The New Hampshire Concord Monitor has an interesting, though perhaps unabashedly partisan, editorial on the paucity of the debate regarding mandates. Read the editors' full discussion here. Again, the issue is that it often takes a lot more than the mere framework of a compulsory system for universal coverage to be achieved.
The article from a recent issue of Health Affairs to which the editorial refers is more illuminating, tracing the relative success of mandates in other public regulations (highway safety, etc.) as well as the fledgling compulsory health insurance program of the fine state of Massachusetts. Worth reading for those of you who have university access to online journals. For those who don't, here's the essay's conclusion (Glied, S.A. et. al., "Consider It Done? The Likely Efficacy of Mandates for Health Insurance", Health Affairs, 26 (2007): 1612-21) :
"Overall, our review suggests that compliance with mandates can be quite low. In some cases, however, compliance is nearly perfect. High-compliance situations share several features: Compliance is easy and relatively inexpensive; penalties for noncompliance are stiff but not excessive; and enforcement is routine, appropriately timed, and frequent. Enforcement is simplified if all (or nearly all) of those subject to the mandate must purchase coverage at one specified time and if enforcement occurs concurrently with purchasing coverage. States contemplating the use of health insurance mandates should recognize that success will likely be determined by the processes governing compliance and enforcement that are established long after the legislation has passed. Putting these often intrusive and costly pieces into place will require much political will. And even the best mandate is unlikely to affect the behavior of those who are transient and have few assets. To reach them, health policymakers will need to go beyond a mandate and make coverage more nearly automatic."
It's worth noting the obvious point that much of this research involves either state-initiated compulsory coverage systems, or comparison with streamlined single-payer health systems in Europe. Health coverage through a U.S. federal mandate (and enforcement of it) without a single-payer system is likely to only magnify the challenges experienced by specific states. No matter what, the process will be gradual, and will require constant tinkering, not to mention (as the Health Affairs authors note explicitly) an oversupply of political will and the capacity to bring disparate groups together productively and efficiency over an extended period of time. For these purposes - I have to agree with the Concord Monitor - Obama may have a leg-up on other candidates.
Sunday, December 9, 2007
Saturday, December 1, 2007
What's in a Health Care Mandate?
With health care surging into second place (just behind Iraq) in Americans' list of concerns about the near future, the top candidates are seeking to discredit one another's plans for health care reform on the stump. The media has in particular seized on a key difference (and one of the only meaningful differences) between the Clinton and the Obama plans: whether or not the purchase of health insurance should be mandatory for all citizens. On Wednesday Clinton, as reported in the Washington Post (via Reuters), claimed that Obama's refusal to put forward a mandatory system "would leave at least 15 million Americans uninsured, including more 100,000 people right here in Iowa." The Obama campaign, of course, shot back with a stiff defense, and the candidates have continued to trade jabs.
Lost in the flux of this sparring and surface media reporting, however, is the question of precisely what's at stake (if anything) in the debate over a mandatory versus a non-mandatory system. Both Clinton and Edwards have embraced mandating insurance as a means of ensuring universal coverage. Obama has consistently claimed that since "affordability" is the most critical issue in our current health care crisis, any initial reforms must therefore focus on increasing access through cutting costs rather than on attempting to roll out care through a blanket mandate.
The fact is that neither position is particularly wrong, though each risks a potential set of initial deleterious effects. This is nicely summed up by Jonathan Oberlander in a recent piece in the New England Journal of Medicine (Volume 357:2101-2104 November 22, 2007 Number 21):
"The Clinton and Edwards plans include an individual mandate requiring all Americans to have insurance; the Obama plan mandates coverage only for children but does not rule out a broader individual mandate in the future. The Clinton and Edwards proposals follow the precedent of Massachusetts, where under a new law, residents deemed able to afford insurance must purchase coverage or pay a penalty. There is both a substantive and a political rationale for individual mandates. They allow reformers to talk about health care as a responsibility and not simply as a right — a rhetoric with bipartisan appeal — and they ensure that healthy persons join insurance pools, thereby helping to spread risk and ensure universal coverage. However, individual mandates are vulnerable to charges of unfairness, since health insurance remains unaffordable for many Americans; the political risk is that health care reform could appear punitive. The impact of an individual mandate ultimately depends on enforcement mechanisms, the price of insurance, and the generosity of available subsidies — how such a mandate would work in practice in the Democratic plans remains unclear."
Lost in the flux of this sparring and surface media reporting, however, is the question of precisely what's at stake (if anything) in the debate over a mandatory versus a non-mandatory system. Both Clinton and Edwards have embraced mandating insurance as a means of ensuring universal coverage. Obama has consistently claimed that since "affordability" is the most critical issue in our current health care crisis, any initial reforms must therefore focus on increasing access through cutting costs rather than on attempting to roll out care through a blanket mandate.
