Jacob Hacker–soon to be at if UC-Berkeley–may have been someone who helped advise the Democratic candidates on their health care plans, but they didn’t listen to his LA Times op-ed yesterday asking for a truce on the question of an “individual mandate.”
They spent 16 minutes of their Ohio debate last night on the differences of their health care plans, mostly on the individual mandate. As Hacker says, it’s not the central benefit of either of their health plans. Rather, it’s the ability to make coverage more available, affordable, and automatic through group coverage.
In their debate, they are arguing over details that neither of their plans currently spell out.
Obama is right to take umbrage at Clinton’s suggestion that his plan isn’t as universal. It would certainly get to 95%+ coverage, the standard of most industrialized nations with “universal” health care. The Obama and Clinton plans are remarkably similar in how it expands coverage, especially with regard to new subsidized public program expansions, new opportunities and automatic enrollment in coverage at work, and a new public coverage option.
Obama is also right to say that the real problem is not that people don’t want coverage–it’s that it is not available or affordable, and the so-called “free rider” problem largely resolves itself. Only 2% of Californians are uninsured yet over the 400% of the federal poverty level, and half of them are under $60K for an individual, or $125K for a family of four.
Clinton is right to be upset at the Obama’s mailers than are suspiciously similar to “Harry and Louise” ads of 15 years ago, and specifically the contention that she would require people to buy coverage, even if it wasn’t “affordable.” Her plan specifically would cap the amount that people would be required to pay at a percentage of their income. It doesn’t say the specific percentage, so perhaps they might disagree on the definition of “affordable,” but right now there’s no way to know.
As a critique, Obama also mentions the Massachusetts plan, which had enforcement where people were required to pay a fine is they were uninsured, but still wouldn’t get coverage. But the Clinton plan doesn’t specify that type of enforcement: In California’s AB x1 1, the proposal was not to have fines, but merely to automatically enroll people in coverage–and then consumers would have to pay the premium, like any other bill, but they would also have the benefit of coverage.
So how about a truce? The individual mandate proponents have a point that everybody needs to contribute to the health care system in order for it to work best. The opponents are correct that any contribution needs to be affordable, and as such scaled to income. While it would be preferable to collect these contributions through a progressive tax based on income, it could possibly be done privately through a requirement to get coverage, but then additional protections are needed: some assurances of the benefits and cost-sharing, the value of group coverage, and yes, an overall structure that provided assurances that coverage is available, adequate, affordable, and administratively simple. If the proponents say that part of the benefit of an individual mandate is to make the government more responsive and accountable to ensure that people can access coverage, then such responsiveness should be built into the proposal at the beginning.
Obama says he’s willing to do a requirement for children because that infrastructure of Medi-Cal and Healthy Families/SCHIP is largely already there. Clinton promises to have that infrastructure in place before her mandate kicks in for adults. Obama said he would consider a mandate for adults.
What are they arguing about?