Theory v. Reality

There's something of an economist's conceit to Paul Krugman's story about Obama, Clinton, and mandates in health insurance. While he outright states that "If Mr. Obama gets to the White House and tries to achieve universal coverage, he’ll find that it can’t be done without mandates" - he scarcely addresses the fact that universal health care and universal health insurance are not the same thing at all. There is very little concern ever in Krugman's articles about what the health insurance industry has traditionally done to those who have their coverage. Clinton's plan limits premiums but does not, to my knowledge, have a cap on how much insurers can spend on things other than health care. To be fair, I don't know if Obama's does either, but without massive regulation of the insurance industry you'll simply have a universal system where everyone has really crappy health care.

Then there's this:

Mr. Obama claims that people will buy insurance if it becomes affordable. Unfortunately, the evidence says otherwise.

After all, we already have programs that make health insurance free or very cheap to many low-income Americans, without requiring that they sign up. And many of those eligible fail, for whatever reason, to enroll.

Because there's so much education in low-income communities about the choices offered to them. This is an ivory tower view of how health care works. A bully pulpit from either President talking about affordable options, and a citizen education program where community clinics are identified and Medicaid-like options are offered is really the only way. If you hit someone when they come into contact with the medical care industry with a whopper of a bill they're going to recoil. And it won't matter at that point from a cost control standpoint, since they will not have had any preventive care and the bill will be enormous.

The problem here is that it's very easy to talk about health care at a wonkish level, but getting into the heart of the matter means that you have to negotiate some landmines in describing it to people, particularly when you're trying to add on to a system that's so broken.

In a day dominated by familiar stump speeches, Hillary Clinton made news by saying she might allow workers' wages to be garnisheed if they refuse to buy health insurance. She has criticized Obama for pushing a health plan that she says would not require universal coverage.

Pressed on how she would enforce her mandate, Clinton said: "I think there are a number of mechanisms" that are possible, including "going after people's wages, automatic enrollment."

She said such measures would apply only to workers who can afford health coverage but refuse to buy it, which puts undue pressure on hospitals and emergency rooms. Under her plan, she said, health care "will be affordable for everyone" because she would limit premium payments "to a low percent of your income."

Obama has said he would require parents to buy health insurance for children, and possibly fine them if they refused. But he would not insist that all adults buy insurance.

Clinton is perfectly right, although she ducked this question over and over again yesterday before finally relenting. But the headline that comes out of this is "Clinton will garnish your wages" for health care. That's a much more frightful scenario for people, even if it wouldn't impact very many of them, than raising taxes for health care in a single-payer format. Because Democrats are so frightened of the "T" word and have basically left it for the Republicans to define, they have to walk on eggshells. In truth, polls show that people will support higher taxes in return for universal health care. But nobody gives them that choice.

On balance I don't totally agree with either of these plans, or at least the emphasis that they make on them; why aren't they more detailed about the public option that competes with the insurers, which made me so excited about the Edwards plan? But Krugman is being silly to make such a hard distinction, because he's basing it on the theoretical and not the actual business of brokering a health care deal in the real world.

UPDATE: In a blog post, Krugman revises and extends. He basically says that universal health care has to be the central item in a progressive agenda, which I find pretty myopic. Why wouldn't changing the neoconservative mindset at the root of our foreign policy, or creating a green economy to fight global warming, or adding all kinds of infrastructure jobs to get America working again, or comprehensive immigration reform, or any number of things, end up paying the dividend of reinvigorating a progressive agenda? I never took Krugman to be such a single-issue voter (while at the same time ditching single payer instead of making the actual argument for it and attacking BOTH of these compromised plans from the left!).