Although I voted for Obama during the primary here in CA, I do agree with Clinton on this. History and numerous studies have shown that if there is no mandatory system people will not take advantage of the benefits. A classic example is vaccinations. An opt in program for vaccines reduces the number getting vaccines by a very large proportion, thats why we force kids to get them and have an opt-out system instead. Obama seems to be saying that we should have an opt in system with penalties for those who do not opt in. But in reality this will likely not work. What good will it be to send some poor parents a bill for not signing up their kid? They would not be able to pay the penalty, never mind the bill itself. Hillary is right, only a mandatory system with full coverage will achieve the goal of true universal health-care.

Now here is a serious question neither of them has answered, how do we pay for such a system? The US government is 410 billion in deficit this year alone, the only way to pay for this thing is to cut spending on say the Pentagon's budget, or/and to raise taxes.

This exchange, and the NPR show, nicely summarized some of the issues we've discussed on this blog earlier. Without going in depth into some of those disagreements, here is my take.

First, let's drop the mystification. This is not a debate about so-called 'universal' healthcare--not, at least, in any interesting or familiar sense of 'universal'--but about transitional programs that would put us closer to that end goal. As was pointed out by the NRP program, both candidate are proposing a mixed system of public and private coverage where private industry competes in the open market with government subsidized care, under much stricter governmental regulations than currently operate.

Clinton continues to evade offering any details on how she plans to enforce mandates; Obama continues to be equally vague about how, exactly, the backpay provisions would work. Both of these issue loom large both on the financial end of how to pay for a plan, and on how to secure the most coverage for the most people, and I don't think we have the resources to debate them, beyond arm-chair, psychological speculation about how likely certain individuals are to 'game' the system--although at least the NPR host tried to ask if there were historical examples to programs or policy efforts which might be analogous, which is the only thing to my mind that might offer prima facie evidence for any such speculation.

In the end, the issue, to me, comes down to this: Moyers and Jacoby joked around about whether any politician would ever actually tell voters about their own ignorance. Obama did essentially that, insisting that it is important that they be 'educated' about the decisions that are being made on healthcare, and that the process be transparent. As I agree with Obama that Clinton failed--in part--in the '90's by trying to create a healthcare plan through backdoor deals and excluding other democrats, I also agree that transparency and coalition building is huge.

Finally, there is the issue of politics. Clinton flaunts 'mandates' and 'universal coverage': this may be part of a brilliant political strategy which, as she insists, starts with the most ambitious proposal possible, in the knowledge that it will stripped in the process of legislation. Obama is typically careful to avoid this kind of rhetoric, deploying instead the rhetoric of 'choice' and 'responsibility', which may resonate with more independent, left-center, and right-leaning voters. (I do not deny Clinton uses this 'responsibility' rhetoric as well, I'm talking about emphasis). I leave it an open question which, in political terms, is the better strategy: that depends not just on the democratic party but the general voting public at large, and which style of rhetoric they are more responsive to.

The issue I have with the difference in the two plans as I understand them is Obama's just expands SCHIP but doesn't really change much(over simplification). I already pay for health insurance so whether it changes or not won't affect me much but Obama doesn't require someone who can afford health insurance to pay into the system.

I am required to have car insurance even though I've never been in an accident but I have it because it's the law. I would much rather have taken the last 20 years of premiums and gained interest on them instead of paying for all the other terrible drivers out there.

So if I'm a person 20-35 and in decent health what is my incentive to contribute to the system rather than take advantage of it in the rare possibility I need care.

I just see his plan as naive in thinking that people will pay into a plan if they don't have to, unless they are not in that great of health.

This is just my opinion of human nature and I might be completely wrong and it could be that everyone will jump at the chance to have health care. I just don't see it happening and it will continue to be the ones that do pay in will continue to foot the bill for those that choose not to.

The are more concerns I have about his plan vs hers but I think that is enough to get me flamed for tonight.

Moral of story.

Clinton-- " I know policy real well, and love this country."

Obama-- "I am smart, I understand policy, my supporters aren't cultists, and I didn't vote for the war."

