Alex Blaze

Obama: To mandate or not to mandate... there really isn't a question

Filed By Alex Blaze | December 12, 2007 3:02 PM | comments

Filed in: Living, Politics
Tags: Barack Obama, Democrats, health care reform, Hillary Rodham Clinton, John Edwards, Paul Krugman

Barack Obama released an opp doc on NY Times columnist Paul Krugman last Friday, hopefully the climax of a battle between progressive columnists and the Obama campaign on one of the stickiest points of health care reform: mandates.

I've previously mentioned my anxiety about health care mandates when I posted about Clinton's health care plan - if done badly, a health care mandate only serves to make the system worse, much worse, for those without health care than it is today. On the other hand, some sort of mandate will eventually be required of a health care plan; that is part of the basic idea behind a single-payer health care system (the other big part being the elimination of any need to go through private sector insurers for basic health care, something none of the top three Dems support).

The mandate is the biggest difference between the top 3's health care plans - Clinton's has an individual mandate (people are required to enroll in private or public health care), Edwards has been more detailed and sounds more like a government mandate (people who don't sign up will be signed up for public health care), and Obama doesn't have one at all. Paul Krugman explains why a mandate is important:

Why have a mandate? The whole point of a universal health insurance system is that everyone pays in, even if they’re currently healthy, and in return everyone has insurance coverage if and when they need it.

And it’s not just a matter of principle. 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.

Here’s why: under the Obama plan, as it now stands, healthy people could choose not to buy insurance — then sign up for it if they developed health problems later. Insurance companies couldn’t turn them away, because Mr. Obama’s plan, like those of his rivals, requires that insurers offer the same policy to everyone.

As a result, people who did the right thing and bought insurance when they were healthy would end up subsidizing those who didn’t sign up for insurance until or unless they needed medical care.

Not to mention the increased costs in health care by those who forgo preventative care because they choose not to sign up for health care.

But while not having a mandate is OK, can come up later, and can be negotiated, Obama's been trying to turn his lack of universality into a selling point, making it harder to believe that he'll come behind a mandate later.

He argues that the reason people don't have health care isn't because they aren't being forced to, it's because they can't afford it. True, but that doesn't address the fact that there will always be people who don't see the benefit of health care coverage, no matter how cheap it gets, because they're rich enough to pay for any procedures themselves, because they think that they're too healthy to need health care, or because they just don't want to participate in what they see as "confiscation" or "big government".

His answers to Clinton on the mandate sound like he's responding to mandate-done-badly - if a health care initiative does in fact make health care cheap enough for people to afford, then a mandate isn't a bad thing, it's necessary for substantive reform. As someone living under a system with a government mandate (France), I can tell you that it's not stifling if part of a progressive tax system.

So this sort of rhetoric is more than just grating, it seems to put any chance at single-payer off the table in an Obama presidency. From Jonathan Cohn:

When Obama first announced his plan, he suggested he was eschewing a mandate primarily because he wanted to take things a little more slowly--to put his other reforms in place before actually requiring everybody to get insurance. If it turned out he needed a mandate later on, he made clear, then he would do it.

Lately, though, he has been arguing as if his decision on a mandate, considered by some (including me) to be his plan's chief failing, is actually a virtue--and that he, frankly, has a better understanding of this whole problem than his rivals do. As he recently said in Iowa, "Their essential argument is the only way to get everybody covered is if the government forces you to buy health insurance. If you don't buy it, then you'll be penalized in some way. ... What I have said repeatedly is that the reason people don't have health insurance isn't because they don't want it, it's because they can't afford it."

But it works for him. His opp doc links to a favorable editorial in the libertarian leaning Concord Monitor, showing, I suppose, the power of triangulation. This sort of talk might quell fears from small-government types regarding health care, but only by hamstringing the process (from Ezra Klein):

Well, it was one thing when Obama simply didn't have a mechanism to achieve universality. It became a whole other when he began criticizing mechanisms to achieve universality. Previously, he'd gotten some flack for buying into the conservative argument that Social Security was in crisis. Now he was constructing a conservative argument against far-reaching reform proposals. And he kept doing it.

