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June 22, 2005

Respectfully, I must dissent

Charley and I agree on a lot of things.  That's why we co-founded this blog a few months back.  And apropos of nothing in particular, I'm pleased to report that within the last couple of hours Blue Mass. Group welcomed its 50,000th unique visitor, according to our friends at statcounter.com.  Not exactly a Daily Kos level of traffic (he gets that every couple of hours! geez!), but it's a start!  Thanks so much to everyone who reads what we put up here.

Like any good Democrats, though, Charley and I disagree on occasion.  Sometimes it's on little stuff.  But sometimes the issues are bigger, in which case I think a separate post rather than a comment on an existing post is appropriate.

So it is today.  Charley gives His Excellency a big thumbs-up for pushing a plan that will include compulsory health insurance.  I am not so sure that this is such a great idea.  Read on...

Here is what Mitt says in his Herald op-ed announcing his plan:

Everyone must either become insured or maintain adequate savings to cover their medical expenses. We cannot expect some citizens to pay for others who can afford to pay some or all of their own way. With Commonwealth Care and Safety Net Care, there would be no reason not to be insured.

So Mitt is giving everyone two choices: "become insured," or "maintain adequate savings to cover their medical expenses."  I have no idea what the second choice means.  Is the government going to start monitoring families' savings accounts to make sure their balance is big enough to cover some measure of medical expenses?  I, for one, really hate that idea.  And what will the measure of "adequate savings" be?  Obviously, almost nobody can maintain savings sufficient to deal with cancer treatment, or open-heart surgery, or almost any other major medical procedure, yet those are the procedures that put real strain on the health care system.  So this choice makes little sense, and I think it should be disregarded in any serious discussion of this topic.

Which leaves the first choice: everyone must "become insured."  I have some practical objections to this.  How will it be enforced - will police officers hand out tickets to people who cannot produce a valid health insurance card when stopped at random on the streets?  What will be the penalty for disobeying this new law - jail time? a fine? harassing phone calls from some state insurance administrator? If someone who is in violation of this law has an accident and requires emergency medical care, what will happen?  I'm not just trying to be clever here (well, maybe a little) - I think these are real issues with any kind of mandate like this, and they are not so easily resolved.

More importantly, though, I have some philosophical objections to requiring people to buy health insurance.  To start, let's debunk this silly idea that it's just like car insurance.  It is in fact very different in at least two respects.  First: obviously, no one has to have a car, so car insurance isn't truly compulsory.  In contrast, apparently under Romney's plan every human living in Massachusetts will have to have health insurance.  Second, and perhaps more important: people are required to carry car insurance because a driver of a car can impose huge costs on another individual, either by harming the individual physically or by damaging the individual's property.  It is therefore a reasonable, and I would say correct, policy choice to require all drivers to carry liability insurance so that innocent people harmed in car accidents should be guaranteed to be compensated instead of having to sue the driver (who may well have no assets anyway) - it is a variant on the Holmesian principle that "my right to swing my fist ends where the other man's nose begins."  But that justification simply does not exist with health insurance, which is essentially a way of protecting people from the cost of their own health care needs, not from the claims of others that they have harmed.  The difference between compulsory car insurance and compulsory health insurance is the difference between the state requiring you to ensure that your actions do not harm others and the state requiring you to ensure that you take adequate steps to protect yourself.  That, to me, is a very big difference.  Remember the hullaballoo about the seat belt law?  Same principle, only the stakes are much bigger - it doesn't cost anything to fasten a seatbelt.

This is a very large topic that I cannot possibly cover in one post.  Also, it's late and I'm getting sleepy.  My basic point is this: of course, I am in favor of everyone being able to have health insurance.  But the reason I feel that way is that I imagine that most people want health insurance.  I have a hard time seeing why government is justified in saying to people who would prefer to spend their money on something else - e.g., better housing, or maybe sending money to their poor relatives back home - "no, you must buy health insurance, because if you don't the profile of our risk pool will not look right.  And besides, it's good for you."  I recognize that there's a possible moral hazard problem here.  But if we really work at making health insurance affordable and available, I would think that pretty much everyone who wants it will be in, and I would further think that that will include a lot of people.  I would like to see whether that would be good enough before taking what strikes me as quite a significant departure from the usual role of government in our lives.

UPDATE (6/22, 9:30 am): Today's Globe has some details of how Romney's proposal would work, as well as some interesting reactions to the mandate idea.  I would note this: if the only time you force people to sign up is when they show up at the hospital needing care (as the article suggests), it's not going to work, because at that moment the patient needs care that is much more expensive than the cost of the policy.  So you're doing exactly the wrong thing: throwing someone into the risk pool who is by definition a bad risk.  To get this to work, you have to get people who aren't sick into the pool.  Can we, and do we really want to, force those people in?  That's the difficult practical and philosophical problem.