The issues distinguishing their healthcare plans from one another, as Obama mentioned, are indeed quite small - they are issues you flesh out when you're actually writing the legislation - they are issues I want eveyone to debate together publicly not during election season but when it's actually getting written. I would rather see Clinton stay in the senate and push healthcare through with her full attention while the Obama presidency forces her to be transparent about it, allowing everyone to participate. If Clinton is the gal that gets things done, leave her in the place where things really get done: the senate. If Obama is the guy that brings people togther, let him rally support for her efforts as the president. In the end, regardless of who is elected president, I expect the resulting legislation regarding healthcare would look very similar. However, eveyone would certainly be better off with a system crafted with transparency. Furthermore, I think Obama is the better suited of these two to keep this kind of transparency feasable by properly mediating the discusion. I simply can't picture Hillary being as effective an arbiter as Obama.

Moral of story. Clinton-- " I know policy real well, and love this country." Obama-- "I am smart, I understand policy, my supporters aren't cultists, and I didn't vote for the war."

Wow thanks. That's very insightful about the two health programs. I think I want to vote Obama now.

You are as bad as senator Kirk Watson.

Now here is a serious question neither of them has answered, how do we pay for such a system? The US government is 410 billion in deficit this year alone, the only way to pay for this thing is to cut spending on say the Pentagon's budget, or/and to raise taxes.

That's my issue with both of them. Neither want to adopt a more isolationist policy in regards to military activity and they both buy into the "American Empire" mentality so the defense budget won't be cut. They will end up cutting social programs to pay for it instead of defense.

Wow thanks. That's very insightful about the two health programs. I think I want to vote Obama now.

Pretty sure that wasn't a persuasion pitch.

My point being, these two don't passionately discuss this small policy difference over and over because they have anything new to say or even because it is relevant.

Clinton does it to prove her superior knowledge of policy.

Obama does it to prove he is not "just words".

Note to self: Sarcasm seems lost on Dar.

Sorry I'm not a big fan of talking points, sound bites or pointless sarcasm.

I'm glad you have an opinion and seem to be working on a career in comedy but it would be nice if you had some substance or at least a rational thought process to back up your opinion on the subject being discussed.

I don't like either plan and know they both would fail to achieve what they keep promising, but Clinton just pisses me off with all the false arguments concerning her opponent's plan - like intentionally leaving 15 million uninsured, and that Forcing people to buy into a private industry for-profit health insurance program with all its inherent conflicts of interest is just like Social Security and Medicare. Really? Is it more like Medicare than Medicare for All, H.R. 676 (www.medicareforall.net)

This healthcare "debate" is going nowhere

Democrats Should Stop Squabbling Over Healthcare Mandates

By Robert B. Reich

Democrats should be celebrating. Their three major candidates have put health insurance front and center on the domestic agenda, and with plans that are remarkably similar. They've done so at a time when the public seems readier than ever before to embrace universal health insurance, and readier to trust a Democratic president to put it into effect. But instead of celebrating, the candidates and left-leaning pundits are squabbling over whether the plans should include so-called mandates that require everyone to purchase health insurance. Talk about self-inflicted wounds. Mandates are a sideshow, and fighting over them risks turning away voters from the main event.

Take a closer look and even the candidates' positions on mandates aren't all that different. John Edwards has proposed to automatically enroll people in health insurance on their tax returns, but has said this mandate won't apply until premiums are affordable. Hillary Clinton says she favors mandates, but isn't sure there should be a penalty for noncompliance. Barack Obama favors an immediate mandate for children, but doesn't include one for adults. He says he's willing to revisit the issue after making health insurance more affordable and enrollment easier, and is also considering an automatic enrollment with an opt-out for those who don't want to be included.

As a practical matter, the difference between Sen. Clinton's and Sen. Obama's approaches come down to timing and sequencing. Mrs. Clinton wants a mandate first, believing that enrolling the younger and healthier will help reduce costs for everyone else. Mr. Obama thinks forcing people to buy health insurance before it's affordable isn't realistic. He wants to lower health costs first, and is willing to consider a mandate only if necessary.

I'm glad you have an opinion and seem to be working on a career in comedy but it would be nice if you had some substance or at least a rational thought process to back up your opinion on the subject being discussed.

Sorry if I don't feel its necessary to write 1,000 words on a policy minutia that in the end of the day is just a vehicle for these two candidates Messages. And really that's all this is. They aren't talking about Healthcare mandates because that is the biggest difference between the two or even because it will make a lick of difference once one of them is president.

