The Nitkin article says, "Former Sen. John Edwards of North Carolina, New Mexico Gov. Bill Richardson and Sen. Christopher J. Dodd of Connecticut have included the requirement [to be covered by health insurance] in their health plans, making Obama the most notable outlier in the party's presidential field." It does not mention Rep. Dennis Kucinich by name as the main presidential proponent of a "single-payer" system of health care financing, called in the article "a Medicare-style government program that replaces private markets."
The article seems to suggest that none of the Republican candidates are offering universal-coverage plans for health insurance. Oddly enough, former Massachusetts Governor Mitt Romney, a GOP presidential hopeful, was responsible for shepherding through the legislative process in his state the only state-level program to date that mandates health coverage. The article says it is too early in the game to see whether that program, which assesses the uninsured with a financial penalty unless they buy insurance, will actually bring about universal coverage. Mrs. Clinton's proposal for the country as a whole is very much like the Massachusetts system.
Switzerland and the Netherlands are the only other countries with a health insurance mandate, but their plans are notably dissimilar to the Clinton proposal. So it's anybody's guess how many people would fail to buy "mandatory" health insurance under the Clinton system, either because they were legally granted exemptions or because they simply scoffed at the law.
Nonetheless, Clinton's side is accusing the Obama proposal of failing to cover everybody. The Obama folks say the "young invincibles" who today opt out of the private health insurance sector could be brought in without a mandate. These are the youthful, healthy souls whose finances are stretched thin enough, during the years in which they are getting started in independent life, that the extra burden of paying premiums for insurance they don't "need" appears an unjustifiable expense. Obama wants to change the law to allow them to continue to be covered under their parents' health insurance until age 25, regardless of whether they are still in school.
He also favors "reducing the costs of insurance, which would almost certainly require huge government subsidies for the poor. Obama says it makes most sense to focus there first" — rather than go immediately to a health insurance mandate, as Clinton wants to do.
The reason both Clinton and Obama want to bring the "young invincibles" and others without health insurance into the system is not just to make sure no one gets slammed with huge, unpayable bills if their health suddenly deteriorates. It is also to make sure those who continue to have good health do their part to spread the risk of illness and its associated cost over as broad a base as possible, providing their fair share of the money to finance the system as a whole.
Supporters of the Clinton mandate are, the article says, intent on changing the thinking of Americans. Robert Blendon, a health policy professor at Harvard University's Kennedy School of Government, is in the Clinton corner:
The details of a mandate are less critical than the change in thinking that such a requirement would instill, Blendon said.Clearly, under the Obama proposal there would be less of an impetus toward such a cultural change of attitude. Even though Obama's voluntary-for-adults approach to health insurance might wind up covering just as many Americans as Clinton's mandatory-for-all approach, it would not stigmatize the uninsured. oldstyleliberal favors the Obama approach for this reason. He does not approve of stigmatizing individuals such that "when you go into a doctor's office, they are horrified if you don't have coverage."
"The most important thing you want to achieve is a cultural change which sort of accepts the responsibility that people have coverage," the Harvard professor said. The country must create an attitude where everyone is expected to have health insurance, he said, so "when you go into a doctor's office, they are horrified if you don't have coverage."
Still, oldstyleliberal feels Barack Obama's approach to health care financing could be improved by including something most of the Republican candidates support: enlarged health savings accounts.
HSAs are only a few years old, and many Americans have yet to hear of them. In their current form, they allow Americans to set up accounts that are like "401(k)s on steroids." Account owners can contribute so many dollars a year to these accounts, and their employers can likewise make contributions up to a certain amount. Both types of contributions are exempt from income and payroll taxes.
If the owner of the account wants to pay for his or her medical expenses out of the HSA, or for the requisite high-deductible health insurance premiums, that too is tax-free — no matter what age the account owner is. After age 65, any withdrawals for all other types of expenses are also tax-exempt. Before age 65, non-medical withdrawals are taxed as income.
Currently, the rules for HSAs insist that the owner have high-deductible health insurance to supplement the accounts. HSA owners are responsible for paying their own way, in terms of their ongoing medical expenses, until the relatively high annual deductible is reached each year. Beyond that, owners continue to pay copayments for their health services, at a set rate, until a certain number of dollars of out-of-pocket expenses (above and beyond the deductible) has been accumulated. Until that point is reached, the requisite insurance covers only those covered medical expenses above and beyond the copays. From that point on, the health insurance takes over and pays all covered medical expenses.
The assumption here is that the deductible amounts and the copayments would come directly out of the HSAs, assuming they contain enough money to begin with, since using HSA funds for medical expenses is tax-free.
HSA advocates want to remove many of the restrictions and limitations of the current law as it pertains to health savings accounts, bringing in the era of so-called "large HSAs." They want to increase the contribution limits to allow employers to deposit the full value of workers' health benefits directly into their HSAs; eliminate the health insurance requirement for HSAs entirely; and allow tax-free HSA withdrawals for all voluntarily incurred health insurance premiums, not just those spent on the currently mandatory high-deductible health insurance.
In other words, owners of "large HSAs" and their employers would be able to choose not to obtain/provide health insurance coverage at all; to choose the currently mandatory high-deductible health insurance; or to choose an "ordinary" health insurance plan that does not feature high deductibles and/or high limits on out-of-pocket copayments. Those who wish to do so could combine a "large HSA" with their existing insurance coverage and then, if they want to later, optionally migrate either to high-deductible coverage or to no coverage at all as they become comfortable with making such choices on their own behalf.
Proponents of "large HSAs" believe they would put more decisions about health-care purchases in the hands of consumers themselves and bring all the benefits of informed marketplace participation to the health-services and health-insurance domains. Competition would flourish. There would be fewer incentives for those who now have comprehensive, low-copay, low-deductible coverage provided by their employer to continue to demand more health services than they would if they were paying the costs themselves. These individuals and their families would opt to save money in HSAs instead and economize on medical outlays, resulting in less health spending overall. Studies show that the "extra" services today demanded by the comprehensively insured don't really improve their health status or life expectancy, but they do inflate health-services prices. Health-services prices would accordingly come down if "large HSAs" were enacted into law.
Opponents of "large HSAs" object that the tax-free aspects of a growing plethora of them would drain the Treasury of needed revenues, in terms of foregone income taxes and payroll taxes. Supporters counter that "large HSAs" would offset the anticipated drain on the Treasury associated with Medicare, as baby boomers cross the age-65 threshold.
Opponents also object that there is no reason to be sure "large HSAs" would spread health risks and their associated costs equitably over the entire population, the way a Clinton-style universal-coverage program supposedly would. An Obama-style universal-access plan would presumably make it less likely that all of the medically needy among us would have insurance.
Still, it's not clear that mandated universal coverage would turn out to be truly universal. And it would stigmatize those who lacked it. That's why oldstyleliberal thinks we ought to try an Obama-style universal-access plan, augmented with "large HSAs," before proceeding — and then only if necessary — to a full-fledged Clinton-style mandate.
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