A View From The Press Box

You are SOOO right about mandatory health insurance.

As a senior, I can just imagine where I would be without Medicare...and then Medicare Supplemental to complete the plicture.

I've always felt your suggested approach makes sense.

Now, if we can just get the politicos on our side....

Over the years, I have had enough phone calls consisting of some variation of, "We just found out my wife is pregnant and so we need health insurance," that I agree completely with mandatory health insurance.

Now whether it is private, government, socialized, or other, I do not know enough to say.

But we have an entire society that, given the opportunity to sacrifice a little today to protect themselves for the long run, are only too happy to go out and buy some more toys and trinkets immediately.

Why should the U.S. even have a "health care system"?

Taking care of one's health, and that of one's children, is every individual's own personal responsibility, to be carried out through healthful living practices, voluntary contracts with health care services providers and, optionally, with health insurance companies.

What you are proposing is the forced subsidy by the young and healthy, whose aggregate health care costs are very predictably low, of the old and the unhealthy, whose aggregate health care costs are very predictably high.

That's not an insurance plan, where the beneficiaries pay premiums closely correlated with their risks as forecast on the basis of the past experience of homogeneous groups with their risk-related characteristics. It's just a wealth redistribution scheme, at the point of the government's guns.

It damages incentives to live prudently, frugally and healthfully, and to make provision for one's old age, just like Social Security and Medicare do. It encourages passing the buck to the next generation, and thereby makes it doubly hard for that next gneration to make provision for its own old age.

If, as you say, "the public in general will not adequately look out for their own long-term financial health", why should that public in general have a right to be bailed out by the other fraction of the public that does live prudently?

Choices should have consequences, that's all that impels people to make good and prudent choices.

If somebody is going to bail you out anyway, why not burn the candle at both ends? (And why not build a mansion on the Florida coast, as another example of imprudence expecting a bailout by the prudent.)

By the way, I don't agree with mandatory auto insurance, either. Whoever is concerned about the risk of injury to his body or damage to his auto ought to buy his own insurance to protect himself and his family, if he needs it.

That's what it is about the utopian left--if the prudent people with some resources don't want to go along with their utopian schemes, they have to be forced, even at the point of a gun, if that's what it takes. Get the gulags ready.

SAM FRIEDMAN RESPONDS (From The "Utopian Left"):

If we adopt your premise, Mikk, why should government supply public education at the taxpayers' expense? If people can't afford to send their kids to private school or teach them at home, the heck with them!

If we took that attitude, of course, we'd have a pretty stupid society, lacking the educational level to create a vibrant and healthy economy and a decent standard of living for all.

I'm frankly weary of those advocating an "every man, woman and child for themselves" philosophy. There are reasonable accommodations that can be made by all to secure a level playing field for all, whether that be for health, safety or education.

There is a benefit for all as well, since we need educated, healthy people to not only serve as our workforce, but to be consumers and fuel the economy as well.

Your premise also ignores the fact that not everyone falls ill by "choice" (via unhealthy habits or neglect). Most, in fact, suffer a health crisis beyond their capability to control. We need a healthcare safety net to keep our society from becoming a Third World country, where you have 98 percent living in abject, hopeless poverty, and 2 percent living the good life.

MIKK HAS THE FINAL WORD:

There is an argument to be made in favor of public education at taxpayer expense (wisely spent, which is another topic) as an investment that is expected to repay itself to taxpayers in the form of a higher economic productivity level by more educated citizens.

I don't see the same argument applying to health care for the elderly infirm, which is where most of the health care dollars are being spent.

I like your reasoning.

One argument for universal mandatory coverage is that you can then wean the insurers away from favorable selection. Favorable selection by workers' comp insurers works as a spur to better risk management.

When health insurers start trying to craft their pricing and distribution and underwriting practices to avoid bad health risks, that doesn't make the bad health risks change their health-- try making yourself free of diabetes.

Universal coverage goes hand in hand with prohibitions against the most aggressive strategies to favorably select.

