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Adverse-Selection Death Spiral
Paul Krugman a couple of weeks ago ("One health care reform, indivisible") on why, if you prohibit insurance companies from denying coverage on pre-existing conditions, you need to institute other reforms as well:
Why not just impose community rating — no discrimination based on medical history?
Well, the answer, backed up by lots of real-world experience, is that this leads to an adverse-selection death spiral: healthy people choose to go uninsured until they get sick, leading to a poor risk pool, leading to high premiums, leading [to] even more healthy people dropping out.
So you have to back community rating up with an individual mandate: people must be required to purchase insurance even if they don't currently think they need it.
But what if they can't afford insurance? Well, you have to have subsidies that cover part of premiums for lower-income Americans.
In short, you end up with the health care bill that's about to get enacted. There's hardly anything arbitrary about the structure: once the decision was made to rely on private insurers rather than a single-payer system — and look, single-payer wasn't going to happen — it had to be more or less what we're getting. It wasn't about ideology, or greediness, it was about making the thing work.
If Krugman is right, where can Obama and the congressional Dems retreat to if they want a health reform that will actually work, and actually be a reform? (One argument, I suppose, is that even if you pass a reform that makes things worse, you've opened the door to making it better over time, whereas if you don't pass anything you've killed health reform and hurt the economy.)
Krugman, btw, made his post before it was clear that Coakley could lose in Massachusetts.
Why not just impose community rating — no discrimination based on medical history?
Well, the answer, backed up by lots of real-world experience, is that this leads to an adverse-selection death spiral: healthy people choose to go uninsured until they get sick, leading to a poor risk pool, leading to high premiums, leading [to] even more healthy people dropping out.
So you have to back community rating up with an individual mandate: people must be required to purchase insurance even if they don't currently think they need it.
But what if they can't afford insurance? Well, you have to have subsidies that cover part of premiums for lower-income Americans.
In short, you end up with the health care bill that's about to get enacted. There's hardly anything arbitrary about the structure: once the decision was made to rely on private insurers rather than a single-payer system — and look, single-payer wasn't going to happen — it had to be more or less what we're getting. It wasn't about ideology, or greediness, it was about making the thing work.
If Krugman is right, where can Obama and the congressional Dems retreat to if they want a health reform that will actually work, and actually be a reform? (One argument, I suppose, is that even if you pass a reform that makes things worse, you've opened the door to making it better over time, whereas if you don't pass anything you've killed health reform and hurt the economy.)
Krugman, btw, made his post before it was clear that Coakley could lose in Massachusetts.
Re: totally
If Obama only pushes for tort reform and cost-cutting, I think some liberal senators say "No, this doesn't even give us a foot in the door."
I'm not optimistic about this at all today.
Krugman's being very funny today, amidst his despair.
Re: totally
At this point I think all energy needs to go into phoning representatives who have expressed wariness about voting for the Senate version of the bill -- it was clear from early on that the even-more-compromised Senate legislation is as good as health reform is going to get right now (barring an overthrow of the idiotic supermajority), and progressives need to find smaller ways to work on the deficiencies in the Senate plan.
I don't think it was at all clear that a slightly retooled and strengthened House bill, when brought back to the Senate, would get Lieberman or the "centrists" again anyway. The logic that they already voted for the bill once doesn't cut to the unavoidable problem that many of these people are pathological in their narrow self-interest and/or borderline insane (Lieberman especially probably wouldn't have any qualms not voting for cloture with a House-enhanced combined bill; it would probably be the least politically toxic thing he's done to himself in a long list.)