Are we even talking about the same Massachussetts?

Michael Tanner of CATO is waxing smug because the Massachusetts plan for universal health care is facing some trouble as deadlines approach. The uninsured in Massachusetts have four months to buy insurance, or they'll face a tax penalty. But as things stand now, "of 170,000 people who are uninsured but have incomes too high for subsidies, only 17,500 have complied with the mandate so far." Tanner claims that CATO called this one in the air - the mandate was unenforceable and they knew it. To bolster the tanks "I-told-you-so" cred, he directs us to his earlier writing on the subject, noting,

"Someone should have pointed out that the Massachusetts mandate is probably unenforceable and almost certainly not going to achieve universal coverage. Oh, that’s right, we did."

Funny thing is, his earlier piece says absolutely nothing about enforceability. In fact, the extensive hand-wringing over allegedly severe restrictions on consumer and employer choice seem to belabor the worry that the Bay State Politburo might enforce it's social experiment all too well (ominous music, lightning).

Interestingly enough, the criticisms that CATO did make turn out to be pretty far off the mark when we consider what's actually going on in Massachusetts.

Criticism 1: " The individual mandate opens the door to widespread regulation of the health care industry and political interference in personal health care decisions."

Now I could always be wrong, but I am almost positive that was the point of passing a regulation on the health care industry. Y'know? So, conceded, I guess.

Criticism 2: " The act's subsidies are poorly targeted and overly generous."

Actually, no. The MSNBC article that Tanner links to (see "trouble", above) reports:

About 160,000 uninsured people in the state have incomes that are too high to qualify for subsidized health insurance — but too low to afford the lowest-cost unsubsidized plans.

The Massachusetts plan is fading in the stretch because the subsidies aren't extended generously enough. For too many people, the mandate has become a choice between paying insurance premiums or paying for their housing or groceries. It takes a willful ignorance of reality to make Tanner's claim. I don't know how to make this any clearer: people are not refusing to enroll because the market is over-regulated. They are refusing to enroll because the current market is cost prohibitive for the working poor of Massachusetts.

Criticism 3: "The Massachusetts Health Care Connector, which restructures the individual and small business insurance markets, is a form of managed competition that has the potential to severely limit consumer choice."

Again, point ceded. Consumer choice does get sidelined by a mandate to purchase insurance. But does this have anything to do with the failure of each Massachusetts citizen to enroll? The market restructuring should be a boon to providers - faced with the threat of fines (a clumsy method of implementation in my opinion), employers and individual buyers have an extra incentive to spend money on premiums that they might have chosen to hold onto before.

Criticism 4: "The act imposes new burdens on business and creates a host of new government bureaucracies to manage the health care system."

I did read a piece talking about some delays in processing caused by a deluge of applicants as the deadline nears... somehow I doubt that's what Tanner was getting at. If you read the MSNBC article, some small business owners are miffed at having to take on the costs of insurance. One restaurateur is perfectly livid. But no examples are given of any businesses actually tipping into bankruptcy from the requirement, while we know that hundreds of thousands of Americans declare bankruptcy annually from insurmountable medical fees. That observed, I'll ad that I'm currently working for a restaurateur who gets ticked when I remind him that he has to pay me the minimum wage. So my sympathies for small businesses are diluted. Small -time capitalists do have a lot of troubles to face, but the idea that they are totally incapable of cutting profits to care for their employees is a myth.

In any event, taking all four criticisms into account reveals that contrary to the CATO blog's current swagger, Tanner's actual predictions are either ideologically driven truisms that are immaterial to the current dilemma faced by Massachusetts - or - in one case, an ideologically driven policy criticism that succeeds in nailing the exact opposite of what is actually going on.

