By Kevin D. Williamson
Friday, December 27, 2019
The grievously misnamed Affordable Care Act was in part
an effort to replicate the widely admired Swiss health-care system in the
American context. The basic problem with that always has been that Switzerland
is full of Swiss people, while the United States is full of maniacs.
The preexisting-conditions mandate, which is popular,
creates a free-rider problem (i.e. nobody has any incentive to sign up for
health insurance until they are actually sick, and so insurance cannot actually
function as insurance), hence the hated individual mandate, the rule that
people buy insurance. The Swiss enforce their individual mandate ruthlessly—if
you fail to sign up for a plan, then the government signs you up for one, and
you owe your new insurer back premiums and interest to cover any lapse in
coverage. The Swiss achieve practically universal compliance; we repealed our
mandate, because we like the benefits but don’t want them to have any strings
attached.
Pete Buttigieg is attempting to resurrect the ACA mandate
in part with his new health-insurance proposal, which would create a public
option: basically Medicare for all who want it . . . and a few who don’t. Under
Buttigieg’s proposal, those who fail to sign up for a qualifying
health-insurance plan would automatically be enrolled in the government plan,
and they would owe premiums — including retroactive premiums for lapses in
coverage.
The Washington Post quotes left-wing critic Matt
Bruenig characterizing the proposal as a “supercharged” version of the ACA
mandate and accusing Buttigieg of deploying “misleading rhetoric” about his
plan. Matt
Bruenig is the dishonest fellow who fabricated quotations from me defending
the racist antics of Donald Sterling, so I suppose he is something of an
authority on misleading.
It is very difficult to disentangle the individual
mandate from the preexisting-conditions rule and other benefits in the form of
coverage and pricing controls. You can have insurance that functions as
insurance (i.e. a financial instrument that hedges against the risk of future
events that may or may not come to pass) but if you want insurance that
functions as a welfare program (performing the logically incoherent task of
“insuring against” preexisting conditions, i.e., things that already have
happened) then you need the individual mandate and other unpopular measures in
order for the market to function.
Buttigieg implicitly concedes as much. He is right to do
so, and Republicans were wrong to repeal the mandate while leaving much of the
rest of the ACA regime in place. An ACA-style program with a robustly enforced
individual mandate may be a bad policy, but it is a coherent policy, and a
better policy than an ACA-style program without an individual mandate.
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