More on Health Care: The Obama Reply

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The Barack Obama campaign takes issue with a couple of points I made in yesterday’s story. By e-mail comes this from ever-vigilant Obama spokesman Bill Burton:

I note that in your story that you write our plan isn’t universal
because it doesn’t include a mandate – a suggestion we fundamentally
reject. Our plan will cover everyone when fully implemented and, if it
doesn’t, we’ll find ways to make sure it does. On the other hand,
having a mandate does not necessarily guarantee coverage.

Here’s the issue: The Obama plan, like that of John Edwards and Hillary Clinton, contains an employer mandate–a requirement that all but the smallest employers either provide health coverage for their workers, or pay into a fund that would. However, there will be people–say, the self-employed, or those who work for smaller firms–who can afford coverage, and simply choose to go without. Young and healthy people are the classic example. All three plans provide additional incentives to bring them in, largely by making it easier and cheaper to buy coverage. (Obama claims his plan would save the average family $2,500 a year.) However, only Edwards and Clinton would require them by law to buy coverage, much as state law requires you now to buy auto insurance if you have a car.

Burton points out that this “individual mandate” doesn’t guarantee that everyone has coverage either, and cites the plan the Mitt Romney signed into law in Massachusetts as the best example:

Well, in Massachusetts, the state has had to exempt 20% of the uninsured because of the cost – which means that 1 in 5 uninsured folks in
Massachusetts will still have no health insurance under this plan that
includes a mandate. That’s why Barack Obama’s plan focuses on cutting
the costs of health insurance. 47 million Americans lack health
insurance not because they don’t want health insurance but because they
can’t afford it.

Here’s another instructive example of what mandating insurance can mean
for achieving universal coverage – although liability auto insurance is
compulsory in 48 states and D.C., 14% of drivers nationwide are still
uninsured.

Only New Hampshire and Wisconsin do not have compulsory auto insurance
liability laws. Despite this, the estimated percentage of uninsured
drivers in the United States increased from 12.7 percent in 1999 to 14.6
percent in 2004. The three states with the highest uninsured driver
estimates were Mississippi (26 percent), Alabama (25 percent) and
California (25 percent), all three of which have mandatory liability
insurance. [Insurance Information Institute, July 2007] the link to the
study is here.

That is a very good point, and what it suggests is that none of the leading Democratic plans would in and of itself get the country to universal health coverage. In fact, the only plan that would do that is single-payer health care–a government-run plan like Medicare, or the health systems used in Canada and Europe, where everyone is automatically eligible for coverage and their taxes pay for it. Of the Democratic contenders, only Dennis Kucinich supports that idea.

The bottom line: All three of the leading Democratic contenders’ plans are both credible and bold. All of them would go a very long way toward assuring health care for the nearly 50 million Americans who now lack coverage. Now that the candidates have put their ideas on the table, the real question is not how airtight a plan is, but how likely it is that the candidate could shepherd it through the minefield of political and economic interests that would stand between having a proposal and passing a law. That, I think, is where the health care debate in the Democratic primary is headed.

UPDATE: Commenter Tim asks a very good question: Who are the uninsured, and where does that number come from?

One compilation of three national surveys put out a little over a year ago by the Kaiser Family Foundation gives us a sense of who they are. More than half are poor, and about half are minority. What’s more, the majority are working, but in jobs that lack employer-sponsored coverage. (The number of employers offering health benefits has dropped to around 60%, compared with 69% in 2000. And nearly everyone has seen the cost of their premiums go up.) The uninsured are not always the same people. Over the course of two years, as many as 85 million people have lacked insurance at one time or another. They are largely adults between 18 and 44 years old (whose children probably qualify for coverage under SCHIP and whose parents are covered by Medicare).

UPDATE2: Talk about reader service! Our commenters are even getting their questions answered on other people’s websites. Over at Pollster.com, Mark Blumenthal digs deeper into the data. Also note this from Carl Bialik’s WSJ blog regarding the fact that the 47 million being quoted as the number of uninsured in this country includes around 10 million non-citizens.