I'll note in closing that I am not a devotee of Plan Massachusetts. I do not think it goes far enough. And I think it leaves an awful lot of power and economic privilege to insurance companies, most egregious being the lack of a cap on annual medical expenses as a proportion of income. Not to mention, every one of the issues at hand - from burdening businesses to non-compliance due to a cost-prohibitive market - are issues that would not exist in a nationalized system funded by a progressive tax scheme. In theory, I'm open to alternatives to a system like Canada's, but I'm seeing few practical reasons to maintain that position as of late. But I'll stick to my guns: I just want to see every person have access to affordable health care. So ideological implications aside, I do hope the Massachusetts plan succeeds. Let the CATO crowd preemptively notch their belts based on who-knows-which facts - the reality based community will keep watching and hope for the best.

No, but seriously, what is your proposal for health insurance?

It's way past official Giuliani simply does not care about health reform. Because anyone who understood the magnitude of the health care disparities in this country would not seriously believe that a plan like this could make a significant impact on the number of uninsured Americans. Then again, it is not designed to - the plan "does not even cite universal coverage as a goal." Giuiliani's plan strikes out right there and not just in the opinion of raving Leftist ol' me, but in the opinion of all 69% of Americans who agreed in November of 2006 that the government has a responsibility to guarantee coverage for everyone. Yet another example of how far out of the mainstream so-called-moderate Republicans truly are when it comes to social policy. And tactically speaking, If Giuliani manages to wrest the Republican nomination away from Romney, any Democrat who runs against him should be making health care the strongest part of their campaign.

That crucial flaw bracketed momentarily, Giuliani's plan does not aspire to alter the current market-based system much at all. It comes down to a Health Insurance Credit and a tax deduction for low income families. Both of those proposals, fortunately, would alleviate some of the tremendous burden that poor Americans face when purchasing health care - although we have to hope that Giuliani is more generous with the eligibility on those than he was with, say, welfare, food stamps, subsidized housing and essentially every major social service offered in NYC under his mayorship.

All the same, what Giuliani is offering fails on two critical counts - highlighted by Matt Miller's recent piece in Time. First, for whatever aid it provides them with, Giuliani's plan still holds out that " individuals' buying their own solo health insurance can be the answer to the problem of the uninsured." Without any new mandates, health insurance companies are still free to reject clients with a history of illness (and these are the men and women who need insurance most) or to cheat their poorest customers out of any real coverage by offering plans with low premiums but through-the-roof deductibles that render the plan useless. Secondly, Giuiliani does not "support limiting a family's annual exposure to medical costs to some reasonable percentage of its income." In fact,

Giuliani actually boasts of an approach certain to hurt people. His health-care tax deduction, he gushed in Iowa recently, "allows you to go out and buy cheaper and cheaper policies [because] you can have higher and higher deductibles." When Americans earning $25,000 a year get sick and end up paying $10,000 or more in hospital charges, their "affordable" insurance courtesy of Giuliani will become a ticket to bankruptcy.

Avoiding political hyperbole is nice, but any critical analysis of what America's Mayor has put on the table for health care reform makes it clear: Giuliani does not care about poor and sick Americans.

Sick and tired of racism?

Two studies, both concerning Asian Americans, found evidence of a causal connection between discrimination and depreciated health. The first study examined experiences with discrimination amongst Korean immigrants to the United States and measured those findings against the mental health quality of the subjects. "Researchers found that both overt and subtle discrimination seemed to influence participants' mental health. Overt discrimination was associated with the erosion of positive mood, while subtle racism was associated with symptoms of depression, possibly because more subtle forms of discrimination create 'ambiguities in terms of social identity.'" A second study looked at the impact of discrimination on chronic illness. They observed associations between discrimination and various respiratory, cardiovascular and pain-causing conditions, concluding:"that the everyday perceived discrimination minorities experience could cause stress that can lead to chronic illnesses."

Studies like these have a lot of interesting implications. They illustrate the extent to which cumulative disadvantages still track to characteristics like race not simply because of class conditions, as some materially inclined post-racists may conjuncture. but as a tangible result of discrimination that is currently happening. They also raise a tough moral dilemma for proponents of a health system like the one in the status quo (though I will admit now they do not go far enough to establish the moral necessity of a completely socialized health system).