This does not mean that non smoker discounts should not be allowed; it means that you are not disadvantaged because you have disease.

I'm sort of caught in the middle on the whole mandatory health coverage issue.

I can see where mandatory implemetation would do a much better job of spreading risk and curtailing unfavorable loss ratio's for insurance companies.

However, on the opposite side of the issue, I hate the fact that in the staunch democratic society we live in that we would force anyone to buy anything for "their own" protection and betterment.

That being said, I do disagree with the former response against mandated auto insurance, as that was put in place for the protection of negligence against another person.

There are pro's and con's to both sides of the argument, which makes this such a hot-button issue.

We all agree that coverage across the board would somewhat stabilize pricing and risk management in the health sector, but do we as a society really want to use words like "force" and "mandate" on an issue that should be a democratic freedom?

Let's face it, if everyone in America had a car alarm, auto rates would go down, too, but I don't think anyone here wants to be forced to buy one.

Looking forward to the presidential run and the ongoing debate as to who has the better plan, I loved that Sen. Clinton proposed that "sick Americans should not have to pay any more for coverage than healthy Americans." I cant wait to see how that shakes out.

SAM RESPONDS:
I appreciate the thoughtful and balanced response, but keep in mind we do mandate that people save for retirement via Social Security payroll deductions, and for their senior medical care via Medicare, and even their unemployment insurance. Why not standard health insurance?

MICHAEL BURNELL HAS THE FINAL WORD:
I do agree with your point on Social Security and Medicare.
With that said, I would also point out that those programs are in the toilet or heading there fast due to the wasteful spending and "pork barrel" mentality of the people who are supposed to be watching over that money. At least with "freedom of choice" I can choose what "I" want to do with "my" money.

I know everyone has concerns about universal health insurance, but having health insurance tied to the job isn't the best, either.

If I become ill and no longer able to work, I also no longer have health insurance.

I know about COBRA, but COBRA does not last forever, and my illness does. The individual market certainly isn't willing to insure me now!

It would be really grand if only peole that did not take care of themselves got sick, but sometimes healthy people get sick, too!

After listening to the pros and cons of mandatory health care coverage and considering the reality of the uninsured using the emergency rooms of this nation as a GP's office (and often pleading for someone else to foot the bill), I've definitely taken on a bent that there is a true benefit to the nation to consider mandated medical coverage.

Logically speaking, if we had "freedom of choice" to elect NOT to purchase medical coverage, that should translate to freedom to choose not to visit an emergency room (or other medical facility) when you get seriously hurt or sick.

Under such plan of taking care of yourself, you can repair your own wounds, x-ray your own broken bones, and purchase your own MRI machine to see if you've got brain damage (though that may already be evident if you choose to NOT purchase medical coverage BEFORE you become sick or injured).

In my mind, if we as citizens want the right to seek appropriate medical care (and I think we all do), then we also have the responsibility to make provisions for financing the cost of that care. A mandate that we all buy health insurance may have to be the price for securing that right.

Mikk argues that such a mandate removes the incentive to take care of yourself. He ignores the consequences of illness that insurance cannot affect.

Insurance cannot eliminate the pain, side effects from medication, inconvenience, indignity (modesty goes out the window when you're sick), and disruption that accompanies serious illness.

Also, I have to think of my mother-in-law, who was knocked over years ago by someone running through a public park. She broke her wrist; the perpetrator never stopped.

Was she to blame for this? Should she not have had recourse to medical coverage? She was 60 when this happened; was her treatment subsidized by the more deserving young and healthy? Mikk's arguments vastly over-simplify the issues.

Thank you for your continuing attention to the country's health care issues.

Tim Dodge, AU, ARM, CPCU
Director of Research & External Communications
Independent Insurance Agents & Brokers of New York, Inc.

I think that ultimately looking at mandatory coverage for everyone will do little to cure the health care probelm we currently face.

Social Security solvency gets hammered all the time, even around the comment section of a prominent insurance news outlet blog.

