Krugman is the guy who gets the big headlines & diaries here. I just want to quickly share thoughts of some others here, including progressive economists who aren't so fired up about the mandate side of the question.
Richard Eskow has a thoughtful piece, very on topic here. I quote from his discussions with economist David Cutler, Obama's senior health advisor..
"You can enroll them," Cutler replied, "and then forcibly collect the premiums. That’s one way to solve the problem. But it’s not necessary to do that."
"A better approach is to do everything possible to make it affordable and available. When it is, almost everyone will have it."
There are a couple of concerns about that approach. One is the problem of "adverse selection." Sicker people – or people with a greater likelihood of becoming sick – will enroll. That will drive plan costs up, making it prohibitively expensive.
(Continued..)
"Let’s look at the level of coverage you can get without a mandate. Our estimates, based on studies in the literature, is that we can get 98% or 99% coverage without a mandate for adults. There may be some small pockets of people who choose not to buy it."
What about those people?
"If there are free riders, Obama is open to mandates. But what he is saying is ‘Look, mandates seem like a panacea, but that’s not where the hard work needs to be done.’ Auto insurance is a mandate, too, and not everyone has that. You’ve got to prove to the public that you’re willing to do the hard work.’"
Would mandates be considered at that point?
"He hasn’t ruled anything out. It’s a matter of priorities. The fact is, the policy differences on the mandate issue aren’t that large at all. Sen. Obama believes they’re an option down the road, if other approaches don’t work."
Also worth reading is this FDL entry pointing out that mandates, by themselves, do not solve the problem of universality and come with a host of other difficulties that need to be sorted out in detail - not in vague generalities like "subsidies" - which don't address the hit middle-class families will or may take, whether policies so-subsidized will have affordable deductibles - and whether mandate/subsidy combinations will serve as a dis-incentive to families facing opportunities to accept higher pay and join the middle class.
Others feel that every non-single-payer system is a boondoggle and a give-away to the for-profit insurance industry. And I'm sure there is some truth to this.
I don't have a lot of my own to add to this. Between Paul Krugman and other economists who feel that mandates are a must for any system to reach 100% coverage, and the other economisists, physicians, and pundits quoted above, there isn't much room for little old me to add anything. But I'll add a couple of thoughts.
I am libertarian enough to personally bristle at the notion of mandates for adults. If I wish not to purchase insurance, I feel I should have the choice to take my own chances with my own health (not that I would do so - I have a family who depends on me, and I'm not going to put them in a situation). I would have less problem, in fact, living in a single-payer society where I payed into a system of progressive taxation a fair share of the total health cost. I feel the government has more right to demand I pay a tax to them than to demand I pay an insurance premium to Unum Provident.
Contrary to the majority of experts, I do not think that mandates are necessary for univesal coverage... so long as coverage is truly optional for those who decline it. My thinking is this:
- Regulations capping policy prices and deductibles
- Tax incentives for companies that find ways to decrease administrative costs in private plans
- SCHIP type coverage, with automatic enrollment, for all minor children not otherwised insured and tax incentives for taking private insurance on one's children instead of relying on the SCHIP type program. Government provided insurance, with automatic enrollment, for all persons below a certain multiple of the Federal Poverty Level.
- Federal rules requiring policies to cover all legitimate claims, without regard to "previously existing conditions" or an HMO's opinions about what is legitimate - with a Federal fund to subsidize costs of those claims to the covering insurance company in certain cases.
- Provision enabling healthcare providers to collect costs from "free-riders", including options for wage garnishment. Possible to decline certain types of (expensive) care to those adults willingly opting out of the system, not covered by a government policy because of their income level.
True - this wouldn't be completely universal, but an argument could be made that these able-minded adults unwilling to opt in to an affordable system should have the option to go without coverage.
It wouldn't be perfect either... and has some of difficult points - just like the mandate plan. But here's the kicker: something like this - or something like Obama's plan - or something like Edwards' or Hillary's plans can solve some of the bigger problems facing us where it concerns our national healthcare system, and where they each fail in their own particular way to solve all of the problems for every American - we have the opportunity to change them so that they do - up to, and including the option of bringing in national single-payer health care.
My point is this - Every plan out there, including single-payer - has negatives and positives, and the results are purely hypothetical now. We should be proud that every candidate out there has a plan, and that every one of those plans is ambitious and will bring needed changes if implemented.
Please use the comments to flame me mercilessly and to debate the relative merits of a variety of steps that could be taken politically to fix our terribly broken health-care mess.