If Norm feels then need to have a minimum word requirement for all posts, I will do my best to abide.

Until then, lighten up.

By the way, Adam, I appreciate all of your well-thought-out posts which few people respond to for some reason. ;) I guess it's easier to get involved in personal attacks.

Susceptor said

Now here is a serious question neither of them has answered, how do we pay for such a system? The US government is 410 billion in deficit this year alone, the only way to pay for this thing is to cut spending on say the Pentagon's budget, or/and to raise taxes.

This is a very serious question that I've been wondering about. The per capita cost of health care here in the U.S. is higher than the per capita cost in countries with universal health care. However, neither Obama nor Clinton have addressed all of the many issues involved with said systems such as single-payer, lawsuits, doctor's salaries (which are in part high because of lawsuits and the exhorbitant cost of a medical degree) etc etc. All we're talking about is mandates.

Isn't health care free in jail?

Thank you for your kind remarks JoAnn (the appreciation is mutual :).

I think you and Susceptor raise an important point on funding. Just to add a little too it: the social health scholar on the NPR raised a good point about how some of the initiatives both are talking about to fund their policies, such as modernizing records, will not help initiate the policy (because federal 'pay-(as-you)-go' constraints on new spending), and only make a minimal contribution to sustaining it. That should make it even more worrisome, I think, where exactly they're going to get the funding to do this.

Another issue I'm curious about, which was raised by the healthcare in Canada article norm posted a couple weeks ago, is that doctors now must hire a number of assistants, some of whom are pretty much devoted simply to calling up different insurance providers, and haggle with them over coverage details. As the article points out, this is a huge source of expense--and so long as there is an open-market system with many competitors, rather than a single provider such as the government which approves almost everything, I don't see that problem going away.

Another issue I'm curious about, which was raised by the healthcare in Canada article norm posted a couple weeks ago, is that doctors now must hire a number of assistants, some of whom are pretty much devoted simply to calling up different insurance providers, and haggle with them over coverage details. As the article points out, this is a huge source of expense--and so long as there is an open-market system with many competitors, rather than a single provider such as the government which approves almost everything, I don't see that problem going away.

You have once again put your finger on the major roadblock. However, Americans equate "single payer" as being "socialist". However, what they don't understand, is that even under our current system, Doctors have to deal with insurance companies re what is covered.

I'm voting for candidate A, because candidate B is too much like candidate C.

The Reich article is superb (and to say it again: the "mandates" issue is a red-herring).

He has another article on his blog that discussing financing health care and other so-called "entitlement" programs in more depth:

http://robertreich.blogspot.com/2008/02/david-brooks-is-wrong-america-can.html

Here is one very important point:

1. Finally, the next president will need to wean the public off the false notion that fiscal austerity is necessarily good for the economy. There's a crucial difference between public spending that builds the future productivity of the nation's workforce -- spending on education and infrastructure, for example -- and spending that improves today's living standards. Borrowing in order to accomplish the former is wise because it enhances the capacity of the nation to produce goods and services, and thereby shrinks both the deficit and debt as percentages of the total economy. By analogy, while it makes no sense for a family already in debt to borrow more money to finance a cruise, it makes eminent sense for it to borrow more in order to send a child to college. This obvious point should be illustrated in the annual budget. Such "investments" should be segregrated from ordinary spending. Annual spending should not exceed annual revenues, but investments should be judged by their potential for growing the overall economy. If the returns to the economy in terms of economic grow are greater than the costs of such borrowing, these public investments are appropriate.

Bullet point review:

1. Both plans involve mandates

2. Both plans are corporate/government hybrids

3. Both plans seek to resolve the issue at hand

4. No one has clearly explained how they will pay for this

I agree with Adam when he questions what exactly either candidate intends to do when it come to enforcing mandates.

I think Dar makes a great analogy with car insurance. He is forced to pay for the mistakes of others. Why shouldn't healthcare work the same?

However, this difference in opinion is the reason I side with whichever candidate has less proposed mandates. I don't think it is fair for Dar to pay for the mistakes of others. I think if Dar chooses to risk the out of pocket expense of a car accident, he should be allowed to. Ditto health insurance.