If you're reading any of this, than you probably have access to an actuary who can easily go over either the annual trustee report or the CBO projections for SS and readily see that the "crisis" is largely manufactured here.

A nominal tax increase coupled with a slight benefit decrease would easily bring the program into actuarial balance over any horizon. Keep in mind the $11 trillion dollar gap is when we consider the program out to infinty!

On the other hand, Medicare will almost certainly be insolvent within 20 years. This is due mostly to the astronomical cost of health care.

While mandatory coverage for everyone would probably help insofar as additional tax dollars would more than offset costs associated to lower risk users of the system, it would not solve the problem in and of itself.

I broke my collarbone and got a sling to take home. The bill for the sling alone was $250. It was canvas and velcro.

I know that part of that money was due to someone else not paying for theirs because they had no insurance, and part of it paid for a lawsuit for some dummy who choked themselves with it.

But that cannot account for even half of the cost, and that says a lot when you consider I should have paid $10 for the thing.

Pricing for medical servies across the board is astonomically expensive due mostly to the greed of those within the health care system. This is the same healthy greed we expect to drive capitalism, which can be positive, but it doesn't work everywhere.

It doesn't work for electricity, water, telephone service or insurance--to name a few industries that had to be heavily regulated to protect us, the consumers. The same is true of medical care.

The knee-jerk reaction is, "We don't need socialized medicine."

Fine, we don't need the government to provide water or electricity, either, but we do need it to regulate these industries and protect us from monopolostic price gouging.

Mandatory coverage alone won't solve the problem. We need a multi-dimensional approach with the foundation lying in regulation aimed at keeping cost for services within reason.

I am active in the health insurance market and have changed my mind on universal/mandatory coverage and now favor this approach. However, I do have major concerns about the costs of such a plan.

We are now seeing Part D Plans having huge increases in costs. I know that there are "costs" to society from people that do not have coverage, but the costs of a mandatory plan could very easily outstrip our ability to pay.

I would like to hear from someone concerning
how we best allocate services and contain costs.

Many of us who live in smaller rural areas see our access to good quality care eroding.

I guess in the end if we go to a mandatory plan all I want is the same plan as my congressman.

Putting aside the pros and cons of the issue for the moment, what do you think should happen to people who disobey the mandate?

SAM RESPONDS:
Great question!

If it's done like Social Security, via payroll deduction and the income tax system for self-employed or unemployed, that should account for a large segment of the population.

But I can see where problems will arise...What to do about those who are unemployed or simply cannot afford the extra payment? What to do about those who simply don't pay? (We have this problem with uninsured drivers, right?)

I don't have a definitive answer, but we are a resourceful nation and if we put our minds to it, we can come up with a solution. We did with Social Security and Medicare.

This entire issue will be a non-starter if a Republican keeps control of the White House. If a Democrat wins next November, the debate will begin in earnest right after Inauguration Day 2009. I personally cannot wait!

Does anyone have any suggestions on how to enforce a mandate or deal with some of the issues raised here???

The general tenor of the argument in favor of mandatory universal medical insurance is that the identifiably old and/or sick should not have to pay any more to guarantee their health care than the identifiably young and/or healthy.

The only way to make ends meet in that scheme is to make the young and healthy pay in far more than is predictably needed to cover the cost of the inevitable but lower-frequency and lower-severity illnesses and injuries that will occur among them, too.

That's not an insurance scheme, that's a simple subsidy or redistribution of wealth scheme.

Sam, you argue that "We need a healthcare safety net to keep our society from becoming a Third World country, where you have 98 percent living in abject, hopeless poverty, and 2 percent living the good life."

That's an argument that has nothing to do with health care and everything to do with the politics of redistribution.

If you favor confiscating the wealth of the rich and paying it over to the poor, by all means make your arguments in favor of that, but don't drag health care into the middle of it!

SAM RESPONDS:
Mikk, first of all, wouldn't this "redistribution of wealth" balance out, since when these young, healthy people get older, THEY will be the ones "subsidizes" as they age???

