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Posted at 11:28 AM ET, 12/14/2010

What an individual mandate gets you

By Ezra Klein


The latest insurance data (pdf) from Massachusetts is out, and it shows what a difference an individual mandate makes: About 98 percent of the state's residents have health insurance, as do 99.8 percent of the state's children. Among adults with incomes below 300 percent of the poverty line, coverage is up to 96 percent. And as you can see in the graph atop this post, those numbers have actually been getting better during the recession -- which is almost unheard of when it comes to health insurance.

For comparison, 17 percent of the country is uninsured, as are 10 percent of American children. And those numbers would of course be higher if Massachusetts wasn't dragging the average down.

(Via The Incidental Economist.)

By Ezra Klein  | December 14, 2010; 11:28 AM ET
Categories:  Health Reform  
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Two other charts seem to be called for here:

1. The insurance premium increases over the same period

2. The state budget costs related to the subsidies for this program over the same period.

Posted by: jnc4p | December 14, 2010 12:58 PM | Report abuse

It's important to note that over this same time period uninsurance rates have fallen for children everywhere in the United States, mostly due to public coverage. This PowerPoint presentation from John Holahan of the Urban Institute shows the relevant details.

Posted by: Wrigleyviller | December 14, 2010 1:00 PM | Report abuse

Leaving aside the insolvency of the Massachusetts health system (which cannot survive without funds collected by the federal government from other states)...

Usurper - One who seizes and holds the rights of another by force of illicitly assumed authority. For example, "Pelosi the Usurper" is a title bestowed by history upon the Speaker of the 111th Congress due to her role is passage of a wantonly unconstitutional statute which purported to require American citizens to purchase goods and services which they did not wish to purchase. Subsequent to passage of the statute, known as the Patient Protection and Affordable Care Act or PPACA, voters removed Pelosi from her role as Speaker of the House. The flag of Virginia, which displays the motto "Sic Semper Tyrannis," flew at the Federal Courthouse which issued the ruling declaring the PPACA unconstitutional.

What does an unconstitutional federal mandate get you?? It seems that the flag of Virginia truly does hold an answer.

Posted by: rmgregory | December 14, 2010 1:23 PM | Report abuse

Great, but we just look at *what* is being mandated? I have no problem mandating some level of insurance if you want to use the emergency services, etc., but the crazy overloaded plans that are required are simply too expensive.

It comes down to make health care cheaper, and by encouraging more blanket coverage plans that don't allow consumers to benefit from choosing lower cost options, we are just driving prices higher. HSA + high deductible should be allowed.

It's not the mandate itself, it's the stupid plans it mandates!

Posted by: staticvars | December 14, 2010 1:34 PM | Report abuse

Is this due to the mandate or the subsidies? Can the effect really be disentangled?

What's going on with elderly - uninsured status went from 0.0% to 0.4%. Not a huge number, but that's what, several thousand people?

On slide 33/40, it shows that nonelderly adults with poor health status are more likely to be uninsured (4.2% vs. 2.9% for all non-elderly adults). That seems a bit counterintuitive as well.

"And those numbers would of course be higher if Massachusetts wasn't dragging the average down."

Massachusetts is very small relative to the entire country. Without including it, the U.S. would have something like 17.3% of the population without coverage rather than 17%.

Posted by: justin84 | December 14, 2010 2:13 PM | Report abuse

Plus I believe Mass. has the highest family health insurance premiums in the country. Mass. has done well on the coverage side, but failed on the cost side.

Posted by: AuthorEditor | December 14, 2010 2:20 PM | Report abuse

To be fair, the proper comparison is Massachusetts before reform, and Massachusetts after reform. Massachusetts always had pretty high coverage levels, if I remember right.

Most of the state's costs are not necessarily attributable to their insurance expansion. Massachusetts is an expensive place to live in general. Its hospital market is dominated by four high-tech and expensive academic medical centers that are regarded as must-have providers by any insurer. This takes away a lot of leverage to contain costs. So, of course its expensive to get care in Massachusetts after reform, but it was expensive to get care in the state before reform as well.

One poster said that initiatives like these are unsustainable at the state level. Massachusetts did, iirc, get a special deal from the Feds related to an expiring Medicaid waiver. It's otherwise probably true that most states, especially with their balanced budget requirements, can't afford to run subsidies sufficient to get lots of purchasers in. That calls for a Federal role. The Feds have more expansive taxing authority, the ability to run a deficit, and the ability to set much larger-scale cost controls in motion than the states do.

