More on Mandates: Ezra’s Take

Is Obama’s decision not to include mandates for health coverage “a policy … his campaign regards as a mistake”? Ezra Klein believes so. Maybe he has some insider info that’s not available to the rest of us. But even if the Obama campaign thinks it’s a mistake, I don’t.

Ezra’s piece is an emphatic and succinct summary of the pro-mandate arguments being made from the left by a number of progressive Democratic health policy analysts. Ezra writes:

I’m getting really tired of Obama’s constant excuse that his health care plan isn’t universal because “The reason Americans don’t have health insurance isn’t because they don’t want it, it’s because they can’t afford it.” The reason Americans don’t all have flat screen televisions is because they can’t afford those, too.

That’s true, I suppose – although I’d hesitate to use an analogy between healthcare and expensive consumer electronics when critiquing a policy from the left. But we’re not mandating televisions. And the mandate we are discussing won’t achieve its stated goal of “universal coverage.”

Most experts agree that compliance with a health mandate will be notably less than universal. It will be greater under the Clinton plan than it would be under Obama’s mandate-free alternative. But we’re talking about relative degrees of coverage, not the “universality” that will remain somewhat elusive even under mandates.

We share similar concerns about each of the Democratic candidates, but Ezra specifically sees Obama’s no-mandate position as a betrayal of progressive principles. He writes of his hopes, now unrealized, that Obama would argue “we as a society needed to unify, come together, make temporary sacrifices to build a better world.” Ezra adds, “his remarkable eloquence rendered him uniquely able to articulate the larger progressive narrative, that our nation must move forward as ‘we,’ rather than continue as a country of I’s.”

Here’s my response: First, when it comes to universal coverage and mandates it’s not a black-and-white matter of “we” vs. “I.” Mandates add some more”I’s” into the “we” pile, but not all of us. How many? That remains to be seen. Massachusetts residents will have to choose between expensive health insurance or a tax penalty that starts at less than $300 but quickly escalates to half their expected premium. Many will buy the insurance, but others will take the penalty.

As Massachusetts “Connector” Authority chief Jon Kingsdale said, “There’s good evidence, whether it’s buying auto insurance or wearing seat belts or motorcycle helmets, that mandates don’t work 100%.”

“So is Obama going to make health insurance free? Ezra asks. “A dollar?” The answer is, we don’t know how much Obama will charge. We also can’t answer these questions: “Is Hillary going to seize assets? Would she charge $15,000 per person for an average premium?”

In fact, there is a serious lack of specificity about numbers all around. That makes this debate especially difficult to conduct. There is the theoretical possibility of a fair and equitable mandate-driven system, but it would require extensive and sophisticated underwriting work. The best-known attempt in recent years, Massachusetts, has been a flop so far, and why? Because they rushed into it.

Score one: Obama.

In a sense, Ezra is channeling John Edwards more than he is Hillary Clinton. “Shared responsibility” is a phrase Edwards used repeatedly in announcing his health plan, which preceded Clinton’s and is also mandate-driven. And Ezra’s concern about Obama and health seems to be that Obama isn’t asking us to make the collective commitment to obtain health coverage.

So what do we do? Both the Edwards and Clinton plans offer the opportunity to buy into a Medicare-like public program. That’s an important first step toward one of two things: either true efficiency among private insurers, or – as I’ve said before – the gradual elimination of for-profit insurance using market forces rather than regulation.

The difference between the Obama position (which I prefer) and the Edwards/Clinton position (which Ezra likes) boils down to this: not if you require full participation, but when and how. For the “when” Ezra – along with Jacob Hacker and others – say “now.” I say “when there is a working system with proven affordability, sophisticated underwriting, and a truly fair system of subsidies.”

(I also think mandates are potentially a political loser for Democrats, but that’s an argument of tactics and not strategy.)

As for “how,” Obama will presumably propose a mandate to pay health premiums at some point in the future. But we already have a proven and time-tested “we” answer: It’s called taxation. A premium-based public system will always be a form of regressive taxation. Why not use a time-tested approach to “mandating” that the public pay for something? It’s generally fair, it distributes the burden equitably, and it puts us in line with other industrialized countries.

Ezra concludes his piece by suggesting that perhaps Obama should find more political courage and go all the way by saying that health care is a right, “because that’s what sort of country we are. ” He adds, “That would be great.”

In the end, maybe we’re on the same page after all.