The basic problem is that he is framing the odious, craptacular "individual mandate" as the only way we can solve our health care crisis - and that to criticize it is to engage in right-wing attacks. In doing this, Krugman writes all of us who support single-payer out of the picture and willfully ignores the multiple, demonstrated problems with mandates.
He begins:
Imagine this: It’s the summer of 2009, and President Barack Obama is about to unveil his plan for universal health care. But his health policy experts have done the math, and they’ve concluded that the plan really needs to include a requirement that everyone have health insurance — a so-called mandate.
Right off the bat, the tone is set - if we "do the math" we'll come to only one conclusion - that mandates are necessary. There Is No Alternative.
(Implied here is an attack on Obama. This isn't his first use of a column to attack Obama. Personally I'm not interested in defending Obama; his health care plan sucks too, and I'm not backing him or anyone else for president at this time.)
But Krugman twists the knife:
Without a mandate, they find, the plan will fall far short of universal coverage. Worse yet, without a mandate health insurance will be much more expensive than it should be for those who do choose to buy it.
His framing is solidifying at this point. Only a mandate can provide universal coverage, he says, and only a mandate can provide affordability. Later on I will explain why this core assumption is totally incorrect - that mandates cannot and will not provide both universality AND affordability. It can only be one or the other.
But Mr. Obama knows that if he tries to include a mandate in the plan, he’ll face a barrage of misleading attacks from conservatives who oppose universal health care in any form. And he’ll have trouble responding — because he made the very same misleading attacks on Hillary Clinton and John Edwards during the race for the Democratic nomination.
And here is where he writes all of us at Daily Kos out of the picture. In the last year there have been a number of excellent diaries from well-respected Kossacks pointing out why individual mandates are flawed. There's bonddad's "Why Market-Based Health Insurance Doesn't Work" (he's written many other diaries this year repeating this point in differents ways). This week nyceve - perhaps the best blogger in the country writing on health care - offered two diaries explaining the flaws of the mandated health insurance approach, yesterday's This better not be what they mean by healthcare reform and Wednesday's Are we being set up for junk healthcare reform - reform in name only?
The point these writers have made is that health insurers as a matter of basic business practice must deny care and claims to maintain profitability - they have to take in more money than they pay out. (bonddad) They also point out that this means health insurers routinely deny care - nyceve has noted her wait time for an MRI, and in Wednesday's diary explained the new trend of doctors refusing to accept health insurance at all for fear of no reimbursement. We also are aware of Markos and Elisa's problems with their health insurance - Markos had to wait weeks to get a necessary CT scan; his wife was told that BCBS wouldn't pay for her epidural.
What all of this demonstrates is that health insurance is NOT health care. Health insurance is no guarantee of health care. Health insurance is nothing more than you paying some company. That's it. Whether you actually get health care is another matter entirely.
Krugman is ignoring this. He is suggesting that our health care crisis can be solved by forcing people to buy insurance. Nowhere does he address bonddad's point that insurers deny care as a basic business model. Nowhere does he address nyceve's point (and Michael Moore's point, in SiCKO) that the real issue in America is that insurance is failing to meet our health care needs. His failure to discuss this, and his desire to frame these points of view right out of the conversation, is deeply troubling and should cause us to question Krugman's sense on this topic.
But lately Mr. Obama has been stressing his differences with his rivals by attacking their plans from the right — which means that he has been giving credence to false talking points that will be used against any Democratic health care plan a couple of years from now.
What Krugman is saying here is that not only is Obama's attack an "attack from the right" but that anyone who uses Obama's terms is ALSO attacking from the right. Because he acknowledges no valid criticisms of mandates from the left, the implication of the column is that in fact, ANY attack on mandates is an attack from the right.
Yeah, it's stunning, isn't it? But here we are. Paul Krugman, after all, is an economist who has previously supported free trade agreements and in the '90s was a defender of much of the neoliberal model. So it really should not come as such a shock. However you react to it, the fact that Krugman is resorting to claiming we're right-wingers is a sign that perhaps he hasn't always been on our side - or that his love of health care mandates is causing him to short a few circuits.
