scheme totally implodes.