Also, the elderly aren't the only "problem." There are tens of millions of middle-age and younger (including millions of children) lacking health insurance as well.

Actually, you cannot separate health care from the broader societal problem of huge gaps in income/wealth/living standards, since medical crises are one of the biggest causes of personal bankruptcy.

There are plenty of ways to tax everyone fairly so that everyone has access to affordable health care without creating a socialist/communist state, my friend.

If you wish to live in an "every man, woman and child for themselves" world, go for it. But our body politic, I believe, has a more benign vision for an equitable, healthy society.

MIKK HAS THE LAST WORD:
What you describe is a continuous involuntary inter-generational transfer of wealth from the young to the old.

The young, however, on the whole have less wealth than the old, or at least they have had less time and opportunity to move up the income scale and accumulate any wealth.

So the poorer segment of society is to subsidize the wealthier. In return, they are promised their opportunity to leech off the incomes of their fellow citizens' children and grandchildren when they get old enough.

If that's not enough incentive to make them pay up, the government will simply force them to pay, at the point of a gun if necessary. That's what "mandate" means.

One hopes that the younger generation will be sufficiently larger than the older generation so that the burden on individual members of the younger ones is widely spread and bearable, but that's not the demographic trend.

I say this is unworthy of our society.

I'm generally opposed to any mandate of any sort, and I do believe it greases that slippery slope of socialism, but if done right it might be tolerable.

The old have to pay more than the young--they will use it more and should pay more based on the experience of their group.

There should be a basic level of coverage with deductibles or co-pays that discourage running to the doctor with every sneeze and sniffle and having it covered.

It can't be loaded up with expensive mandates that are used by the few (mental health and fertility treatments come to mind). There should be options for expanded coverage at a higher price.

I liken that to auto insurance (since that was brought up to justify this). My state only mandates a relatively low level of liability coverage or a bond for that amount. I can choose higher limits, UMC, physical damage, etc., as options to my auto policy.

The coming debate should be interesting!

You mention several items that could be done to make a national health care system better.

You make a phenomenal conjecture that "without the safety nets of Social Security and Medicare, the vast majority of our elderly population would be out of luck."

If that is true, couldn't we also make the conjecture that without a national health care system the same would be true of our medical situation? Since we don't have a national health care system and we are not "out of luck" proves that we can survive without one.

The same logic would apply to whatever private systems would be in place if we did not have any Social Security system.

This kind of projection of doom shows a complete lack of confidence in America's ability to solve problems apart from the government. The government is not part of the solution--it is part of the problem.

Please explain to me how the government involvement in education has benefited our education system. As you know, a new cabinet position was created by President Jimmy Carter. Is our education better now than it was prior to the Department of Education's creation?

We put a man on the moon prior to the Department of Education and haven't done it since the Department of Education was created.

You also mention, "The biggest reason this country can't get a handle on its many long-term problems is that no one is ever asked to sacrifice anything for the greater good. That's what I call true patriotism."

Well, Sam, that's what I call socialism. Look around you at the marvels of what the free enterprise system has provided us--a health care system that is the greatest in the world. People from all over the world come here for treatment because they recognize it as the best.

We have people coming into this country illegally and risking everything just to get here and have opportunity for success.

On another issue, if "no one is asked to sacrifice anything for the greater good," what is your view of our military?

As an insurance agent, I believe our industry is on the cutting edge of the free enterprise system.

As a result, I have a great deal of confidence in this free enterprise system and the American people. We can solve problems without the interference of the federal government.

That's what I call patriotism.

SAM RESPONDS:

It boggles my mind, Gordon, that you can argue we are not "out of luck" with a health care system in which 50 million have no insurance coverage, and even those who do face huge, confusing gaps in coverage.

Second, to say the American health care system is the envy of the world is also an overstatement. If you look at life expectancy, especially for kids, that just ain't the case, sir. In fact, a growing number of people are being forced to LEAVE the country to get affordable medical care. Is that what America has come to?

And can you seriously argue that if we didn't have either Medicare or Social Security, the elderly of this country would be getting along just fine? You've got to be kidding.

