Policy aside I'm still not sure why anyone thinks mandates will work politically.

I don't like the combination of mandates and relying on competition to keep prices low. They seem to be at odds with one another IMO.

I'm a single-payer supporter (actually, I think it's single-payer or economic death..it's that dire), who doesn't like mandates as a part of THIS go-around for reform.

Second, single payer, which so many folks love, is a mandate by a different name. That name is taxes.

I may be alone in this, but the difference between the two is important to me. The government has a right to take taxes from me -- it's pretty rare to find Americans who are against that. It's harder (in my mind) to say that the government has the right to make me purchase something.

But the problem with mandates -- structured as mandates rather than as general taxes -- is that they focus the pain on a small group of people who will be outraged.

We are seeing this in Massachusetts. The majority of people see no change in their health insurance or financial situation. They keep getting health insurance from work or wherever they've been getting it from.

But there are a small number of people who suddenly have a new $6,000 per year or $12,000 per year bill to pay. Those people are the makings of a political catastrophe.

You can't institute mandates without (a) cost savings, and (b) some kind of fundamental restructuring of the way everyone pays for healthcare, so that the visibility of the pain and the visibility of the cost is similar for everyone.

Nice arguments for mandates per se...

but if you define mandates that broadly, fire-department taxes are not analogous to Clinton-style mandates. It's different when the mandate includes purchase from a private, for-profit entity.

Private insurers are currently a big part of the overriding inefficiency in US health care. I find it hard to see how mandates to buy private insurance fundamentally address that inefficiency. And electronic medical records can only take us so far.

Ultimately, an Obama-style plan may not address the inefficiencies either---but his re-insurance plan at least tries to address the issue from the back end by limiting the risk that insurers can claim.

I tend to agree that the problem here isn't mandates as policy, it's mandates as politically unattractive. I think none of this looks attractive unless people feel comfortable with what they're getting out of the bargain... hence, you se people who struggle without insurance, or who have fought insurers over medical care, or otherwise dealt with the systems in favor of mandates, whereas healthy people and the well insured wonder why they're needed. It's not that people don't want to pay for fire departments or the police... but they will wonder if we need quite so many police or fire depts. or why they should be paid quite so much. As long as people don't understand why we need more universal coverage or universal access to care, "mandates" look big, scary, expensive, and unworkable. And, I've said all along, I think this may be the wrong focus anyway: if we want better healthcare, then let's make that the issue. How we pay for it doesn't necessarily make for a solution.

Now I wait for wisewon to say something pithier far more clearly. :)

Would mandates literally apply to everyone, regardless of individual situation? I mean, if you have income below a certain level, you don't have to pay taxes. If you don't own a car, you need not have car insurance. I'm not sure you actually *must* have a Social Security number. Would Hillary's health mandates be the first thing that is absolutely mandatory? Are we going to hunt down everyone living off the grid, and punish them for not buying health insurance?

The bank mandates insurance as a condition of the loan because it has a lien on the house-that's their security for the mortgage. Are you and Smith suggesting that the government has some sort of lien on our bodies?
Also, isn't being able to make your own decisions about your body(including not getting health insurance) part of the benefits of living in a free country?
I suppose you could argue uninsured people going to emergency rooms imposes externalities on the rest of us, but really those externalities are not nearly as large as forcing me (I'm 24) to pay for the healthcare of a bunch of old sick people (which is what a mandate would do).

jamie, you already pay "for the healthcare of a bunch of old sick people..." it's called Medicare.

It's different when the mandate includes purchase from a private, for-profit entity.

I mean,

It's different when the mandate includes purchase from a private, for-profit entity.

!

Also, isn't being able to make your own decisions about your body(including not getting health insurance) part of the benefits of living in a free country?

Shouldn't not getting sick and dying so your government can enrich a handful of insurance companies be part of the benefits of living in a free country?

That's why we force everyone to pay into fire departments through taxes.

Right - and don't forget POSS.
[Plain ol' Social Security]...
Actually does work as a buffer
for the spendthrift & improvident....
[Can be an actual 'lifesaver'.]

