Tuesday, January 8, 2008

Mandates - Political Realities Mug Mandated Coverage

It remains incredibly difficult for states by themselves to get all the uninsured covered,” said Robert Blendon, a Harvard professor of health policy and political analysis. “There just is not a consensus on who should pay.”

Health Care Expansion Hits Roadblocks, New York Times, December 25, 2007

Mark Twain said of Richard Wagner’s music, “It’s not as bad as it sounds.”

Similarly, “Mandated universal coverage isn’t as good as sounds.” All for one, one for all; unity among diversity; fairness. affordable costs; no medical bankruptcies; low drug prices; fewer ER visits; no more guilt about the “moral disgrace” of U.S. health care, no more uninsured or holes in the safety net,

It surely sounds good, and it has its truths, particularly on the safety net issue. Public hospitals provide 2% of care but absorb 25% of uncompensated care. At Grady Hospital in Atlanta, only 8% of patients are privately pay.

The utopian “sound good” scenario goes:

Big government fans say if the U.S. were like countries with single-payer mandates, costs might be 40-50% lower, everybody might be covered, and infant mortality longevity, and health statistics might improve

But U.S. political realities may mug “mandatory coverage.”

• Philosophical conflicts – “Mandatory” means government demands and commands.. This doesn’t sit well with those Americans who say mandates impinge on “liberties, “choices,” and “freedoms” in a free society where health care is part of the marketplace.

• Cost and Who Will Pay – In California, mandatory coverage’s price is estimated at $14.4 billion, the size of California’s current budget deficit. Who will pay? Taxpayers? Corporations and small businesses? Hospitals, doctors, and health plans? Imposing mandatory coverage on the present U.S, health system will entail massive expenditures. “Savings” so far suggested – preventive care, compulsory doctor computerization, and government negotiated drug prices – will take time to get in place.

• Fairness Fallacy - Under present premium structures, 25 year olds pay ¼ to 1/3 of what 55 year olds pay. The young may view mandatory higher premiums as a “rip-off.” Massachusetts is already having a tough go at tracking down 200,000 people, mostly young, who refuse to pay individual mandated premiums. Mandates suggested by Senator Clinton give no tax breaks to the young. Some say mandates exploit the young to pay for the old. In America where we believe the old should make way for the young. Significantly, Senator Obama, who caters to the young, doesn’t recommend “mandates, ‘ but “comprehensive affordable care.”. The main sdifference between Mr. Obama’s and Mrs. Clinton's plan is she would dictate that everyone have health insurance, while Mr. Obama's would only require the coverage of children.

• The Emergency Room Illusion - Some say lack of uninsured coverage is mainly responsible for crowded emergency rooms. This may not be so. Fully insured Medicare recipients are much more likely to go to the ER . “Frequent flyers” suffering from mental illness or substance abuse also commonly visit ERs. Mandates will not change where they seek care.

• “Moral Disgrace” Argument - John Edwards argues “a system that leaves 47 million Americans uninsured is a moral disgrace.” This argument neglects the immigration problem. Most , 75%, of the 2 million rise in the uninsured over the last five years occurs in five Border States – Arizona, California, Texas, New Mexico, and Texas. Of the 10 million immigrants who entered in the last 7 years, half were illegal. Also legal immigrants’ cultural unfamiliarity with U.S insurance means many go uninsured when they can afford premiums. Of the 47 million uninsured, 10 million have incomes of $75,000 or more. Many choose to spend their money elsewhere. Another 14 million are eligible for Medicaid of SCHIP and simply need to sign up. company. Mary McCaughey, former lieutenant governor of New York, concludes.

Mandating that everyone, including young adults, buy insurance, and then hiding a hefty, cost-sharing tax inside that premium is an unfair solution.

The foreign mandated coverage music, as applied to the U.S., sounds good, but so far it isn’t playing well in America.

1. Kevin Sack, Health Care Expansion Hits Roadblocks, New York Times, December 25, 2007.

2. Betsy McCaughey, the Truth about Mandatory Health Insurance, Wall Street Journal, January 4, 2008.

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