By Kevin D. Williamson
Wednesday, January 04, 2017
Republicans have begun the process of repealing the
grievously misnamed and soon-to-be-unlamented Affordable Care Act through the
process of budget reconciliation, a parliamentary maneuver the Democrats had
threatened to use to pass the ACA over minority Republican opposition. (In the
end, it was not needed, though significant changes to the law were made via
subsequent reconciliation bills.) As with President Barack Obama’s
pen-and-phone aggrandizement of presidential power and Senate Democrats’
weakening of the filibuster, Chuck Schumer’s party is going to regret a great
deal of what Harry Reid’s party did.
It is not the case, as Democrats insist, that Republicans
are simply repealing Obamacare without having given sufficient thought to what
ought to replace it. Congressional Republicans finally seem to have learned
that their prior strategy — simply insisting that a set of incoherent policies
causing a great deal of stress and uncertainty constituted “the greatest
health-care system in the world” and doing nothing more — was a mistake, a
critical one.
But there is a problem.
There are two big, important pieces of the Affordable
Care Act that will be of concern as Republicans go about replacing it. The
first is the so-called individual mandate, which actually isn’t all that much
of a mandate but which theoretically requires the great majority of American
adults to purchase a federally defined minimum level of health insurance. The
second is the rule requiring that insurance companies cover “preexisting
conditions,” which mandates that U.S. insurance companies participate in the fantasy
that we can insure against events that already have happened.
The preexisting-coverage rule defies economic reality
(also space-time reality) and hence is the popular part of the law. The
individual mandate is less popular, because people do not like being told what
to do by the government, especially if it costs them money.
You can see the obvious problem here.
We have to have an individual mandate because we want a preexisting-coverage
mandate. If insurers have to pick up the expenses for everyone who shows up at
their door with lung cancer or HIV or severe diabetes, that has to be paid for.
The only way to pay for it is a rule that requires everybody to have insurance;
otherwise, economic self-interest ensures that most people have no reason to
pay for insurance until they become sick, meaning that they pay no premiums
until they have expenses that will far exceed them. An insurance market made up
exclusively of sick people is financially unsustainable.
Together, the individual mandate and the preexisting-coverage
rule make up the basic policy architecture of Obamacare. There isn’t a feasible
way to have the popular preexisting-conditions coverage without the unpopular
mandate. In fact, in order to make the system work, we would need to put some
more teeth into that mandate: Because the penalties associated with it are very
mild, many people, disproportionately young and healthy, prefer to pay the fine
than pay a great deal more for insurance. Hence, the pool of newly insured
people under Obamacare has been much sicker than insurance companies had
expected, which has them squealing. And more than that: It has them pulling out
of ACA exchanges and markets around the country, leaving consumers with fewer
choices and much higher premiums than they had expected.
If you want to keep the preexisting-coverage rule — and
Republicans say they do — then you are going to end up with Obamacare, or at
least a version of it. It might be a slightly better or slightly worse version,
but that is what you will have.
There are a few ideas for finessing that problem away,
such as creating a series of “high-risk pools” or a single federal high-risk
pool for sick people seeking health insurance. What this means is that the sick
people without insurance who want it would go into a separate insurance pool
full of other people likely to require lots of expensive medical care.
Naturally, the premiums in this market would be much higher than in the regular
market, meaning that state governments and the federal government would be
expected to subsidize them heavily, lest sick people be entirely priced out of
the market and we’re right back where we started. But this creates the same
moral hazard as the familiar Obamacare system: Why not just wait until you are
sick to buy insurance if government is picking up the economic penalty for
being in the high-risk pool?
The way to cut this Gordian knot is to treat insurance
like insurance.
Insurance is not a way to pre-pay for health care, though
we insist on treating it as though it is. Properly understood, insurance is not
a health-care product at all: It is a financial product, the purpose of which
is to mitigate the risk of incurring large and unexpected costs, whether that
is damage to an automobile (your car insurance does not pay for oil changes) or
health-care costs. It is necessarily prospective, which is to say,
forward-looking. No one can say whether you’ll have a heart attack tomorrow or
get brain cancer in 20 years, though our actuaries are really very good at
determining how many people out of a million will have a problem like that in
any given year, and what it will cost to treat them. But we insist on trying to
bend insurance into a retrospective product, as though it were possible to play
the odds on something that already has happened. So long as we try to push off
the obligation for paying for preexisting conditions onto financial firms —
which is what insurance companies are — we are simply using those companies to
launder health-care benefits that are in reality publicly financed, in part or
in total.
It would make much more sense to do the opposite of what
the pollsters would advise: Keep the unpopular mandate — strengthen it — and do
away with the popular preexisting-conditions rule, replacing it with stronger
regulation protecting people with insurance from losing their coverage once
they become sick or grow old. For the people without coverage? Medicaid stinks,
but in a reformed version it is the most obvious solution, a way to pay
directly for health-care services rather than paying insurance companies to pay
for services, as though putting a financial middleman in the equation were
going to improve things.
Ultimately, health-care reform that treats insurance as
insurance means that Americans will simply pay out-of-pocket for most of their
medical needs, with insurance in most cases picking up the cost of catastrophic
accidents and illnesses. Empowering consumers to do this means creating a real
market with real prices, which simply does not exist now: Try getting three
competing quotes on a 2017 Honda Civic and then do the same with an
appendectomy and see which market has real prices. That will be a long and
difficult reform project, one that will not be achieved through a single piece
of legislation, or indeed through legislation alone.
Good health-care reform is not going to be popular,
because paying bills is not popular. But so long as we are trying to pass the
bill on to someone else, health care will remain a mess.
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