Also, today's editorial reaction is interesting.  The Globe likes the individual mandate idea, adopting the flawed analogy to car insurance.  The Herald likes the new insurance proposals, but says nothing about the mandate.

Posted by David at 12:25 AM in Massachusetts | Permalink

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Well, the Governor has finally put some health care specifics on the table. Where he got them, or what chance he thinks they have of being enacted, is beyond me. [Read More]

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Comments

I see both sides. I think your analogy to car insurance is valid -- nobody requires you to own a car (I don't!).

But, the law does allow for free emergency room care; while that externalizes the cost to 6,000,000 other Massholes instead of the 1 or 2 others involved in a car accident, it is similar in principle.

I'd like to see the state offer minimum care to everyone. In a sense, it already does (emergency room) -- but expand it to include annual physicals, prenatal, postnatal, etc. Preventative maintainance care type stuff. Now, if you want to carry your own insurance to cover cancer, heart disease, whatever -- by all means.

Ultimately, I like the idea of requiring all Massholes to be insured. But, I think the state ought to provide that (minimal) coverage for anyone who chooses not to cover it himself.

Posted by: stomv | Jun 22, 2005 9:17:05 AM

the law does allow for free emergency room care; while that externalizes the cost to 6,000,000 other Massholes instead of the 1 or 2 others involved in a car accident, it is similar in principle.
Well, yes and no. The reason consumers of so-called "free care" impose costs on society is precisely because society has chosen (through the free care pool and other mechanisms) to absorb those costs by spreading them to the taxpayers rather than making one of the other two choices, which are (1) deny care to those who can't afford it, or (2) provide care but then aggressively collect its cost, including going after assets etc. (this issue has arisen here before). The proposals on the table now are basically variants on that idea: find a better, more cost-effective, more equitable way of spreading the cost of health care. An individual mandate is a possible (but in my view not essential) part of that idea. But I do think this notion is qualitatively different from requiring drivers to carry car insurance in order to protect individuals from the cost of injury being inflicted upon them by others. Like I said above, it's one thing for government to require you to buy liability insurance before engaging in what is essentially quite a hazardous activity with the potential to seriously injure others, namely, driving a car. It's quite another for government to require you to buy insurance for the privilege of living in this state so that the risk profile of the free care pool looks a little better.

Posted by: David | Jun 22, 2005 9:58:43 AM

This is another Romney vaudville act. Nothing there. No particulars and doomed to fail from the start. But Romney gets toi say he tried but Mass Dems stopped him because of party politics.

Posted by: The troll | Jun 22, 2005 10:01:27 AM

P.S.
I mentioned once bfore the handwritten charter given to Mass General Hosp by the state legislature. It is in MGH lobby.
Anyway.... it mandates that hospital provide care to all those that cannot afford it.
Same , i believe for all hospitals. hence their non-profit status

Posted by: The troll | Jun 22, 2005 12:10:18 PM

But, I think the state ought to provide that (minimal) coverage for anyone who chooses not to cover it himself.

Chooses not to? CHOOSES? I think you might want to reconsider that... :)

The exorbitant cost of health care chooses for an awful lot of us.

Mandating coverage before addressing the cost problem (either with regulation or a universal single-payer system) will only hurt businesses and people. I have a small business (though only a DBA right now). If someone mandated me to cover myself (oh how I wish I could!) I would have to not work for myself (and would be out of a job). It's that simple.

Though, it would be NICE if someone mandated companies that are "contract agencies" to cover their "temp" employees - I mean, after almost 6 years of being a contract IT worker with the same company, you'd think my husband would be eligible for something decent.

Something tells me I have to agree with the Troll. This is a Romney "I tried and failed, wah wah wah it's all the Dem's fault" act.

Posted by: Lynne | Jun 22, 2005 12:47:58 PM

There now Lynne, doesn't that feel better?

Posted by: The troll | Jun 22, 2005 12:53:00 PM

^ I meant chooses.

Look, there's "can't" and there's can't. Most people could buy healthcare, at the cost of giving up lots of other things. I don't begrudge them for the choices they make.

I also meant chooses to intentionally allow those who can afford basic health care (and more) to choose not to pay for it.

It just seems to me that if the state is going to insure those who choose to not carry health insurance/can't afford health insurance, there's no reason to mess with a means test. Just allow anyone to opt in to a free* MA health insurance system that covers minimal care. Then, if you (or your employer) wants to suppliment that free* insurance with additional coverage, feel free to do so.


