Health Care Mandates: Arnold, Obama and Edwards

It is a scary word isn't it? Unfortunately, most health care experts believe it is the only way to achieve our health care goals. However, for months now, I have been railing against Arnold's plan because of its insistence on individual mandates. Those two sentence are not in direct conflict with each other and let me explain why.

Mandates are a good thing, when you are forcing people to participate in a plan that actually makes sense and will be beneficial to the individual and society. Arnold's plan forces individuals to purchase insurance that does not cover enough to justify its cost. The problem is particularly acute for lower-income Californians, since he is not subsidizing expenses at a high enough level. On the whole, Arnold's plan does not do enough to reform the private health care industry and that makes his mandates worse than the original problem.

Now, John Edwards too supports individual mandates, but they would only be implemented after his other reforms are up and running. Over all, Edwards plan is much more robust than Schwarzenegger's proposal. That is why there has been little outcry over the inclusion of mandates.

Obama on the other hand is has pushed forward a pretty good plan, but the absence of mandates will cause problems down the road, if it is passed. Why? Well, our health care system will not function efficiently if large groups of people do not participate. We need the healthy young people to pay into the system to help offset the costs of the sick and elderly. It is too expensive to have people exist outside of the system, relying on emergency rooms for primary care. Obama's approach is to put the reforms in place, then see if people are opting out in large enough numbers to create problems. If and when that happens, he would go back to Congress for a mandate. Ezra says that just is not practical:

I should add,that Obama's staff is firm in upholding that they'd happily revisit the mandate issue later on, and that Obama's commitment is to full coverage by the end of his first term. I'm skeptical, though, that after passing a universal health care bill that fails to deliver on its promises, Obama will have the capital to come back to Congress in three years and ask for a purely punitive measure to enhance coverage. Maybe I'm wrong.

Given that most experts believe we will have problems getting people to voluntarily join, this seems to be a likely outcome. So why has Obama opted for this tact? Ezra has a theory.

I know nary a health policy expert who doesn't believe you need a mandate of some kind. But I know more than a few who are leery of the political consequences of mandates (albeit in a general election rather than primary). My guess isn't that anyone convinced the campaign that there's a better way than mandates -- Obama certainly didn't offer an alternative policy solution -- but that someone convinced the campaign that they'd be better off politically without a mandate. That's actually a very defensible approach, just not one I agree with.

That is quite a political calculation, but it probably has resonance. It is unlikely that most voters will go through what I laid out above and understand the need for a mandate.

Atrios wants to know why we would need to have an enforcement mechanism. Can't we simply just send people a membership card in the mail, he asks.

Even recognizing the political realities of the situation, it seems that the way to sign everyone up is to... sign everyone up. Instead of having "mandates" requiring that people sign up to some plan, just sign them up. Instead of mandating that they pay their premiums every month, just pay for it out of general tax revenues (adding a new payroll tax or raising top marginal rates or whatever to do so).

The answer is that the mandate simply refers to the enforcement mechanism. We are not talking about the federal government sending individuals a bill each month. A payroll tax is an employer mandate, which Obama has endorsed. The people we are talking about here are those who are in school, self-employed, or an employee at a small firm (less than 15 employees). These individuals would not be captured by a payroll tax. To include them in an universal health care program, we would need to find a way to get them to join (aka pay). How we do that is a bone of contention. To be fair, Edwards has not talked about how he would enforce his individual and employer mandates. Those details were not included in his proposal.

Talking about mandates may have some political consequences, but it is the right thing to do. Health care policy is a disaster right now and Americans are acutely aware of the problems. Polling indicates that they are supportive of major changes to our health systems. It is not crazy to think that the public would be willing to support mandates, though it certainly would not be easy.