"Like for me", he murmured
ashamedly..., too

Here's a problem I foresee:

The cost-saving benefits of mandates will be politically more popular than the subsidies and the various other programs that will make it affordable for everyone.

It is like those who advocate "free trade and displacement aid/job training."

It turns out that the free trade gets passed and the job re-training goes out the window.

Put it this way, if Clinton is given the opportunity to get the mandate plan passed WITHOUT the subsidies and tax cuts that will make them affordable, will she take that deal?

I am guessing...yes.

The issue of single-payer health care and mandates should be separated. You can have either one without the other, though, of course, it's very natural to have mandates if you have a single-payer system.

But it could be that everyone pays for health care without being required to carry it.

Conceptually there just isn't the connection you claim.

That said, policy-wise, mandates vis a' vis health care are very important. (And vis a' vis flu shots.)

If only Obama hadn't listend to David Cutler (or whomever advised him), 9/10 of the progressives who now abhor mandates would have thought it was a great way to break the impasse and finally get universal coverage. It's hard to find anyone on the left making the arguments that are now commonplace before Obamania. Sure, there were arguments for single payer and against any role for health plans, but try to find progressives arguing that people shouldn't be forced to purchase things that are good for them, like health insurance or car insurance, etc. In particular, try to find progressives make the automatic assumption that the subsidies offered as part of a mandate plan for the working poor would be inadequate and make them worse off rather than better off, as andrew does above. It's a shame the primaries have damaged this policy debate so badly, and turned people who otherwise would be supporters against the mandate idea.

If no UHC gets passed in the next 8 years, it will be because we gave up on mandates. And if we give up on mandates, it will be because the left lost its way and fell into bickering on the best approach to UHC, rather than present a united front.

As for the main point of the post, I've been saying for a while now that taxes to pay for health care are mandates by a different name. Not only are we mandated to pay for Medicaid, Medicare, the VA system, etc., but when we do buy something--almost anything--we are mandated to purchase things that meet certain criteria. The vast majority of these mandates have come from the left and been weakened by the right: fuel efficiency in cars, safety standards in food, vehicles, construction, etc. In health insurance, there are currently dozens of mandates at the state and federal level affecting conditions that must be covered, reserve levels, minimum MERs, etc.

Now, technically I don't have to buy any one of these products, but collectively there is no way to escape buying things to which mandates apply, and they do generally tend to raise the price of things.

Mandates in their various forms have been the chief weapons of social progress for the left since the 1930s. Way to miss the point, everybody.

MattD,

"Single payer" is just shorthand for single payer universal health care system. You can separate the two, but does it make any difference for the debates we're now having?

If you outlawed other means of payment for health care, but did not require that everyone join the single payer system, it seems you would be giving them the option to get health care and have it paid for by the system they pay taxes into, or pay their taxes and then pay again out of pocket for your healthcare if they're even allowed to purchase it independently at all.

Not much of a choice.

My concern with mandates to buy private insurance is that the mandate may end up being one-way. In other words, I will have to buy insurance, but the insurance company will not be required to cover my medical expenses. The reason I don't have insurance now is that they won't cover any of my pre-existing conditions, which are obviously my most likely medical needs. The current mandate plans seem to address this issue, but will they still have those provisions once the bill is passed? Probably not. We have seen many times before that the interests of the pharmaceutical and insurance industries are always met before the interests of the people. How will it be different this time? To make mandates palatable to me, the pre-existing condition ban must be passed in a separate bill BEFORE the individual mandate is passed. Otherwise, it will just be stripped in the House-Senate conference.

First of all, thank you JD. You nailed it. This division among the Democrats over mandates has been so artificial – and so unnecessary -- from the beginning. Obama, because he was truly green in judgment, bought bad advice on trying to distinguish his healthcare position from Edwards' and Clinton's by sidestepping mandates for the 19 to 64 population.

Notice what I just said: for the 19 to 64 population.

Yes, most of you people who have posted above who Obominate mandates -- for political, libertarian, holding out for the Parousia of single payer, or whatever other reason -- it may come as a shock to you, but Obama has mandates in his plan – mandates for the

Have you ever even taken the trouble to read Obama's health care plan? Here's the link. Better yet, here's the exact wording from the plan.