Posted by: weiwentg | December 14, 2010 2:32 PM | Report abuse

All Ezra seems to be arguing is how *convenient* a mandate is to the promotion of universal healthcare.

Here are the words Ezra doesn't mention when discussing this issue:


Posted by: WrongfulDeath | December 14, 2010 3:31 PM | Report abuse

To be fair, the proper comparison is Massachusetts before reform, and Massachusetts after reform. Massachusetts always had pretty high coverage levels, if I remember right.

Posted by: weiwentg | December 14, 2010 2:32 PM | Report abuse

yes and states that have had low coverages (and low premiums to be fair) will see with PPACA great increases in coverage but also great increases in costs to get to required levels that the Federal Government is requiring.

I'll second, or third or fourth the statement that its only looking at the positive side of things when Ezra mentions the number covered in MA without also speaking about cost and the fact that its unsustainable now to the point that they're looking at what the rest of the country would consider draconian cuts.

Also somehow I don't think we'll get the same outcry from liberals about "THESE" wage freezes.

Posted by: visionbrkr | December 14, 2010 4:50 PM | Report abuse

One thing Ezra always seems to leave out of his posts on mandates and insurance is a detailed treatment of just what having health insurance gets someone, either in Massachusetts or under the Affordable Care Act nationally. I'm generally opposed to an individual mandate for the simple reason that insurance is often a terrible deal for consumers, providing very limited coverage for the cost, and I'm deeply skeptical that whatever regulations exist in the law will change that dynamic for people who are now obligated under law to buy such a crappy product. What are the minimum coverage requirements that insurance plans have to meet to be on the exchanges, for example? I'm sure Ezra has answered this before in some post, but it should be repeated from time to time along with the cheers he raises for the individual mandate or the health care law in general.

Posted by: andrewbaron78 | December 14, 2010 5:23 PM | Report abuse

These "penetration" statistics in general and this particular statistic are not very instructive. No one in Massachusetts disagrees that having insurance is a good idea; healthcare insurance was “invented” here 150 years ago. The vast majority of the Massachusetts population has always been insured. But the bad news is that the actual number of people really buying healthcare insurance (taking money out of their own pockets to pay premiums) in Massachusetts is down about 50,000 since 2007 when the Romneycare mandate started (see the quarterly Key Indicators report on the Massachusetts government web site).

So use any statistics source you want. Did the needle move from 90% to 95% (according to the U.S. census bureau) between 2000 and 2009 or was it flat at 94% (according to the old DHCFP methodology) from 2000 to 2007 or did it move from 97% to 98% (according to the Urban Institute survey referenced in the above article) between 2008 and 2010? It doesn't matter. All you are talking about in any of the competing surveys — not even statistically significant in my opinion (read the fine print about two-tailed — is a couple of hundred thousand people out of the over 6,000,000 of us in Massachusetts.

And yes, for that, we got the doubling premiums, the reduced access to doctors, the higher co-pays, the higher taxes and all the other things mentioned by other commenters.

Thanks Mitt!

Posted by: byrondennis | December 14, 2010 6:46 PM | Report abuse

The Republicans are the ultimate hypocrites! Simply put, Collapse of America!
1. How do we pay for health care reform ?
2. How do you pay for tax cuts for the wealthy ?
(a). First attempt : threatening Social Security and Medicare Cut through the deficit panel.
(b). Second attempt : holding the desperate Hostage, say, by the Ransom.
3. Auto insurance mandate !
Under historical interpretations of the Constitution, Congress can dictate the economic activity of citizens so long as that activity will have profound, large-scale effects on the national economy.
4. Simply put, Collapse of America!
** Inaction cost, $9trillion over the next decade, ((Some of CBO analysis : While the costs of the financial bailouts and economic stimulus bills are staggering, they are only a fraction of the coming costs from Social Security, Medicare, and Medicaid. Over the next decade, the Congressional Budget Office (CBO) projects that each year Medicaid will expand by 7 percent, Medicare by 6 percent, and Social Security by 5 percent. These programs face a 75-year shortfall of $43 trillion--60 times greater than the gross cost of the $700 billion TARP financial bailout)).
Over the duration of healthcare debate, using the preliminary cost analysis of CBO, the reps opposed the public option stubbornly, but after the release of final score, they have been defiant on the referee.
The nonpartisan Congressional Budget Office estimates that :
Inaction cost in relation to health care reform totals $9trillion over the next decade.
Reform will reduce the federal deficit by $143 billion over the next 10 years and as much as $1 trillion during the following decade.

Posted by: hsr06011 | December 19, 2010 9:44 PM | Report abuse

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