PrintFebruary 12, 2008
Mandate Me, Baby
I am not much of a policy wonk. Rarely do I don my pointy hat and delve into the mysteries of exactly how government tries to run our lives. Usually it is enough for me to spout generalities while railing against bureaucrats, liberals, and eager beaver do gooders who often act as surrogates for government policy in lieu of direct intervention by agencies.
No, I have eschewed covering policy for the most part. I am not smart enough and fear if I cram my head with too much of that stuff, other more important things will dribble out of my ears. Why take a chance on losing vital information like what Eva Longoria likes to do in bed or the name of Britney Spears' favorite psychiatrist?
But I'll take that chance by delving into what promises to be the number one controversy that will hit the internet if a Democrat is elected president next November; mandates and the drive to coerce the American people into buying health insurance.
What is a health insurance mandate? Basically, it is government forcing you to purchase insurance even if you don't want it or feel you have no need for it. The principle is based on the idea that those who do not have health insurance are getting a "free ride" from the rest of us when they get sick or injured. Since hospitals are forced to treat you even if you have no money, the cost of treating your sorry butt if you are uninsured is born by the rest of us who carry insurance or, in 85% of cases, by local, state, and federal government. As a result, health care costs skyrocket and premiums become more expensive.
Apparently around 21% of people out of the 44 million who don't purchase health insurance are young, single, healthy workers who can afford individual premiums but refuse to cover themselves. This drives the price of health insurance up even more because it leaves older, less healthy people in the insurance pool who are more likely to need health care.
So the thinking is if we get everyone covered under an insurance program, premiums will come down and we will be able to get health care costs under control.
And we all live happily ever after...
Not exactly. For instance, what do you do with people who despite the gentle entreaties of government, refuse to buy insurance? No Democrat will give a straight answer to this question and for good reason; the only cost effective, efficient way to round up the health insurance deadbeats is to garnish their wages or assess a penalty by using the IRS to enforce the law. The idea is that taxpayers would provide proof of insurance when they file their tax return. Scofflaws would have the premium come out of their refund or the IRS could simply bill them for the amount owed. Failing to get the money that way, wage garnishment would be in the offing.
But there is a huge problem with using the IRS to ensure we're insured; nearly 18 million low income tax payers aren't required to file a tax return while another 9 million Americans refuse to do so. That's 27 million Americans who could potentially fall through the cracks of any enforcement regime. One plan advanced by The New America Foundation would mandate that all Americans file a proof of insurance with the IRS whether they pay taxes or not. But that plan doesn't allow for people who simply refuse to file. And, after all, some of the uninsured are elderly, homeless, or mentally ill. Others may have changed their address multiple times.
Perhaps looking at compliance rates for other mandates might give us an idea of what we might expect with health insurance strictures. Most of us are mandated to pay for auto liability insurance. Compliance varies but ranges from between 66% - 96% depending on the state. Also, in states where there is a childhood immunization requirement, compliance reaches an average of 77%.
Authors of this paper published in Health Affairs journal found several factors affecting the rate of compliance with mandates:
"Compliance is easy and relatively inexpensive; penalties for non-compliance are stiff but not excessive; and enforcement is routine, appropriately timed, and frequent."
Using the above criteria, one can see problems immediately. For instance, has government ever made anything "easy and relatively inexpensive?" Even if mandates started out that way, there is every reason to believe that the cost would rise swiftly with more and more rules promulgated and exceptions made.
And those who have dealt with the IRS can attest better than I whether any enforcement done by the agency is "routine" or "appropriately timed." Congress and others have been trying to change the corporate culture at the IRS for years and have failed utterly. It seems far fetched to expect the agency to change in the matter of collecting for health insurance.
Both Democratic candidates would probably use the IRS to enforce their idea of universal coverage. The difference is that Hillary Clinton's plan specifically calls for mandates to coerce people and businesses to purchase insurance while Obama's plan relies on a somewhat more voluntary (and probably less successful) belief that making insurance affordable will automatically cause the vast majority of those who don't have insurance presently to buy some.
Both plans would call on healthy insureds to subsidize unhealthy insureds by ignoring such supposed trivialities as pre-existing conditions or other actuarial criteria. Instead of those who are more likely to use the health care system paying more in premiums, those less likely to be sick are asked to pay the same amount as those actually using the system. It's like telling someone with three drunk driving convictions and a history of accidents that he doesn't have to pay any more in insurance than someone who has never had so much as a speeding ticket.
Both plans would subsidize those who can't afford health insurance through tax credits or direct federal subsidies. As mentioned previously, most poor people do not pay any taxes at all which would make a tax credit an interesting exercise in government coercion. Those who currently don't need to file a tax return would be forced to do so in order to claim the tax credit.
Even a direct subsidy as proposed by Obama has problems. One must assume a mechanism to insure that the subsidy is spent on health insurance and not some other less vital household expense like food or cable TV.