"(4) MANDATORY COVERAGE OF CHILDREN. Obama will require that all children have health care coverage."

Now, explain to those of us who noticed this a long time ago, how Obama's scorched earth policy on Clinton's mandates during the campaign is going to survive the general election onslaught of John McCain, who doesn't believe in any kind of mandates, not even for kids? He will be touting the magic of tax credits and healthcare savings accounts (HSAs) – and spouting the kind of nonsense that some people in this blog have been spouting, namely:

McCAIN: My friends, mandates of any form will fail until we have brought down the cost of healthcare. That is where we must begin, not with unenforceable mandates.

Obama is like a sheep heading to a new Harry and Louise slaughter on this issue. Indeed, the Republicans will be able to simply pick up the Harry and Louise redux attack brochures on mandates he floated against Clinton in the campaign and use them against him. All because he didn't think the issue through clearly at the front end. So sad.

I happen to think he will still get elected, but not for any of his genius policy proposals. And he is even already outmaneuvered on Iraq.

The principal reason he'll get elected is because there will be a perception that the economy really sucks. In my view the actual state of the economy won't be quite as bad as it is perceived to be. But the perception that it is really in the toilet will be a sufficient reality to get a Democrat elected.

But not without the well having been thoroughly poisoned for any material kind of healthcare reform. It's really a shame.

By the way, for all of those whose big objection to having mandates is that it would just drive more business to the private healthcare insurance companies, do your brain a favor and go read Obama's plan and Clinton's plan too. Each has a public option for insurance which, if set up properly, over time will take more and more business away from private health insurers, who simply won't be able to compete on a cost basis.

This is all Healthcare Economics 101. And with Google and the Internet out there it should not be necessary to go over this point – especially in a blog like this, one whose blogger-in-chief (rightly) prides himself on being a healthcare wonk.

But, alas, it appears to be necessary to repeat these sorts of basic facts over and over and over again. Only to find someone five minutes later reminding us all what a political genius Obama is for not having mandates in his healthcare plan.

fostert,

I won't be able to allay your fears, but I can point out the following:

The insurance industry knows...it really, really knows...that if people are going to be required to buy their products, or if people are going to be given the choice of buying their products or a Medicare-like alternative, then they are going to have to change their business model somewhat and they are going to have to accept some additional regulation.

One essential change will be guaranteed issue. No insurer will be able to reject an applicant (unless we create a system in which some people with extremely bad health are put into a public system, as New York's managed Medicaid program does with premature babies). That is not negotiable, and insurers know it.

The issue of medical expense ratios is also one that everyone is aware of. In CA, a medical expense ratio of (I think) 85% was built into the UHC bill that was just considered. The only health plan that opposed it was the one that had an MER of less than 85%. On a national level you'd probably have to start lower--say, 80%--and build in a gradual climb--say, 1% every two years until it hit 90%.

Insurers could deal with this more readily if we build more standardization into the benefits and payments, reducing some of the friction in the system and the need for admin to handle it. Also, they will want to be able to include expenses for disease management and wellness as medical expenses rather than administrative expenses. But the main way they'd deal with it is by merging, I think. At this point, most of the mergers would have to occur among non-profits because there are only a few for-profits left that could merge without anti-trust issues.

"If only Obama hadn't listend to David Cutler (or whomever advised him), 9/10 of the progressives who now abhor mandates would have thought it was a great way to break the impasse and finally get universal coverage. It's hard to find anyone on the left making the arguments that are now commonplace before Obamania. "

The reason why people are having detailed discussions about health care expansion is because it wasn't a very real possibility the way it is now. So, lots of people weren't talking about lots issues related to healthcare before now (mandates included).

I think that very few people know the exact etiology of Obama's plan. But I think that almost every liberal (maybe I'm wrong; correct me if you think I am) thinks that universal mandates with adequate subsidies and universal access to Medicare is a superior plan, if enacted, to the one Obama is putting forth. And nearly all liberals think that single-payer is better than either Obama's or Clinton's proposals.