The fact is that neither position is particularly wrong, though each risks a potential set of initial deleterious effects. This is nicely summed up by Jonathan Oberlander in a recent piece in the New England Journal of Medicine (Volume 357:2101-2104 November 22, 2007 Number 21):
"The Clinton and Edwards plans include an individual mandate requiring all Americans to have insurance; the Obama plan mandates coverage only for children but does not rule out a broader individual mandate in the future. The Clinton and Edwards proposals follow the precedent of Massachusetts, where under a new law, residents deemed able to afford insurance must purchase coverage or pay a penalty. There is both a substantive and a political rationale for individual mandates. They allow reformers to talk about health care as a responsibility and not simply as a right — a rhetoric with bipartisan appeal — and they ensure that healthy persons join insurance pools, thereby helping to spread risk and ensure universal coverage. However, individual mandates are vulnerable to charges of unfairness, since health insurance remains unaffordable for many Americans; the political risk is that health care reform could appear punitive. The impact of an individual mandate ultimately depends on enforcement mechanisms, the price of insurance, and the generosity of available subsidies — how such a mandate would work in practice in the Democratic plans remains unclear."
If we mandate without simultaneously enhancing affordability and bureaucratic accesss to coverage, we penalize those for whom access is already most difficult. As proper as the rhetoric of responsibility may be, we also risk creating a culture of blame in which those already marginalized from health services (for reasons beyond their control and "responsibility"!) are wrongfully cast as irresponsible. We risk blaming the victim rather than fixing the system that victimizes. On the other hand, affordability and access are not going to change positively overnight. The favorite Obama line that his plan will save each American insurance holder an estimated $2,500 per annum is more than a little bit simplistic. Whoever is inaugurated in January 2009 will face fierce bureaucratic entanglement and debate among the various players of the health care industry, and success will likely be gradual. If this is so, then might mandating coverage provide a sharp spur to get the horse moving?
This blogger is not yet sure which approach is most salient, though he is leaning toward the Obama perspective, in part because it does not rule out future mandating once affordability and access have been enhanced. There's a final point, however, worth making, and that's the question of whether universal coverage--mandated or not--will alone succeed in making us healthier. Access to care is certainly a citizen's right and must be achieved, and the heavy burden of health care costs currently borne by Americans must certaintly be alleviated, but these issues comprise just one side of the coin. Access is about managing disease but cannot achieve the levels of disease prevention that we Americans desperately need. While the top-tier candidates occasionally drop a few lines about prevention, this discussion has barely nicked the surface of what is necessary. The simple fact is that health care costs will continue to spiral high unless the incidence of chronic diseases like cardiovascular diseases, diabetes, and cancers begin to decline. Successful prevention is as much a cure for our woes as is access. Who will be the candidate capable of pushing forth on both fronts?
This blogger is not yet sure which approach is most salient, though he is leaning toward the Obama perspective, in part because it does not rule out future mandating once affordability and access have been enhanced. There's a final point, however, worth making, and that's the question of whether universal coverage--mandated or not--will alone succeed in making us healthier. Access to care is certainly a citizen's right and must be achieved, and the heavy burden of health care costs currently borne by Americans must certaintly be alleviated, but these issues comprise just one side of the coin. Access is about managing disease but cannot achieve the levels of disease prevention that we Americans desperately need. While the top-tier candidates occasionally drop a few lines about prevention, this discussion has barely nicked the surface of what is necessary. The simple fact is that health care costs will continue to spiral high unless the incidence of chronic diseases like cardiovascular diseases, diabetes, and cancers begin to decline. Successful prevention is as much a cure for our woes as is access. Who will be the candidate capable of pushing forth on both fronts?
Sunday, November 18, 2007
OK, but what is it you're for?
DailyKos' Markos Moulitsas, better known as Kos, suggests in this week's issue of Newsweek that Democrats make George W. Bush the central issue of their 2008 campaign.
This is precisely the wrong approach for Democrats to take in 2008. No matter how bad a president you think Bush has been (debate rages in America's coffee shops over whether his presidency is transcendentally atrocious or merely disastrous), attacking him is no substitute for an actual platform. Thinking otherwise is exactly how Democrats managed the improbable feat of losing in 2004.
Back then, some friends of mine wrote the following in a New York Times op-ed about the relationship between what a party puts in its platforms, and how they do at the polls that year:
The simple fact is that Americans are looking for more than just a change. They are looking for answers. In 2006, a Democratic Congress was elected, pretty much on the basis of not being Republican. One year later, Congress is one of the few political entities in America even less popular than the president. A recent Reuters/Zogby poll found that Congress enjoys the approval of just 11 percent of Americans. That's worse than O.J. Simpson (16 percent), to say nothing of our own cosmically awful (or was it astonishingly dreadful) president, who weighed in at 29 percent.