First is the claim that a mandate is unenforceable. Mr. Obama’s advisers have seized on the widely cited statistic that 15 percent of drivers are uninsured, even though insurance is legally required.
But this statistic is known to be seriously overstated — and some states have managed to get the number of uninsured drivers down to as little as 2 percent. Besides, while the enforcement of car insurance mandates isn’t perfect, it does greatly increase the number of insured drivers.
Here in California the estimates run from 25% to as high as 45% depending on the location.
Further, car insurance and health insurance are completely different. I've been a licensed driver for 12 years and have been insured that entire time. In those 12 years I have only ONCE ever had to make a car insurance claim, when some idiot ran a red light and hit me in the middle of an intersection (I was OK).
With health insurance, however, I'd use it at least once every six months, and many Americans would use their insurance once a MONTH - as opposed to once in 12 years for auto insurance. That's a totally different ballgame.
Anyway, why talk about car insurance rather than looking at direct evidence on how health care mandates perform? Other countries — notably Switzerland and the Netherlands — already have such mandates. And guess what? They work.
Krugman should know better. Switzerland and the Netherlands are completely different cases. First, neither have for-profit insurers. Second, there is much less income inequality and a higher average income in both countries, which routinely top global rankings for standard of living. This means that citizens in these countries have more disposable wealth which which they can buy insurance. Third, their health insurance markets are VERY strongly regulated, much more strongly than here in the US, and much more strongly than in any of the individual mandate plans being offered.
Krugman is well aware of the fundamental problems of rising inequality in America and the role of corporations in promoting that. He is taking a flight from reality when he says that the Swiss and Dutch examples are relevant to America in the '00s.
The second false claim is that people won’t be able to afford the insurance they’re required to have — a claim usually supported with data about how expensive insurance is. But all the Democratic plans include subsidies to lower-income families to help them pay for insurance, plus a promise to increase the subsidies if they prove insufficient.
There are so many problems with this that I literally do not know where to begin. First, he is dismissing the multiple concerns about the cost of health insurance with little more than a wave of the hand. Second, he zeroes in on "lower-income families" - but what about middle income families?? The very families that Krugman has spent 7 years explaining how they're facing crisis? By Krugman's own implicit admission here, mandates do nothing to help them afford what could be a crushing financial blow.
Further, he should know better than a "promise to increase the subsidies" is no substitute for actual provision and detailed planning for this. Such promises are pie-in-the-sky no matter who is offering them.
Finally, there is an economic argument against these subsidies - they're wasteful and ineffecient. Wouldn't those subsidies be better spent by government paying for low-income folks' health care itself, instead of giving subsidies to health insurers in the hopes that those insurers will, against all evidence, actually spend it on patient care?
By the way, the limitations of the Massachusetts plan to cover all the state’s uninsured — which is actually doing much better than most reports suggest — come not from the difficulty of enforcing mandates, but from the fact that the state hasn’t yet allocated enough money for subsidies.
Krugman is flat wrong on this and I have to believe it is a willful error. Currently 230,000 Massachusetts residents remain uninsured even though the mandate has gone into effect - which is more than half the original number of 400,000 uninsured prior to the mandate. As CBS News explained:
It's a tough sell because one of the cheapest family plans available, unsubsidized, with drug coverage, is $662 a month. When [CBS reporter Wyatt] Andrews talked to contractor Roger Thompson, there was no way.
"I have no choice. It would be like another mortgage payment for my family and I can't afford that," he said.
Krugman dismisses this man's concerns and goes on to claim that the problem is merely a lack of money. Well, why is that? Krugman should know better than anyone - government is being starved of resources by conservative policies. Those policies are undermining the social safety net and contributing to what Krugman himself called "the Great Unraveling."
Further, who is it in MA that hasn't appropriated the money? Democrats. Romney may have signed the bill, but the MA mandates were a Democratic plan. Here in 2007 MA has a Democratic governor and massive Democratic legislative majorities. If these Democrats haven't provided the proper funding, then what is to guarantee that a Democratic president and a Democratic Congress will?