I am not a socialist, but I am also not an anarchist. I do not believe government is the problem. Unengaged, irresponsible and incompetent government is the problem.

Our free enterprise system is terrific, but when profit is the only motivation, lots of people get dumped on the side of the road. Government involvement can even out the odds for those who "lose" in this system.

How exactly is the free enterprise system on its own "solving" the problem with providing everyone with affordable health care?

As for sacrifice, this country sends its young men and women off to fight wars over oil, while flying flags on the antennas of their gas-guzzling SUVs to feel patriotic. Instead, we should be taking dramatic steps to ween ourselves off our fatal addiction to foreign oil, but we can't even bring ourselves to drive more fuel-efficient cars!

The military--all volunteers--is doing an outstanding job in an impossible circumstance. But if we are really in an endless war against terrorism, shouldn't we have a draft so that everyone serves? If you had a draft, there would be massive protests against the war. As long as someone else is fighting it, people spend more time worrying about Britney Spears than about Iraq.

This discussion is ranging far afield, but you get my point. If not, we'll have to agree to disagree and settle some of these points in the next election.

I agree that something needs to be done, but I'm not sure that our government can operate a primary or partial care system with any degree of effectiveness.

For example, if the state of Ohio Bureau of Workers' Compensation was regulated by its own department of insurance (workers' comp is insurance, after all), it would seem likely that it would be shut down.

It seems our government holds private enterprise to a different set of standards than it applies to its own conduct and procedures.

It's just very hard for me to accept that the only solution to this problem is for our government to jump in with both feet.

P.S. Have our goverment fix Medicare first, then I MIGHT give them the benefit of the doubt.

Some points to consider from the perspective of a licensed life and health insurance agent since 1995, who is currently spending most of my work time with commercial property-casualty:

* It has never been hard to find health insurance for young and healthy people. I tell clients that the #1 reason to buy health insurance is to avoid bankruptcy from unplanned medical bills. Whoever plans to have large medical bills?

* After years of dealing with the difficulties in finding health insurance for unhealthy people (diabetes, brain tumors, depression, cancer and heart problems), I am convined that we should have a basic level of national health insurance covering preventative care, doctor office visits and generic drugs.

Individuals could optionally buy a supplement, similar to Medicare supplements, for things the national plan does not include.

* There is a gap in the age 55-to-65 range for those financially able to retire, but who cannot afford the uncertainty and rising costs of private health before they qualify for Medicare.

* I don't see any way to avoid rules for rationing. No doubt there will emotional, heart-rending pleas for treatment of rare, exotic and high-risk surgeries with low-percentage outcomes. Should we do a $50,000 surgery on a 62-year-old women with ovarian cancer and a 2 percent survival rate?

These may be the most difficult decisions to make, and who will make them?

I feel that the national health insurance plan should be financed by an import tax. This would kill two birds with one stone.

The July-to-September 2007 trade deficit was $178.5 billion. An import health tax would provide a dis-incentive to buy imports, and therefore a positive incentive for American industry.

How long do we think the magic act of importing an excess of $59.5 billion per month in American greenbacks can last?

Foreigners will soon own every bit of American infrastructure, real estate and stocks, including the insurance companies!

SAM RESPONDS:
You make some interesting points! However, a full-fledged value-added (VAT) tax on all goods purchased might be better, since slapping an import tax might not only be considered an illegal trade barrier, but it might also encourage countries to slap retaliatory taxes on our exports. Trade wars never benefit anyone.

I couldn't agree with you more. It's way past time someone in this country stands up and says, "this is what we have to do for the good of the country, even if it means sacrifices on your part," instead of the "business as usual," "how can I get mine and most of yours as well" approach of too many in our political system.

It doesn't matter whether it's a Democrat or a Republican, whether they are a man or a woman, what race they are, or how they feel about abortion, immigration or Iraq, as long as they have the courage to put the good of the majority first instead of lining their own pockets or keeping the special interests happy.