So the debate is over how one moves toward the goal of a single-payer system. Why aren't many people upset (some are, but most aren't) that Clinton and Obama aren't pushing single-payer? It's not because liberals don't want it. It's because we don't think we can get there in one step, and getting part-way is better than staying where we are. The question now is with respect to how far we should move in this first (for many years) step.

(I would like to include myself in those who complain about the posting system on TAP blogs. You not only have to enter the non-spam letters, but frequently the site says that you didn't enter them correctly when you did. It's very cumbersome and unique among any of the dozens of blogs I read.)

JD:

""Single payer" is just shorthand for single payer universal health care system. You can separate the two, but does it make any difference for the debates we're now having?

If you outlawed other means of payment for health care, but did not require that everyone join the single payer system, it seems you would be giving them the option to get health care and have it paid for by the system they pay taxes into, or pay their taxes and then pay again out of pocket for your healthcare if they're even allowed to purchase it independently at all.

Not much of a choice."

*De facto*, you're right. But EK's point was, I think that there was some sort of entailment between single-payer and mandates and there's not, at least not conceptually.

But when we do get single-payer, there will be mandates.

(I'm reminded of the SNL skit (from memory, which I'm very sure is off in the phrasing)):

Reporter to Bush: You've just clearly won the election. Based on what you've accomplished, will you have mandate?

Bush: (Sputtering) Oh, no. No. I haven't done that in years.

Wow, this is a seriously weak brew. Single payer is the same thing as a mandate to buy private insurance? That's absurd.

As to mandates more broadly, I think the argument from Obama supporters is mostly "the two plans are mostly similar, neither is going to be enacted as written, and Clinton's plan doesn't have an effective enforcement mechanism, anyway, so why on earth should anyone decide their vote based on that?"

MattD, I accept the conceptual point to an extent. Any single payer system I've ever seen has mandates for the financing of it (taxpayer dollars). It might not have mandates for receiving your care through it, but generally it's a bad idea to opt out for the benefits when you've already paid in.

But the mandatory participation in the funding of it is primarily what Ezra and I were talking about.

JD- Do the insurance companies really know that they have to accept new regulation? I'm not sure. They obviously will have to give the APPEARANCE of accepting new regulation. But a few changes to some obscure clauses in the House-Senate conference could gut the new regulations with nobody noticing. How many people actually compare the bill that comes out of conference to the original bills? Pretty much nobody. But if the insurance companies really are willing to accept new regulation, then let's call them on it. Pass the regulations first. I can guarantee that if the regulations pass, the insurance companies will force Congress to pass the mandates very quickly afterwards. I've just been screwed by the insurance companies too many times to trust them anymore.

John, nobody said, "Single payer is the same thing as a mandate to buy private insurance." The observation was that single payer schemes also include a mandate (to pay for UHC through taxes). So, if an objection is made that mandates are bad because they force people to pay for health coverage they don't want or need, then single payer is bad too.

The same problem arises if you argue that mandates are bad because some people can't afford them. If I pay an extra $2,000 in premium or in taxes, it's still $2,000. You can't assume that a taxation system would be more progressive (in the narrow, tax sense) than a subsidy system for insurance purchases.

The basic point is that there are arguments for single payer, but carping on the mere existence of a mandate to purchase health care coverage is not one of them.

Massachusetts resident here.

There are people in this commonwealth who are now being fined for not having health insurance, and still can't afford it.

As opposed to single payer, where you are guaranteed coverage.

That's a pretty big difference.

If I pay an extra $2,000 in premium or in taxes, it's still $2,000.

If you're Rational Profit-Maximizing Economic Man, maybe.

If you are a member of species homo sapien, not so much.

fostert,

I work in the industry at a mid-level position that has a strategic dimension which requires me to keep up on policy developments and industry trends. I also happen to know a few people in the C-suite both at my company and others fairly well. I can tell you, unequivocally, that the industry on the whole knows that they will have to accept new regulation. More than that, the industry will advocate for new regulations.

Here is a recent statement from AHIP:
third party review of rescissions
Expect to see more like this soon.

