The Wages of HillaryCare

Hillary Clinton and Barack Obama agree on most policy issues, but that makes their rare differences all the more revealing. To wit, their running scrap over Mrs. Clinton's "individual mandate" for health care, which Mr. Obama has now had the nerve to expose for its inevitable government coercion.

Mrs. Clinton's proposal requires everyone to buy health insurance, along with more insurance regulation, a government insurance option for everyone and tax hikes. Mr. Obama likes all that but his mandate would only apply to children. He argues that the reason many people aren't insured is because it's too expensive, not because they don't want it. Mrs. Clinton counters that coverage can't be "universal" without a mandate.

But then Mr. Obama had the impudence to defend his views. His campaign distributed a mailer in key primary states that claimed the Clinton plan "forces everyone to buy insurance, even if you can't afford it." It also featured an image of an anxious couple at a kitchen table. The Clinton apparat went apoplectic, claiming the flyer evokes the famous "Harry and Louise" commercials. A common article of liberal faith is that this "smear campaign" doomed HillaryCare in 1994 -- as opposed to, say, its huge cost and complexities. But never mind.

Yet if Mrs. Clinton's plan is better because it has a mandate, how does it work in the real world, where some people still won't be able to afford insurance, or would decline to acquire it? At a recent debate, the Illinois Senator drove the point home, asking Mrs. Clinton, "You can mandate it but there will still be people who can't afford it. And if they can't afford it, what are you going to fine them? Are you going to garnish their wages?" And in an interview with ABC's George Stephanopoulos on Sunday, Mrs. Clinton conceded that "we will have an enforcement mechanism" that might include "you know, going after people's wages."

Well, well. In other words, HillaryCare II isn't all about "choice," but would require financial penalties for people to pay attention, including garnishing wages. To put it more accurately, the individual mandate is really a government mandate that requires brute force plus huge subsidies to get anywhere near its goal of universal coverage.

Mitt Romney's mandate program in Massachusetts is already expected to reach $1.35 billion in annual costs by 2011, up from $158 million today. And that's with only half of the previously uninsured currently enrolled; no less than 20% didn't qualify for subsidies and were granted exemptions because the costs were too much of a hardship.

Most experts calculate that a national mandate with subsidies like Mrs. Clinton's would enroll about half to two-thirds of the uninsured, less for a voluntary plan and subsidies alone. But such guesswork is pointless without the basic enforcement assumptions, which Mrs. Clinton refuses to provide. She's more interested in wielding what she calls "a core Democratic principle" against Mr. Obama. "My opponent will not commit to universal health care," she said Saturday.

The logic of Mr. Obama's approach is that policy makers should target those who are priced out of coverage. The Census Bureau says 38% of the uninsured earned more than $50,000 in 2006, 19% above $75,000. They aren't a major public policy problem -- except that a big reason they lack coverage is because it is more expensive than it needs to be thanks to government market interference. And 29% earn under $25,000, which means they probably qualify for existing subsidy programs like Medicaid or Schip but haven't enrolled.

The news here is that all of this is being exposed now, and by a fellow Democrat. Many Americans are uncomfortable with the coercion of the mandate -- and not all of them are Republicans. The California health-care overhaul was recently done in by liberals concerned about its consequences for the working poor.

The political lesson that Mrs. Clinton learned in 1994 wasn't about compromise or market forces. It was that a government health-care takeover can only be achieved gradually and by stealth. Her individual mandate is an attempt to force everyone to buy into a highly regulated and price-controlled system where government redistributes income and dictates coverage. We assume the McCain campaign is paying attention.

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Britain: Foreign doctors face competence inquiry

Britain's medical regulator has launched a major inquiry into the competence of foreign doctors after it emerged that they are now twice as likely to face disciplinary hearings as UK medical graduates. Figures seen by The Times also reveal that triple the number of doctors who trained abroad were struck off the UK medical register last year compared with 2005.

The findings, part of a report compiled by the General Medical Council, have prompted the profession's regulator to commission seven research projects, which will cover issues including the competence of foreign doctors and whether they are subject to institutional racism within the health service. More than 5,000 cases were dealt with by the GMC in 2006, 303 of which culminated in fitness-to-practise hearings and 54 doctors were struck off. Of these, nearly two thirds - 35 doctors - had trained outside the UK.

The range of offences included sexual misconduct, dishonesty and failing to provide an adequate level of care for patients. Among the cases in the past three months have been a Hungarian doctor struck off for dishonesty, a Nigerian for clinical incompetence and misdiagnosis and an American-trained doctor who had sexually harassed a nurse. One Spanish-trained psychiatrist was found to have abused his position over the use of prescription drugs.

Last month Gordon Brown pledged to tighten checks on medical staff who trained overseas after three NHS doctors were charged in connection with the attempted car bomb attacks on London and Glasgow.

But medical regulators suggest that patient safety may be compromised by current procedures, which require some doctors to produce no more than a degree certificate and a letter of reference before they can start work. The GMC said there was a growing number of complaints about GPs and hospital doctors, but a "disproportionate" number of overseas-trained doctors were appearing before its disciplinary panels. Strikingly, 30 per cent of complaints against foreign doctors came from other health professionals or the police, who were the source of less than 15 per cent of complaints against UK-trained doctors.

The GMC has commissioned researchers to look into the pattern, for which there is currently "no good explanation", it said. It added that doctors were only struck off when it would endanger patients and the wider public to do otherwise.

One of the projects coordinated by the Economic and Social Research Council is already under way, while six others are due to start in the next few months. They include proposals from academics at the London School of Economics and the universities of Newcastle and Leicester to investigate how doctors come to work in the UK and set out which of them might present a particular risk to patients.

Under current rules, doctors from Europe can register and treat patients in Britain but are not tested for clinical competence and do not have to prove they can speak English, unlike those from Australia or elsewhere who are naturally fluent. The GMC and other regulators fear that patient care may be at risk , and have called for a change in the law to test doctors from the EU.

This week The Times revealed that hundreds of junior doctors who took up posts this month have not been vetted by the Criminal Records Bureau. Hospital trust managers complained that they could not check the criminal records of some applicants because they received the names too late.

Of the 5,085 complaints lodged against doctors last year, a rate of almost 100 a week, nearly 40 per cent referred to overseas-trained doctors - roughly in proportion to their numbers in the NHS workforce. A far greater number of international medical graduates were referred to hearings compared with UK graduates (34 per cent as against 16 per cent last year).

Paul Philips, director of standards and fitness-to-practise at the GMC, said: "The number of fitness-to-prac-tise cases we deal with is going up year on year. Doctors with a primary medical qualification from overseas or within the EU are disproportionately represented, and more are being referred to us than we should be see without a good explanation." The British Medical Association said that the pattern might be accounted for by a culture of institutional racism within the NHS. A Department of Health spokesperson said all NHS doctors were subject to stringent pre-employment checks.

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