It is certainly possible that our almost pathological obssession with attacking Bush at the expense of all other political discourse will lead Democrats to one or two more successful elections. But every day the Party slouches forward with no direction in mind besides doing whatever is the opposite of Bush, it hurts our chances of winning in the long run. Changing the direction of America takes more than saying that the present direction is terrible, even if that's true (and it is). It takes a proactive vision whose starting point is not "What are the other guys doing" but rather "What does America need right now?"
A genuine progressive agenda won't get off the ground in this country until activists like Kos figure out that Bush just doesn't merit his current position as organizing principle for the American left. If you really want to make Americans mad enough to put you in charge, don't just show them that everything we have now is terrible. Show them what you would do with the country if you were given the chance. Then, you can remind them that the goons now in power are standing in the way. Not only is that more compelling to voters, it also compels you to think about how to lead. Because leadership--not just a chance at replacing the other guy--is supposed to be what you're campaigning for in the first place.
Consequently, to stand any chance of winning next year, Republicans must pray for a national amnesia to erase the previous eight years from the minds of voters. But amnesia only happens in soap operas—and that's why Democrats will win in 2008. As long as Democratic candidates remind voters that the Republican platform and Bush's record are one and the same, victory will be assured.
This is precisely the wrong approach for Democrats to take in 2008. No matter how bad a president you think Bush has been (debate rages in America's coffee shops over whether his presidency is transcendentally atrocious or merely disastrous), attacking him is no substitute for an actual platform. Thinking otherwise is exactly how Democrats managed the improbable feat of losing in 2004.
Back then, some friends of mine wrote the following in a New York Times op-ed about the relationship between what a party puts in its platforms, and how they do at the polls that year:
Another platform indicator is the candidate-to-opponent ratio. In 1984, the Democrats, in their hulking platform, found it almost impossible to spell out their policies without reference to the Republicans. Ronald Reagan, for example, was mentioned 213 times, while Walter Mondale, the nominee, didn't come up once -- and he lost in a rout. Republicans tried the same tactic in 1996, singling out Bill Clinton 153 times -- and giving Bob Dole a paltry 45 mentions. If the strategy was to rally the base, it fell flat with the voters -- an important lesson for members of the ''anybody but Bush'' crowd, who trust hatred of the president, and not support for John Kerry, to ensure a Democratic victory this year.
The simple fact is that Americans are looking for more than just a change. They are looking for answers. In 2006, a Democratic Congress was elected, pretty much on the basis of not being Republican. One year later, Congress is one of the few political entities in America even less popular than the president. A recent Reuters/Zogby poll found that Congress enjoys the approval of just 11 percent of Americans. That's worse than O.J. Simpson (16 percent), to say nothing of our own cosmically awful (or was it astonishingly dreadful) president, who weighed in at 29 percent.
It is certainly possible that our almost pathological obssession with attacking Bush at the expense of all other political discourse will lead Democrats to one or two more successful elections. But every day the Party slouches forward with no direction in mind besides doing whatever is the opposite of Bush, it hurts our chances of winning in the long run. Changing the direction of America takes more than saying that the present direction is terrible, even if that's true (and it is). It takes a proactive vision whose starting point is not "What are the other guys doing" but rather "What does America need right now?"
A genuine progressive agenda won't get off the ground in this country until activists like Kos figure out that Bush just doesn't merit his current position as organizing principle for the American left. If you really want to make Americans mad enough to put you in charge, don't just show them that everything we have now is terrible. Show them what you would do with the country if you were given the chance. Then, you can remind them that the goons now in power are standing in the way. Not only is that more compelling to voters, it also compels you to think about how to lead. Because leadership--not just a chance at replacing the other guy--is supposed to be what you're campaigning for in the first place.
Saturday, November 3, 2007
Welcome
This is the pilot site of the blog for the Democratic Renaissance Project. Like the DRP, this blog seeks to push Democrats' thinking forward until it can answer the challenges facing America first, and Republican challenges second. Members will post here as a sounding board for new ideas as well as a space for commentary on the articles and books that now fill the intellectual space of liberal soul-searching. It is also a place to try new and risky ideas on for size, and members who aren't sure how committed they are to a thought they express here are encouraged to use a pseudonym to post. Answering America's new challenges is a long term project, and this will be a long term blog with a long term view. But we cannot delay putting pen to paper and building the new ideas that America needs. Let us get to work.
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