Barack Obama and Hillary Clinton are slugging it out over their respective health-care plans. It's a fairly pointless argument to begin with, because they both have pretty good proposals on the table. (Click here for my earlier discussion of Obama's plan, and here for my earlier discussion of Hillary's.) Paul Krugman of the New York Times has weighed in on Hillary's side of the dispute, and so, less emphatically, has John Nichols of TheNation. But to the very limited extent that this debate is worth following at all, it's Obama who has the better argument.
At issue is how "universal" we can expect any health-care reform to be. Obama's plan creates various mechanisms to make both private and public health insurance more readily available. Hillary's plan does the same, but also creates an "individual mandate" requiring every American to buy health insurance. Obama's plan creates an "individual mandate" too, but only for children. Otherwise, under Obamacare, citizens would remain free to buy private health insurance or not as they pleased.
Clinton is attacking Obama for running an ad in which he says his health plan will "cover everyone." No it won't, says Clinton campaign manager Patty Solis Doyle. "Until the time comes when Sen. Obama has a plan that will cover everyone, [he] should stop running this false advertisement." The campaign is gathering lettersfrom health-care professionals across Iowa urging Obama to "support universal health care."
Obama replies that Hillary's individual mandate is a bluff. "Without an enforcement mechanism," Obama says, "there is no mandate. It's just a political talking point." He's right. Clinton has outlined no such enforcement mechanism (and neither has Obama for his own, more limited mandate). John Edwards, whose plan also includes an "individual mandate," recently secondedClinton's criticism of Obama and Obama's criticism of Clinton. Edwards has outlined how he would compel Americans to buy health insurance. He
will require proof of insurance when income taxes are paid and when health care is provided. Families without insurance will be enrolled in Medicare, Medicaid, S-Chip or another targeted plan or be assigned a plan within new Health Care Markets. [These are regional markets Edwards would create in which private insurers would be invited to compete with public health care plans.]
Families who lose coverage will be expected to enroll in another plan or be assigned one. For the few people who refuse to pay, the government will help collect back premiums with interest and collection costs by using tools like the ones it uses for student loans and taxes, including collection agencies and wage garnishment.
Krugman says this is a fine calling of Obama's bluff and
a terrific idea — not only would it prevent people from gaming the system, it would have the side benefit of enrolling people who qualify for S-Chip and other government programs, but don't know it.
I have my doubts. Enrolling people in a private health care plan isn't the hard part; forcing people to pay for a private health care plan is the hard part. Yes, the government has procedures to collect student loans and unpaid taxes, but it's understood that such payments are obligations. There's little disagreement that if you take out a loan, you're obliged to repay it, and only slightly more disagreement (mostly among crackpots) that as a citizen you are obliged to share in the cost of government. I believe there would be a lot of disagreement about whether the government could compel you to buy a private health insurance policy.
If you want to drive a car, it's accepted that you have to buy private auto insurance. But that's conditional on enjoying the societal privilege of driving a car; you can avoid the requirement by choosing not to drive one. A mandate to buy private health insurance, however, would be conditional on … being alive. I can't think of another instance in which the government says outright, "You must buy this or that," independent of any special privilege or subsidy it may bestow on you. Even if such a requirement could pass muster in the courts—and I have my doubts—it seems to me that politically it would give the inevitable conservative opposition a nice fat target to rally around. Big Brother will steal your wages if you don't buy a health insurance policy! Harry and Louisehad a lot less to work with.
Political salability is the only reason for Democratic candidates to bend themselves into pretzels to maintain a meaningful role for private health insurers in the first place. It wouldn't make much sense to sacrifice that salability by forcing voters to participate in the private health insurance market more than they wish to.
Advocates of individual mandates are right to worry about nonparticipation. "As a practical matter, letting people opt out if they don't feel like buying insurance would make insurance substantially more expensive for everyone else," Krugman points out. But the most logical solution to this problem, as Krugman himself has written elsewhere, is to make health insurance a function of the government, as it is already for the poor and the elderly. People may object to the specter of "socialized medicine," but at least they grasp that there's nothing unusual about the government collecting insurance premiums in the form of taxes for Medicare and Medicaid.
It may be necessary to achieve the goal of expanding government-administered health insurance in stages. All the health care plans of the major Democratic candidates are premised on that assumption, whether they acknowledge it or not. The only Democratic candidate I'm aware of who dispenses with such gradualism is Dennis Kucinich, whose solution—" Medicare For All"—is the only one that will solve the health care mess in the long run. Clinton, Obama, and Edwards all have plans that would steadily enlarge the role of government health insurance. These are accommodations to political reality. I question the wisdom of including, within such an accommodation, a mandate that would render that accomodation unattractive to a large bloc of voters. If we're going to create a ruckus, better to do it in the service of a more comprehensive solution than either Clinton or Edwards has put forth. If we aren't, Obama's resistence to an individual mandate makes perfect sense.
Health-Care Primary Archive:
Oct. 16, 2007: " McCaincare: Provocative But Vague"
Oct. 3, 2007: " Why Bush Was Dumb To Veto SCHIP"
Sept. 28, 2007: " Would Universal Health Care Wreck Cancer Treatment?"
Sept. 20, 2007: " Hillarycare II: New and Improved"
Aug. 2, 2007: " Giuliani's Tepid Health Reform"
July 5, 2007: " Edwardscare: An Elegant, Laudable Trojan Horse"
July 1, 2007: " Health Costs Screw Business, Too"
June 19, 2007: " Obamacare: Better Than It Looks"
March 13, 2007: " A Short History of Health Care"
Nov. 8, 2006: " Time To Socialize Medicine"
March 9, 2005: " Socialized Medicine, Part 2"
March 8, 2005: " The Triumph of Socialized Medicine"