My question to the experts: which plan will reduce health costs more? Why?

Moore took a shot at both candidates plans

http://thehill.com/leading-the-news/michael-moore-says-insurance-industry-would-love-clintons-healthcare-plan-2008-02-22.html

Adam, thank you so much for your summaries above. I've heard so much noise about this issue; it's immeasurably helpful to get some signal.

I think Dar makes a great analogy with car insurance. He is forced to pay for the mistakes of others. Why shouldn't healthcare work the same?

I too found this analogy thought-provoking. I'll have to think about it some more, but I myself don't endorse it. I read an article--can't seem to find it now, I'll keep looking--that said around 17% of drivers on the road are not insured. If we are using car-insurance as the model for how mandates are supposed to work, it doesn't make HRC plan look much better than Obama's. She's caught between a rock and a hard-place on this, I think: if the mandates are punitive, then they are counter-productive when enforced against low income earners. If they aren't strong enough, they are unlikely to prevent anyone from opting out. This is why it matter that she doesn't explain the enforcement issue. That is also why you have to bring cost down first, IMO.

But again, I think the mandates issue is about rhetoric, not policy, and it nicely demonstrates Obama and HRC's respective strategies of political will formation. HRC puts a plan on the table that is bold, in your face, and unmistakably leftist, using the jargon of 'universality' and 'mandate': the advantage is , putatively, that by the time it gets stripped down and gets through the legislation fight something worthwhile will be left over. Let's call this: "The in-your-face strategy".

Obama's strategy is simply different, not 'naive'. He uses the jargon of 'responsibility' and 'choice'; this has a better chance, IMO, of undermining absurd attacks about "socialism" and Big Brother by essentially co-opting (a mild version of) right-wing rhetoric and buzz words in the service of a leftist plan that differs from Clinton's only in packaging but not substance. Let's call this, "I have just undercut your entire line of attack" strategy. The idea isn't to avoid a fight--that is inevitably in any case, it seems to me--it is to de-fang the opposition before it can even lodge an objection.

I have to agree that the plans presented by Obama and Clinton are not that far apart. The only thing to debate is that little difference on mandates, so that's where they go at it. The debate really just gives a little practice the Democratic nominee when it comes time to debate McCain. In part, that leads me to disagree that the Dems are shooting themselves in our collective feet by debating the issue.

I had the opportunity to hear both Nancy Kassebaum-Baker and Gary Hart speak at Des Moines's global impact 08 meeting this fall. Both were brilliant, and both supported the notion of the danger of candidates laying out every detail of how they would accomplish their aims. Such a tendency can only lead to future scrutiny when the details weren't carried out as stated. Better to be the the one who brings folks together out in the open and gets the job done.

Hmmm I have a question, no doubt I would rather my tax dollars go to help a sick kid in the hospital or a grandma, as opposed to my tax dollars being dropped in the form of bombs on iraqi civilians, but why couldnt we just get rid of the personal income tax, and start taxing corporations more like the constitution originally intended for? Then we could pay for health care for all without taxing the people, or make some sort of system that the price for health care cant go higher than a certain proportion of the lowest income families, so it would actually be affordable.

REally we need to correct our system so that working for minimum wage doesnt mean you just scrape by, where minimum wage is a decent living.

and get rid of the fed please :)

"why couldnt we just get rid of the personal income tax, and start taxing corporations more like the constitution originally intended for?"

Do you think corporations just magically make dollars appear or do you think they get dollars from customers (the public)? It's nice to think taxing corporations just comes out of the company profits, but in reality they just build the tax into the price of the goods they sell.

Don't get me wrong, Brian. I'm not against corporate taxes. They're a lot closer to the Fair Tax (sales tax) system I support than the mess we have today, but don't kid yourself. Only people pay taxes.

but even the fair tax system taxes more whoever saves their money the least, so a poor person would be taxed higher than a rich person who can afford to save their money, right?

Not to mention higher taxation on corporations will, like you said build themselves into the products, which atleast less people will buy products they dont need if they are more expensive, but also they will be more likely to lay off the people on the lower rungs of the ladder, so that doesnt help anybody either. So it's like walking a tight rope, but these huge corporations already have a stranglehold on our country, that deprive many people from earning a better living.