But back to the original issue - the fact that the Obama campaign has set its sights on attacking on one of the best known progressives in the mainstream media. What this says about the Obama campaign, to me, is that they're looking to the national election where progressive policy is going to be a hard sell. From Digby:

Running to the right on health care and social security combined with the anti-gay gospel singer, taking Robert Novak smears at face value, repeating Jeff Gerth lies and now going after Paul Krugman, leads me to the niggling awareness that this is a conscious, if subtle, strategy. Any one of those things could be an accident, and perhaps some of them are. But taken as a whole, conscious or not, liberal fighters in the partisan wars are being sistah soljahed. Unlike the big issue of Iraq where being on the right side is being on the left side, these little digs and policy positioning are all sweet spots for the Village --- and sore spots for the base.

Perhaps that's the smart move. It has long been known by just about everyone who matters that the rank and file activists of the Democratic party are a huge liability. And anyway, where are we going to go? Mike Huckabee? Ron Paul? We have no choice. So, no harm no foul. Running to the right of even Hillary Clinton on health care and social security and using GOP talking points and symbolism is probably all upside. It may be the best way to insure a win in the fall. But I can't say that it looks like either a transformative inspirational politics or a willingness to fight the conservatives and win on the merits.

Oh, well. It was fun while it lasted. Anyone can do the "transcendent politics" blah blah blah (remember "uniter, not a divider"?), but let's learn to examine policy instead of soaking up the rhetoric.

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Is it wrong to say I just don't care about the details as much as I do getting some sort of health care? I just want somebody to do something! (Rather like the whole "anybody but Bush" theory...

The New York Times ran an interesting Op-Ed piece yesterday that illustrates your point well:

Well, France spent $3,464 per person on health care in 2004, compared with $6,096 in the United States, according to the World Health Organization. Yet Frenchmen live on average two years longer than American men do, and Frenchwomen live four years longer. The infant mortality rate in France is 43 percent lower than in the United States.

The French bureaucracy isn’t so bad either. Typically you pay the doctor in full, then you or he sends a one-page form to the state health system. The state wires its reimbursement right into your bank account. If there’s anything left on the bill, it sends that to your private insurer, which wires its own payment into your account.

The system also has its budget problems, of course. And while the French system far outranked the American system overall in a 2000 W.H.O. study, it did slightly worse on "responsiveness," which includes waiting times. But the French government wouldn’t dream of challenging the idea that everyone pays into the system and everyone gets basic care."

Yes, Bil. Somebody doing something can possibly be disastrous, you know, if the plan is bad.

I saw that op-ed this morning. It makes one of the most valid points for single-payer out there - that the countries with good single-payer are paying about half per person on health care that Americans are and getting a lot more.

'Single payer' is code for 'socialized medicine’. What ever you call it I'm for it. The Physicians for a National Health Program (PHNP) has some 11,000 members and their web site can be linked at They note that "The Congressional Budget Office projects that single payer would reduce overall health costs..." by over "$225 billion" and that "No other plan projects this kind of savings." That money now goes to the owners of insurance companies and HMO's who live in obscene luxury while patients patiently wait to die because care is refused or delayed.

PHNP says that “the need for a ‘wallet biopsy’ before treatment would be eliminated; time currently wasted on administrative duties could be channeled into providing care; and clinical decisions would no longer be dictated by insurance company policy.' PHNP has over 11,000 members, including 9,000 doctors.

Obama’s plan is a rehash of the Clinton plan with minor differences. Both are condemned by the National Nurses Organizing Committee, AFL-CIO, a rapidly growing group who terrify hospital owners because they go on strike to protect patients. They oppose Obama’s HMO/Insurance Industry plan. Their site can be found at The US Labor Party’s program for ‘Just Heath Care’ can be viewed at

All the proposals put forward by Republicans and Democrats share the disgrace of being written by or for the freeloading owners of the health denial industry. Michael Moore’s SICKO is a graphic look at the cost we pay to make them rich. In one scene a doctor who worked for Humana explains that she committed murder on several occasions by following guidelines to maximize profits. She condemns that system that allows her and the many others like her to get away with murder. No DA in the country would risk their career by going after them or the owners of HMO’s and insurance companies on murder charges. But if a victim of spousal abuse kills in self defense that’s a different story.