As this diarist pointed out, there are more similarities than differences between Obama and Clinton on universal healthcare, and there are differences which will have an impact on the outcome for people in our country.
But before we go into why I differ with that diarist in calling Obama's plan "wrong", let me just point out the obvious: both are "wrong", in a sense. Single-payer is the solution that is needed in the U.S. today. Both candidates are realists enough to know that we are not at a point, politically speaking, where that option is attainable, nor are we very likely to get there soon enough to justify putting off action for that day. In fact, putting off action might just keep us from reaching that point. And so could doing it in a politically risky way - since that could poison the UH well and lead to another embarrassing defeat like the one we experienced in '94. We don't need another 14 year setback right now.
While I'm not completely certain about which plan is better or more politically feasible (and it may well be Clinton's that is), I'd like to point out why I am very comfortable giving Obama's just as much benefit of the doubt as I do Clinton's.
Now, I'll cover the same three areas that the other diarist covered, briefly:
1. Broadening the Risk Pool
The diarist argues that people who are not ill will self-select out of the risk pool. This is a reasonable and true argument. However, it is not the whole story. As Obama hinted in the debate, people will opt out of either system, and those who will opt out of the mandate system are those who cannot get subsidies (because they don't quite qualify, or because there wasn't enough subsidy money), but still cannot make ends meet while paying for insurance. Some may carry low-value/low-cost insurance to be in compliance but will not join the pool of high-quality users to share the risk there. Will these self-removers be healthier, and therefore less costly than the population sharing risk? Sure - but they are likely to be under either scenario. However, most of them - healthy or not - would gladly join in if the cost were low enough. So the real solution to skewing the risk pool is to make sure the insurance is affordable enough. Mandates take a distant second in importance for that purpose.
There is a bit of circularity here, because the diarist maintains that mandates will lower costs for every participant. But, they have to work before they can lower costs, and they won't work until cost is lowered. In effect - if cost is lowered by other means sufficiently first, then mandates might further lower it.
Finally, the age group most likely to opt out are those who can be covered under their older, wiser parents' policies under Obama's plan. (Aside: as I typed this, it occurred to me that you could swap the words "plan" & "policy" and it would mean the same thing - or that use could use the same word in both places and not change the meaning, but leave a bunch of people going "huh"?)
2. Preventing Free Riders
I will quote the original diarist:
At one point, Obama suggested he might create a penalty for people who attempt this scheme. There are two problems with this. First, Obama hasn't actually proposed it. Second, it's the same basic problem as underwriting--people will be charged more for coverage if they're sick, which makes it less likely that the people who need care the most will be able to afford it.
The way I understood Obama's stance in the Thursday night debate was this: Free-riders, who could afford insurance but did not buy it would be responsible for their own medical bills. In essence, they would become self-insured, by their own choice. This would require some teeth for allowing providers to recover their costs from those patients (up to a reasonable degree), rather than passing those costs on to the insurance companies or government through higher priced services. The end result would be that we would still be publicly financing some of that cost for free-riders, but the "free-rider" would at least pay as much as he/she would have paid in insurance premiums to date. Of course, if the "free-rider" were someone who could not have afforded it, then we would have publicly financed their costs anyway. And, under mandates, the "free-rider" problem doesn't go away - it just shifts. Just as with auto-insurance, people would comply by buying junk policies that do little or nothing to offset the costs of free-ridership and do not leave them truly insured.
3. Elevating Public Health
There's little to argue here, except the same point I made in point 2. Under mandates, junk policies would leave preventative medicine too expensive for most, and the public health would suffer as a result. However, going back to point 1, making quality care affordable will go a long way toward enhancing the publich health.
In discussing Senator Enzi's efforts to derail healthcare, the diarist said:
The essence of Enzi's argument is very much the same as Obama's argument against mandates. They're misleading, dispassionate, and in opposition to the ideals of the Democratic Party. Health care is a right, not a privilege. The only way to secure that right is to make it truly universal.
Where Enzi was concerned, he is correct. Obama brings up similar criticisms as Enzi, but not in an effort to derail healthcare - rather in an effort to insulate it from efforts like Enzi's. And that last statement says it all. We are not "there" until we have truly universal healthcare, which is not an option with either of our two current Presidential candidates.
Fortunately, with either of them, we have a fighting chance to make positive change toward universal health coverage, which brings me back to the opening of my post.
Which candidate, and which candidate's plan, will move us down that road? Certainly, both will, if implemented effectively. Certainly neither will, if they cannot sell themselves, or their plan, to the American people. I buy my own insurance now (at exorbitant prices), and I would buy it under either of the two plans available. But I do have enough of an independent streak to resent a new burden imposed on me by the government. Health care may be a right, but it isn't a Constitutional Right... and after the last 8 years, I am leary of government power excercised outside the color of the Constitution. I will accept & even vote for mandates. I don't know that many will, outside the progressive wing of the Democratic Party. Will a candidate who promises them win the general election? Will a President who lobbies for them pass them through a frightened Congress? It is impossible to predict. But I think it is safe to say that Obama's plan is going to be more palatable to a wide swath of people, including any given Congressperson's constituents, than Clinton's will, even if not decisively so. We do have to place our bets not only on the merits of these two programs against one another, but on the merits of each against the possibility of another decade in the desert. My gut tells me to vote against mandates in the primary, despite my head saying that mandates may present a somewhat better bargain in the short-run.