But, at the end of the day, let's go ahead and try to provide basic insurance to all people who currently want it before trying to force it on those who don't.

* paid for through general legislative funds, not through fees or premiums

Posted by: stomv | Jun 22, 2005 3:04:17 PM

Mandating health insurance coverage forces consumers to support a private industry; huzzah for state-sanctioned monopolies.

Truth is, Some people, like myself, who are young and healthy, benefit from being young and healthy. They need one checkup a year at say, $500, which is cheaper than $1500 annually to cover insurance. Is it a bad idea since we could be hit by lightning tomorrow? Probably. But then again, people are allowed to have bad ideas. They're allowed to spend more than they can cover. They're allowed to smoke, and drink, and go skydiving.

This is a bankruptcy plan for medicine, plain and simple. People fail to cover themselves and get nailed. Government bails them out. How come we can just let people live with their choices? Granted, no one chooses to get sick, but PLENTY OF PEOPLE CHOOSE NOT TO CARRY INSURANCE AND INSTEAD SPEND THE $1500 per annum ON PHAT RIMZ FOR THEIR HONDA CIVIC. Then when their babymomma gets sick they take her to the emergency room, knowing they can get free care.

Posted by: Ed | Jun 22, 2005 4:05:00 PM

I'm self employed, so my insurance is my business. Normal insurance like one would get in the corporate world is exorbitant when you're 40, married and have two kids ($750/month). So we bought insurance for the things we can't afford to pay for out of pocket.

Look, I don't need insurance for when I get the flu. I don't need insurance to get the kids annual check-ups. I don't need insurance for when my wife needs to get a pap smear. What I do need insurance for is if I get hit by a bus, am in the ICU for two weeks, and come out of the ICU with a $250,000 bill.

We now have insurance with a $10,000 deductible. $10K was the largest amount I was comfortable just writing a check to cover. The cost of this policy is quite reasonable ($200/month).

Posted by: Erik Schwartz | Jun 22, 2005 7:00:52 PM

Ha ... nice trick of David to put up a post @ 12:30am, just enough time for me to read it, bleary-eyed, and not really have time to respond to it until ... soon. :)

Never fear, we're largely in agreement...

Posted by: Charley on the MTA | Jun 22, 2005 7:20:11 PM

Ha ... nice trick of David to put up a post @ 12:30am, just enough time for me to read it, bleary-eyed, and not really have time to respond to it until ... soon. :)

Never fear, we're largely in agreement...

Posted by: Charley on the MTA | Jun 22, 2005 7:38:21 PM

Those of us who havve chronic conditions find that paying list price for prescription drugs is unaffordable.

David, how would you feel about a single-payer? My vote goes for medicare for all. Then could we please fix the dtupid medicare part D?

Posted by: Abby | Jun 22, 2005 8:06:05 PM

I think Lynne and Troll are right about this:

"This is a Romney "I tried and failed, wah wah wah it's all the Dem's fault" act.."

The question is: how in Sam Heck does that get you elected president? Or even governor for a 2nd term (as seems unlikely)?

Posted by: Charley on the MTA | Jun 22, 2005 8:18:25 PM

Abby: I honestly don't know enough about the economics of single-payer to know whether I think it would work. I have heard ideas floated along the lines of the state serving as a re-insurer for very large losses of private insurers as a way of bringing premiums way down; I'd like to hear more about that sort of thing as well. But the objections in my post go only to forcing people to buy something they may not want - and from private companies, as Ed notes. That objection doesn't apply to single payer, so I have no philosophical quarrel with it.

Charley: in addition to not liking Romney's idea on the merits, I have no idea why he think it helps him politically. I'd think most conservative Republicans of the type he has been courting lately would run screaming from the idea of the state forcing people to buy health insurance. Very mysterious.

Posted by: David | Jun 22, 2005 9:02:02 PM

Erik: I am curious - do you live in Massachusetts? I had thought that policies of the kind you describe were not available here.

Posted by: David | Jun 22, 2005 9:04:29 PM

If most Republicans were conservatives they'd run away screaming from Mit's proposal. But there are no conservatives in the Republican party (witness: Iraq, deficits, more government). The evangelical Republicans left the conservatives behind long ago.

If I had to classify the Republicans today I'd say they are some kind of bizarre evangelical, nationalist socialists.

Conservatism in the US is dead.

Posted by: Erik Schwartz | Jun 22, 2005 9:11:57 PM

We live in Maine now.

Lived in California for 15 years.

Grew up in MA (but if you think back, you knew that).


The $10 co-pay is killing health insurance. Any kind of first dollar insurance coverage is insanely expensive. Can you imagine what your homeowner or car insurance would cost with essentially no deductible?