I don't expect your trust to be renewed by what I'm saying. But I do recommend not assuming the worst. I think you and other progressives will be surprised by what the industry does in the next 2-3 years. So much so, that you will soon forget how low your original expectations were. Instead of being pleased that the industry endorses guaranteed issue (to take a hypothetical example) you will soon be angry at it for only accepting a version of it that limits their risk with reinsurance, or whatever.

joe,

Whether you maximize expected utility or behave according to prospect theory, $2,000 is still $2,000. How you perceive it may change depending on the description, but if you've only got $1,000 in the bank and have to pay $2,000, you're just as broke no matter what kind of (quasi) rational agent you are.

Money going to private insurance, plus a fixed premium, feels different from a %age withholding.

It just does, regardless of whether it's 6% or 10%, because a) it's money you never had in the bank; b) it means, more or less, that the money you do have in the bank (or, more likely, your credit limit) doesn't come out through to pay for healthcare..

My objection to a partial mandate is that if you're going to deal with healthcare, you deal with it properly: you're going to invest enough money into it, presumably, that you might as well go the whole fucking hog.

My objection to a mandate that's arranged as a premium is that, in complete honesty, soaking the rich to get UHC doesn't bother me in the slightest. They don't like it? Tough shit.

"maybe single payer is a better way to structure the mandate. But it's a mandate nevertheless"

Tax-financing, which is what you are pointing to, does make more sense than a mandate, as a way of closing the health insurance gap.

'Now, maybe single payer is a better way to structure the mandate. But it's a mandate nevertheless.'

This is the trap that many policy people fall into. They note that $2000 is $2000, so what does it matter how it gets paid. Well, it does matter. It matters a LOT.

There is powerful psychology behind money. People will threaten to boycott gas stations for selling $3/gal gas but will spend $2 to buy half a liter of tap water each day.

A mandate is an added demand by the government for money. Further, it is itemized - it is money ONLY for healthcare, even if you didn't get sick at all in the last year. By making it a tax, it's not an added demand (since we already pay taxes) and it gets lost in among all of the other things the government spends money on. Psychologically, it's a huge difference for citizens. But it's also easier to sell. Telling people that their taxes will go up isn't a radical thing. It happens all the time. Telling people that they'll get free healthcare (or some approximation thereof) in exchange for that makes it a fairly easy sell compared with what previous presidents have had to do.

But another advantage of the tax approach is that we already have a mechanism to process it and to handle all of the boundary cases. That's where the mandate approach always falls apart - it carries a different set of rules for people at the bottom of the income scale that may be incompatible with the tax rules (see Mass).

The real problem for single payer is that an entire industry essentially goes out of business. Good riddance, I say, but politically that's a bitter pill to swallow.

To economists, single-payer and mandates are the same.

To somebody living paycheck-to-paycheck, with a lien on their house and quite possibly having a good portion of their paycheck being garnished, the promise of a tax-credit as subsidy for a premium that they just cannot afford TODAY because they are trying to pay for the life-sustaining prescription medications for their wife, they are entirely different animals.

"There's a reason the bank makes you buy insurance on our -- excuse me, their -- house. "

in this anology, who is the bank(an insurance company) and who is the house(my body)?

Let's be blunt here: the only reason to favor any system that involves the existence of private-sector, for-profit insurers over Medicare for All is that the Insurers are demanding a vig on our health care spending -- if we don't give them a percentage off the top, they'll come back and smash the place up.

It's a racket. We may need to pay the mobsters off to keep them from breaking our kneecaps, but there's no need to dress it up with ridiculous justifications of how the system works better that way.

So the difference between Medicare for All and mandates or a non-mandate system, is the difference between relying on the police that you pay for with taxes to protect your car, and relying on the guys hanging on the corner with crowbars offering to "watch your car for $20".

This is why democrats lose. They always sound like they dont trust the american people.

folks have to be protected from their worst instincts. That's why we force everyone to pay into fire departments through taxes.

Presumably we have to make them vote the right way as well. People who cannot run their own lives cannot be trusted to run everyone elses via control of the government.

The government should compel people to vote for the right Party. Otherwise, they might give in to their worst instincts. You can hardly trust them to think more wisely about what other people should do, than about what they should do.