In an article published today in the American Spectator, David Catron gives his views on Obama's and Clinton's health care plans. He describes himself as a health care finance expert who has spent more than twenty years working for and advising hospitals and medical practices. He opposes universal health care, stating that our current health care system allows for capitalism to take control. We pay higher costs and get higher quality treatment because the better doctors charge more and the okay doctors charge lower rates. It encourages competition and competition drives doctors to become better so they can in turn charge more.
Needless to say his conservative views on health care are not mine. However, his article nevertheless contains useful advice for Democrats as we prepare to push for health care reform. Let me say up front that I think Obama's and Hillary's plans are quite similar; both would be an acceptable starting point and both need to be improved before they are actually passed. However, the differences are real and they are politically meaningful.
First, his impression on which candidate poses a greater threat (from his conservative perspective) to win in November. He thinks that Obama is more likely to win in the general because he is "more charming" and has "far less political baggage." Take it for what it's worth, it's just one person's opinion, but my impression is that it is aligned with mainstream conservative attitudes. Obama is outperforming Hillary in recent head-to-head matchups against McCain (and Romney, but they both hammer Romney).
For conservatives, watching Barack Obama challenge Mrs. Clinton's claim to the Democratic Presidential nomination provides no small amount of schadenfreude. [...] It would, however, be far less pleasant to watch the eventual Republican Presidential nominee grapple with Obama in the general election. The Illinois Senator would be much harder to beat than Hillary.
Next, his take on their health care plans. Remember, he opposes universal health care. He does not want either the Clinton or the Obama plan to be implemented, but which does he think is more likely to get traction with the public? He thinks that mandates will turn off some Democrats, who worry about what they will look like in practice. Indeed, Hillary continues to avoid specifics on penalties for noncompliance, although she indicated she would consider garnishing wages. He also thinks mandates won't play with those conservatives who don't like such heavy-handed governmental control. I suppose any universal health care plan will be greeted with cries of "socialism!" from some quarters on the right, but seems to me that demanding mandates needlessly invites opposition that wouldn't necessarily materialize if we first try to cut costs (and provide subsidies) so everyone who wants insurance can afford it.
In addition to making him seem far less threatening than Hillary, Obama's mandate position would serve him well in the general election. As Jonathan Cohn pointed out in the New Republic, Obama's argument resonates not only with "liberals who worry a mandate simply cannot work in practice," but also "among conservatives who simply don't like the government telling anybody what to do."
Finally, he notes that one of the Republican candidates, Romney, already tried mandates in Massachusetts, with mixed results. Quoting from the Boston Globe:
Even at these reduced rates, the plans will still not be attractive to many. People earning between 151 percent and 300 percent of the federal poverty limit -- $25,000 to $110,000 for families and $15,316 to $50,000 for individuals -- are expected to pay up to 9.6 percent of their income on insurance premiums, or pay fines. (This 9.6 percent is before any co pays and cost sharing.) [...] Politicians will be under strong pressure to not enforce the mandate once the fines increase to meaningful levels. Indeed, they have already shown their willingness to back away from it for the 20 percent of people, and have set up a waiver process to exempt others on a case-by-case basis.
[...] The system is set up to tax the young and healthy -- who typically have both less income and less wealth -- to subsidize those who are older and less healthy. One goal, according to the organization Health Care For All, is "to create a statewide credible risk pool, so healthy people 'prepay' toward their medical care."
The problem with this is that the young and healthy, who are already prepaying for Medicare out of every paycheck, may object to this new form of taxation.
Now, some of these problems are specific to MA, and some to state-level plans (see also the failed effort in CA), and some wouldn't apply because of how Clinton's plan is structured. I'm not trying to suggest that Romney's experience is the definitive word on mandates. But there are some relevant cautions here that anyone backing Hillary's plan needs to consider.
From my perspective, the whole debate over mandates is a bit misplaced. They don't impact that large a percentage of the population, they don't make a huge difference in premiums or perhaps even in coverage, and the sudden viciousness of this debate (and yes, Obama's mailer didn't help the tone) is making it appear that Dems are divided when in fact there is broad agreement on the important details of health care reform. Don't listen to me, listen to former Labor Secretary Robert Reich on his blog:
As a practical matter, the difference between Sen. Clinton's and Sen. Obama's approaches come down to timing and sequencing. Mrs. Clinton wants a mandate first, believing that enrolling the younger and healthier will help reduce costs for everyone else. Mr. Obama thinks forcing people to buy health insurance before it's affordable isn't realistic. He wants to lower health costs first, and is willing to consider a mandate only if necessary.
This fight is little more than a distraction, given that a mandate would matter only to a tiny portion of Americans. All major Democratic candidates and virtually all experts agree that the combination of purchasing pools, subsidies, easy enrollment and mandatory coverage of children will cover a large majority of those who currently lack insurance -- even without a mandate that adults purchase it.
Mandates aren't the key issue; I happen to think they are counterproductive at this point, but on policy grounds I could live with them if it brought us universal health care. However, there are political avenues of attack against Clinton's plan that are closed off by Obama's plan. There are also very real positives to the coalition-building approach Obama utilizes: to pass universal health care in any reasonable form will require leadership that can unite liberals, moderate conservatives, and independents behind a solidly progressive bill that everyone can accept.