Im not smart enough to know what to do, but I know we seem to have a messed up system now.

hi Joann, Adam, i've been on vacation so there's a lot of catching up to do on ogm here especially on the healthcare debate.

i'm glad to see that despite all the 'flaming ' and personal nonsequiturs from other posters, both of you have pretty much stayed on message and so it's easy for me to pick up were we left off a week (it seems ages ago).

again I believe that the clinton strategy of setting mandates is the transitional approach with the greatest likelihood of achieving a measure of success (compared with obama's strategy) for the reasons that:

1. it aims higher (and so if it, as all other more 'socialist'-leaning proposals are whittled down - it will still have achieved some important milestones)

2. it makes for greater economic sense - i.e. the more that participate, the lower the cost

3. it considers the social attitude to healthcare - given a choice, those who think they are healthy will not participate knowing they can take advantage of the weakest and costliest part of the system (emergency care) to the detriment of the system as a howl for their own benefit - that's human nature and it's undeniable.

finally, Joann, I have to say that putting dr's salaries into the mix with all the other factors you mention is literally a drop in the ocean of healthcare costs. while you are fair in attributing some of these rising dr salary costs to medical school, malpractice, etc, ; even taking into account all these rising costs, dr salaries have fallen behind inflation, overhead, etc so the illusion that most drs make a killing off healthcare or their salaries are contributing to the rising costs of healthcare is simply false.

did I say 'the system as a howl' ???!

my brain is still on vacation - that should be 'the system as a whole'

although for some i guess the whole healthcare debacle is a howl.

Hi zdzp!

Just wanted to let you know that I read your comment and I respect what you said and agree with the points that you made. Norm is annoyed that I have been commenting too much, so I'll keep this short. Just wanted to let you know that I read what you said and appreciate your well-balanced commentary.

Thanks JoAnn!

not to get all kumbaya now- (because we democrats will need to put on our game-face again when facing the republican political machine - and I mean machine - in the general election), but it goes without saying that I have a great deal of respect for the opinions you and Adam (and Norm) post and go straight to your posts to get some clarity into the issues when a new topic is posted.

keep on!

(you may not hear from me for a while, its busy time at work - but I'll be reading...)

hey Adam,

i found it!

that reference i mentioned some postings back about how the relatively well-off still choose to go without health insurance even if they could afford it now - (it was to support my argument that if that is the situation now, then, without a mandate for health insurance, there will only be so many more people who will choose to opt out):

from the NY Times

( http://www.nytimes.com/2008/02/23/us/politics/23health.html?pagewanted=2&fta=y )

"There is no consensus among health economists about how many free riders there are, or on their economic impact. But of the 47 million uninsured people in the United States, 7.3 million come from families with incomes of $75,000 or more, and an additional 6.9 million earn between $50,000 and $75,000, according to 2006 census estimates." >

Hi ZDZP: My apologies for the delayed response, and thanks for the link. (And as long as we're giving shoutouts, I enjoy very much your comments, JoAnn's (yes, ALL of them), and Tim's, to name just a few of the ones I find especially informative).

Now. To business. Although this article is very helpful--it cuts through a lot of BS very quickly--all I can say is that I endorse its ambivalence. And 7.3M of 47M is a rather small percentage (15.5%) of the total number of people without health insurance. Also notice that combining the figures on the two groups suggests--because at 14.2M of 47M they are 30 percent of those surveyed--that the majority (70%) of those without health insurance have annual incomes below 50,000.

I like this part especially:

Neither campaign has provided enough detail about its plan to enable more than guesswork about how it might influence consumers like Ms. Coons. They have not detailed what kind of subsidies would be needed or who would be entitled to them. Mrs. Clinton has not fully explained how she would make everyone comply with her plan or exactly how she would cap the amount a family would have to spend on premiums...

But there is little certainty about how much those initiatives might save, or when. Nor can it be known if the savings would offset the potential cost of new technology and drugs and the cost of providing care to the newly insured. There are also questions about whether the new savings and tax increases would be enough to subsidize insurance for all who need help.

Both candidates are backed by teams of prominent economists from top universities and policy groups. But with little real-world precedent to guide them, their assessments are necessarily an amalgam of statistical modeling and back-of-the-envelope calculation.