Both candidates offer plans that would coerce businesses to give health care benefits to their employees. Which is more draconian? Both would penalize businesses through increased taxes if they failed to cover their employees. Obama would give a break to the very small business by making them exempt. Clinton would offer a tax break to smaller businesses to encourage them to offer insurance. If they don't, they pay a penalty.
Obama's plan differs from Clinton's not only on mandates but also by his proposing a "National Health Insurance Exchange" - nanny statism run wild:
The Obama plan will create a National Health Insurance Exchange to help individuals who wish to purchase a private insurance plan. The Exchange will act as a watchdog group and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible. Insurers would have to issue every applicant a policy, and charge fair and stable premiums that will not depend upon health status. The Exchange will require that all the plans offered are at least as generous as the new public plan and have the same standards for quality and efficiency. The Exchange would evaluate plans and make the differences among the plans, including cost of services, public.
Why doesn't the government just take over the health insurance industry? Under this "Exchange," all market forces would be corrupted because of interference by this quaisi-government board of inquisitors.
Both plans make grandiose claims about bringing down the cost of health care through "preventive" measures. Unfortunately, that idea has limited use both for improving health and bringing down the cost of health care.
Ezra Klein, who has written extensively on the health care issue from a liberal perspective, outlines the problems with preventive care:
First, the impacts of preventive medicine are often overstated. It's not that cleaning up the air or putting everyone on a gym regimen would greatly improve health-but people don't follow gym regimens, and business doesn't let you clean air. Furthermore, not all interventions are created equal. Better parenting might be beneficial, but it's unlikely to be more effective-either on economic or biological grounds-than the use of statins, or hypertensive drugs, or daily tablets of aspirin. There are a lot of highly effective medical interventions which are very, very cheap. But our system is very poor at incentivizing their use.Meanwhile, the reason doctors are constantly prescribing statins along with admonitions to exercise and eat better is because using public policy to change diet and exercise habits is really, really, hard, unless you're prepared to be very heavy-handed (i.e, outlawing trans fats in restaurants, setting portion limits, etc). Indeed, part of the problem with preventive health measures is that, rather often, they don't work very well. Like with traditional health care, some things really succeed (stripping lead out of gasoline, giving people antibiotics), and lots of things...don't. And that's to sidestep the weird reality that what drives health care politics is concern over money which, in fact, is quite rational: Folks don't want to go bankrupt, and smart politicians don't want the government to lose all space for spending on other priorities.
All of these measures to bring down the cost of health care and insure more Americans basically come down to this; government coercion on a level rarely seen in America. And it only promises to get worse. Neither the Clinton or Obama plan will cover everyone simply because people - millions of people - will refuse to take part. The Massachusetts plan which mandates people buy insurance is failing to cover those who don't have insurance simply because half of them refuse to sign up - despite the penalties:
A group of doctors and health policy analysts, including a number of Obama advisers, pointed out in a letter released Thursday that Massachusetts, the only state with an insurance mandate, has thus far failed to enroll nearly half of its uninsured despite imposing a modest first-year tax penalty of $219 (the fine increases significantly this year). Because the Massachusetts program is less than a year old, it is not yet possible to fully judge the effectiveness of its mandate.Mr. Obama raised the Clinton campaign's ire late last week by charging in a voter mailing that "Hillary's health care plan forces everyone to buy insurance, even if you can't afford it... and you pay a penalty if you don't."
And that brings us back to questioning the efficacy of health insurance mandates - not as a vehicle to solve the problem of "free riders" or those who can't afford the cost of health insurance. The rock bottom, basic reality is that in a free society, when government forces people to do something they do not wish to do, liberty is lost and individual rights are trampled upon.
The argument that "We already have mandates for auto insurance among other things so what's the big deal?" doesn't hold water either. Every additional mandate initiated by government cuts into the notion of individual responsibility and substitutes collective will. The Congressional Budget Office put it thusly:
An individual mandate has two features that, in combination, make it unique. First, it would impose a duty on members of society. Second, it would require people to purchase a specific service that would have to be heavily regulated by the federal government.
As this Cato Institute policy analysis points out, mandates are a "slippery slope" to national health care insurance. And the plans offered by both Democratic candidates promise little in the way of relief while virtually guaranteeing that the quality of health care for the average American will go down.
In future years - as with all government run health care plans in the industrialized world - costs will rise, benefits will go down, and some form of rationing health care services will be inevitable.
There are free market solutions to many of our problems with affordable health insurance and rising health care costs. But in the rush to pile the responsibility on the back of government, no one seems willing to even try them. The Democrats have successfully spun the narrative that only government can solve these problems, that the market doesn't work and that therefore, only mandates and "Exchanges" can save the American family from the health care monster.
If one of them is elected next November, we will probably see the biggest change in the American citizen's relationship to government since the income tax amendment was ratified. Intrusive, coercive government polices will become the law of the land. And we will be poorer in liberty and individual freedom because of it.
Rick Moran is associate editor of American Thinker and proprietor of Rightwing Nuthouse.