More specifically, yes, we need to get over the idea of national health insurance being "socialized medicine" and so an evil to be avoided at all costs.

It's already happening at the state level with the CHIPs program to protect the young and at the national level with Medicare to protect the old, so let's get it done at all levels for all ages, so we can have a reasonably healthy citizenry able to take on our many other problems.

Good for you for taking an enlightened stand on this very important issue.

I read your colummn and blog on universal health care and yelled, “BRAVO!”

I am as fiscally conservative as anyone I know, but there comes a point where the American community has to realize that our present system is unraveling.

Those of us who are healthy will naturally despise the idea of spending extra tax dollars to cover everybody’s every-kind-of-sickness.

It is only when we honestly confront our own mortality and our own morbidity that we realize that one day we, too, will be in desperate need of medical care.

Nobody gets outta here alive and well.

Our agency functions on a book of business made up entirely of property and liability insurance coverage for nursing homes and assisted-living facilities.

We have had to accept the fact that if it were not for Medicare and Medicaid, this nation’s seniors would, for the very large part, be sleeping in the alleys and abandoned buildings.

The down side, as I see it, is that once we put together universal health care, we will have to mandate a quick and summary beheading (or something equally frightening) for the hordes of thieves who seek to defraud the system.

If not, the program will become even more expensive and wasteful than that thing that’s going on in Iraq right now.

A payroll tax for basic health coverage would be wonderful except for one thing. What are we going to do about the unemployed who pay no payroll taxes?

I’m certainly for some kind of basic universal health care as you have mentioned.

A group of folks with knowledge of the industry need to sequester themselves at an out-of-the-way, hidden and unknown location for several days with a mandate to come out with several possibilities for such coverage. It can be done.

Also, along those same lines, having fought the uninsured motorist liability problem for many years, I am about to come to the conclusion that we should all pay for basic auto insurance coverage at the pump.

As you mentioned, those who wanted to could also purchase additional supplemental coverage if desired to take themselves over the basic coverages, as you also briefly mention on health coverage.

You have probably stirred up some insurance folks, but they, and we, need to have our cages rattled from time to time.

We are too smart a nation to allow health coverage and the number of uninsured autos to continue as is.

How refreshing to hear a prestigious person in our insurance industry stand up for health care reform, Social Security and Medicare!

Thank you for the reminder that we need "to do what's best for society."

I hope that our colleagues who read this will take it to heart. It's a message that the American people must take to heart if we are to survive as a democratic nation.

Friedman for President!

I just returned from Florida, and my father's emergency surgery and his convalescence in a nursing home/rehab center, and read your column, "Curing a Sick System," in the Dec. 10, 2007 NU. 

The only cure I can see for a very sick system is that every executive of an insurance company should  be sentenced to having to call their own company and deal with insurance for a loved one at a time of crisis. 

In the 10 days it took the insurance company to approve my father's simple procedure on his back, his condition deteriorated to the point where he needed a surgical incision and two rods, screws and a plate in his back--otherwise known as a laminectomy. 

Rather than risk 10 days for approval over the holidays, I ran to Florida to admit him through the emergency room.

Then the next morning, instead of outpatient ambulatory surgery, they performed, "emergency back surgery." 

Meanwhile, the insurance company had to pay for the emergency room visit and the Sunday night stay in the hospital. 

But the most amazing thing was the phone call my mother received at 7 a.m. that fateful Monday morning, when the hospital asked her, where is the patient? 

I called my father after my mother called me hysterical, and asked him where he was. (It's a good thing I gave him a cell phone.)  He told me they woke him at 5:30 and prepped him. 

So I called the hospital to tell them what room the patient was in. 

When I got to the hospital I confronted the hospital administrator with the embarassing phone call, and told him I have no faith in the medical prognosis based upon the fact that they couldn't find the patient.

His response to that was to dispatch the V.P. of customer service to separate me from the other people waiting in the surgical waiting area, where I was gleefully telling my story, and I was placed in solitary confinement in a room where the doors were locked and the windows bolted!