Posted by: Erik Schwartz | Jun 22, 2005 9:18:35 PM

Ed writes: "How come we [can't] just let people live with their choices?"

Ed, that's a very neat and ostensibly fair idea, but you be a doctor in an emergency room with a guy who's having a heart attack, and you tell me whether you're going to treat him or send him away. You treat him, because you took your oath to do so. And, well, that costs.

Posted by: Charley on the MTA | Jun 22, 2005 9:28:58 PM

Thanks David: I think that the key distinction is forcing you to buy something from a private company. Single payer would force you to pay higher payroll taxes of course,

At the Federal level I would be comfortable with a tax code which effectively made everyone buy insurance. The idea would be that there would be a tax credit, fully refundable, ( similar to a voucher) equal to the cost of an FEHB plan. If you didn't buy health insurance, you would wind up paying the money in income taxes or else you would forego a refund.

I am moving toward single payer, because I think it would facilitate the introduction of things like electronic medical records and allow for greater coordination on public health issues. I know that that's not politically feasible now, but I think it's probably worth working towards.

Matthew Holt's healthcare blog has some great thoughts on these issues. He's also filling in as a sub at Ezra Klein's place.

His own blog is The Health Care Blog

Posted by: Abby | Jun 22, 2005 9:46:18 PM

Charley,

I'm not saying that the doctor shouldn't treat the heart attack patient. What I'm saying is that the doctor, and the hospital, should be able to seek money from the patient after the fact.

Right now, the way the system works is that collection agencies end up buying the debts for pennies on the dollar, and hospitals have to write off large losses. Essentially, hospitals end up taking those losses and factoring them into the costs of care, so that those costs rise. And because costs rise, insurance companies up their premiums, since they now are liable for larger payouts. And because insurance becomes more expensive, less people buy it. Its a positive feedback loop, really.

Or, to reference my other posts; Can't we seize and sell those phat rims to cover the costs of the medical care received?

Posted by: Ed | Jun 23, 2005 9:16:12 AM

Alternative approach to the Romney plan:

Instead of forcing people to have insurance or the like:

1) All medical care spending is taxed the same way, e.g., out of before tax income.

2) If you are too poor for insurance, you get a certification, and welfare picks it up as now. If you have insurance, you have plastic.

3) Outlaw cost transfers. This cuts in half--say some numbers which I suspect are oversated--the cost of insurance.

4)If you are not poor, and you are not insured, you can put down a bond in advance, e.g., the bonding agency is freezing your medical care account, just like another type of bondsman is freezing your savings account, or you can find a charity to cover you. Otherwise, "I'm sorry, it is against the law for a nonprofit to treat you."

"Charity" includes clinics provided by contributions of phsyician time. "Charities" provide the medical care they can from the resources they have, and cannot be sued for providing the care they can afford rather than the best available care.

I am not saying this is a good idea, but it provides a baseline in a different direction, and it protects the poor and the sensible, including the people who are happy to have a reasonable sum in cash, credit line, stocks, or real estate available to be frozen, from medical care providers leeching off good people's insurance and medicaid coverage.

Posted by: George Phillies | Jun 26, 2005 7:40:29 PM

The assertion above about physicians "you took your oath to treat him" is false, and an urban legend.

Physicians have not taken such an oath for two millennia, for the most part. There was a revival wave several decades ago, but it emphasized 'at worst, do no harm'. The authetic version my late father, a phsyician, read in the original Attic (ancient) Greek (this was back when public schools took scholarship seriously) had some really interesting parts, including the part mandating fee splitting (in modern terms, tithing to your medical school) and the part forbidding physicans to consort with surgeons (this is not modern standard medical practice).

However, the notion that physicians must take a Hypocritic Oath before they may practice is even less accurate than that police TV show in which, in the first episode, the 'heroes' killed as many people as (it was set in a real large city) the real city, county, and state police departments had killed in the last year.

Posted by: George Phillies | Jun 26, 2005 7:47:53 PM

Wikipedia article on the Hippocratic Oath here.

"Most schools administer some form of oath, but the great majority no longer use this ancient version... Some doctors prefer to drop all pretenses of oaths, since medical boards and courtrooms are the real forces where unethical conduct is judged today.

"...In the 1970s cultural and social forces induced many American medical schools to abandon the Hippocratic Oath as part of graduation ceremonies, usually substituting a version modified to something considered more politically up to date, or an alternate pledge like the Oath or Prayer of Maimonides."

None of this has anything to do with federal law, which requires ER docs to treat people regardless of insurance status. Needless to say, I think that's a good idea.

Posted by: Charley on the MTA | Jun 26, 2005 11:03:33 PM

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