If we take up the meritocratic position held by many (though certainly not all) opponents of socialized medicine which states that people's capacity to afford health care should, and more or less does, track to decisions about work, education and life-path that people have freely made themselves the status quo would be easier to accept. As one anonymous interlocutor put it in an online forum, claims that the 40 million or so uninsured Americans represent a failure of distributive justice suffer from "a lack of true knowledge as to why those "40 million" are uninsured (here's a hint - a significant number choose to be that way for a variety of reasons beyond "I can't afford insurance") and we start getting down to the real issues at hand." Following this argument to it's conclusion, the quality and cost of a person's health care, and indeed whether a person has any at all, is just if it indexes to that persons choice. So if I choose to remain unemployed or to become obese then I deserve whatever hardships come my way in the market-based health system. Bracketing the (numerous) complications that employment, obesity and the like raise in terms of cumulative disadvantage, we will take that idealized, rationalist approach and put to it the question of race.

A Korean American who either (1) suffered from a mental health disorder as a result of discrimination or (2) suffered from a chronic illness as a result of stress caused by discrimination would face considerable difficulty in paying for health care. At best, our hypothetical Korean would pay much higher premiums and/or deductible and face still higher expenses in treatment. At worst, she or he might be totally unable to find a provider, as many people with chronic and mental illnesses are.

Now, in this person's case there is absolutely no sense in which she or he could be said to have "earned" discrimination, even indirectly by putting oneself in a risky position. Yet she or he may well be priced out of insurance simply as a result of a prejudiced society. Why should our Korean have to face inordinately high costs of health care - or worse, go without any - simply because living as a Korean in a racist white society is difficult?

The moral dilemma illustrated by these studies, put simply, is that there are systematic inequalities in the allocation of health burdens in our society, which impose costs on the people burdened with them that are, as Rawls would have said, arbitrary from a moral point of view. Yet we ask that those people face the costs with whatever resources they can cobble together (forgetting for now that their capacity to do so will be inhibited by their health conditions ). Why shouldn't all members of a society marked by inequality that is arbitrary (morally) and systematic (distributively) have some obligation to contribute to offset those disadvantages?

Invisible and barely getting by

The rhetorical weight swung hardest in debates over socialized medicine is the ghastly number of Americans - over 40 million - who live without health insurance. Overlooked too frequently are the stories of Americans who can afford health insurance, but not comprehensive health insurance, who spend their entire lives fighting with their providers over plans, omissions, coverage gaps and reimbursements. They often find that themselves uncovered and unable to pay for crucial medical treatment and preventative care. What I found most powerful about Moore's SiCKO was not it's celebration of nationalized systems in Canada and Europe, but the haunting portraits of insured Americans for whom the system does not work.

Take for example, childhood immunizations. New reports indicate that children who are underinsured (as opposed to fully insured or uninsured) are the least likely to get vaccinations on time and at affordable rates. Working class families are left to choose: pay thousands for the injections, or let their kids go without critical preventative medicine. For families with good plans, the costs are covered - but many providers simply don't cover the vaccinations. And for those without any insurance, there's Medicaid and the FQHC system. As with so many other places in the American class system, its those who barely get by who feel the squeeze.

All the same, libertarians like John Stossel lambaste the type of government guidelines for providers that would close these coverage gaps:

Does it never occur to the progressives that the legislature's intrusion into private contracts is one reason health care and health insurance are expensive now? The average annual health-insurance premium for a family in Wisconsin is $4,462 partly because Wisconsin imposes 29 mandates on health insurers: Every policy must cover chiropractors, dentists, genetic testing, etc.

Absent those "intrusions", however, the full cost of health care is passed on to the people who are not able to pay, but who all the same are not the listless hordes of welfare-state-dependents that libertarians like to deride (a blogger at KXMC seems convinced that anyone who can't afford to pay for every health expenditure is a "lay-about").

Free marketeers and fiscal conservatives don't like to discuss the working poor because they defy easy stereotyping: they don't have much money but are demonstrably hard working; they pay taxes but still need state assistance. They make visible the long spectrum between dependency and autonomy that rabid individualists can't seem to grasp as the fundamental quality of social life.