Tuesday, February 26, 2008

On Clinton vs. Obama on individual adult mandates for health coverage

A number of prominent health care experts, most former officials in the previous Clinton Administration, have lent their support to Senator Clinton's attack on brochures distributed in recent weeks by the Obama campaign, linking the brochure to the infamous "Harry and Louise" ads of 1993-4. The issue is discussed in a posting on the online blog site of The New Republic. Herewith my response:

I strongly favor a single payer financing system with universal coverage for health care. Such a system would not solve all the problems of American health care--no system would. But it would move us closer to universal coverage than any alternative, would provide the best basis for administrative simplification and cost savings , and would provide the strongest basis for controlling high and rapidly rising costs of pharmaceuticals, technology, and fees. The plans advocated by Clinton, Edwards, and Obama don't come close.

As between the variants proposed by Edwards/Clinton and Obama, I prefer the plans with an individual mandate covering both children and adults to one covering children only, and believe that some such arrangement will ultimately be necessary if we move down this particular road. But this is, I think, a matter of timing and a study in grays, not an earth-shattering, epic battle between virtue and vice. An individual mandate is very tough to enforce effectively and without negative side-effects. I am inclined to believe that Hillary's plan would cover somewhat more individuals than Obama's, but both would be vast improvements over existing policy, and neither would effect the major advantages, including but not limited to scope of coverage, of single payer.

The signers of this letter--the vast majority of whom held senior positions in the (first?) Clinton Administration--address the brochure in question devoid of political context. Senator Clinton has been trying to clobber Senator Obama with what is likely an exaggerated version of the coverage limits of his plan, and an exaggerated version of the benefits of hers. She suggests that Obama simply doesn't care about achieving universal coverage, and refuses utterly to credit that he might have plausible policy and political /strategic reasons (looking to the general election, and to the political negotiations that will be required to win Congressional approval for any major health care reform package) for downplaying an (only partially effective) individual adult mandate from the outset. On policy, I am closer to Clinton than to Obama on this point. But politically (in terms of both the general election and future Congressional negotiations), I think it is a tough call, and one well beyond my expertise.

But the relevant point here, I think, is that Hillary has not sought a measured discussion and debate over the complex tradeoffs involved, and has refused to acknowledge that her approach involves some casts and risks as well as benefits. Her approach to Obama has been punishing and demagogic (on a variety of issues, not limited to this one). All purity is with her. It was particularly ironic in the Texas debate when she invoked Social Security and Medicare in favor of her plan and against Obama's, while studiously ignoring the fact that those programs are much more akin to single payer than to any of the Clinton/Edwards/Obama approaches.

Signers, what exactly would you have Obama do in these circumstances? Is Hillary free to say what she will, while Obama is debarred from explaining the factors that led him to make a somewhat different set of tradeoffs in what are fundamentally very similar plans? This sounds all too much like a call for unilateral disarmament, in the tradition of Kerry's inability to respond quickly and effectively to the Republican slime attacks of 2004. Obama needs to show he can and will fight back. Senator Clinton's angry whining in response seems, yet again, a likely instance of her own psychological projection, accusing her opponent of tactics (and motivations) all too present in her own campaign. Signers, I fear that you are at risk of becoming enablers in this regard.

I very much doubt Senator Obama would be distributing a brochure highlighting the tradeoffs implicit in any system of individual mandates had Senator Clinton not placed her central campaign focus (beyond "experience", from which she seems to have learned all too little) on demagoguing a debatable tradeoff in Obama's health policy by accusing him, repeatedly, of indifference to their shared goal of vastly expanding the scope of health coverage.

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