Finally, Mr. Obama is storing up trouble for health reformers by suggesting that there is something nasty about plans that "force every American to buy health care."
Look, the point of a mandate isn’t to dictate how people should live their lives — it’s to prevent some people from gaming the system. Under the Obama plan, healthy people could choose not to buy insurance, then sign up for it if they developed health problems later. This would lead to higher premiums for everyone else. It would reward the irresponsible, while punishing those who did the right thing and bought insurance while they were healthy.
WOW. Wow...just...wow.
Krugman is saying here that we who cannot afford insurance but are "healthy" (I am 28 and uninsured) are "gaming the system." He's calling us cheats! He's engaging in classic conservative rhetoric by ignoring the financial problems causing us to forego insurance and then castigating us for daring to need public assistance when we do get sick. I find this to be a personally offensive statement right there - and if you recall the fact that health insurance is no guarantee of health care, this part of Krugman's column becomes totally indefensible.
But don't just listen to me on this. The Rockridge Institute in October launched Don't Think of a Sick Child: The Logic of the Health Care Debate. In it, the Rockridge Institute argues that the health care debate is a moral debate above all else. If we are to achieve progressive ends - ensuring every Californian has access to health care - we must employ progressive means.
Their analysis turns on an assessment of the "neoliberal" argument that has seduced many Democrats and even some progressives, that the market can be harnessed for progressive health care outcomes. As the Rockridge Institute explains, it simply does not work that way:
Neoliberal thought accepts a conservative version of market principles that guarantees profits to insurance and drug companies. Often, this is done in the name of political pragmatism, as a way to mute expected conservative opposition. This creates an inherent tension between the moral mission of government to provide for the protection - in this case the health security - of all of its people and the profit-maximizing insurance marketplace, which works only by denying care....
Progressives who adopt a neoliberal mode of thought, or align themselves with others who do, could inadvertently undermine progressive values and policy goals, surrendering them in advance - anticipating conservative resistance even before negotiations occur - and before the public has a chance to even consider such values.
What Lakoff and his fellows are explaining is the same phenomenon that Krugman has fallen victim to. Krugman is arguing that neoliberal methods can achieve progressive goals - but in fact, they cannot. And as you argue in favor of neoliberal methods, you start making neoliberal arguments, deeply anti-progressive arguments such as the BS that Krugman spouted about how we who can't afford insurance but who need care are "gaming the system."
Krugman closes his column by bashing further we who raise serious questions about mandates:
My main concern right now is with Mr. Obama’s rhetoric: by echoing the talking points of those who oppose any form of universal health care, he’s making the task of any future president who tries to deliver universal care considerably more difficult.
Of course, that only holds true if you equate universal health care with individual mandates. We're not the ones making universal care more difficult, Krugman - it's folks who pass off an insurance company giveaway as "reform" that are engaging in that act.
I’d add, however, a further concern: the debate over mandates has reinforced the uncomfortable sense among some health reformers that Mr. Obama just isn’t that serious about achieving universal care — that he introduced a plan because he had to, but that every time there’s a hard choice to be made he comes down on the side of doing less.
That closes Krugman's column, and is a warning shot across not just Obama's bow but ours too: that if we oppose mandates, we're shrinking from "hard choices" in favor of "doing less."
I don't support Obama's plan, and I think Obama is a coward for not supporting single-payer care. But I think Krugman is WAY off base with this column. He's trying to shape the argument around health care reform to exclude truly progressive options and frame the discussion so that it's the neoliberal answer - mandates - or nothing at all.
Krugman's column, at times offensive, at other times wrong on the facts, is something we should reject in its entirety. That Paul Krugman is its author suggests that we progressives are best off not relying on Ivy League economists with a history of backing neoliberal policies to argue for our cause, but that we should instead be doing this ourselves.
We need to reinforce our efforts to achieve single-payer care, and we need to stand up to Krugman's baiting attacks, not on behalf of Obama but on behalf of all Americans who understand that health care is a RIGHT, not a market privilege.
