Sunday, June 4, 2017

What Do Republicans Want on Healthcare Policy?

As people following the Republican health insurance debate can attest, the Republicans' underlying problem in attempting to write a health insurance law is that they are opposed to health insurance as a matter of basic principle.  It's collectivist.  It undermines individual responsibility.  It "enslaves" the healthy by forcing them to subsidize the sick.  And that's even before the Evil Government gets involved and subsidizes the thing.

So what do they want instead?

So far as I can tell, the real Republican/conservative/libertarian ideal would be for there to be no health insurance whatever, and instead for everyone to pay all health care costs out of pocket.  The statement "That's not insurance, it's prepaid healthcare," is to R/C/L's a devastating criticism.  One might fairly ask why.  Most people, after all, would rather budget expenses in predictable, manageable-sized increments than in lump sums.  Many people, for instance, pay higher interest on their home mortgages to have a fixed monthly payment, or make arrangements with their utility company to have their bills evened out around the year.  Why not do the same with healthcare?

So far as I can tell, the R/C/L response would be that there is nothing wrong with that; people should be allowed to pay into health savings accounts as much or as little as they wish.  R/C/L's would presumably also endorse the idea of healthcare credit cards, so long as the resulting debt was not too easy to discharge in bankruptcy.  Health savings accounts would be favored as a system of pure individual responsibility -- you can't get healthcare unless you can pay for it; with healthcare credit cards accepted because at least the individual bears the expense and is not subsidized by anyone else.

At the same time, even R/C/L's would presumably acknowledge that this is a hypothetical, rather than a practical, ideal.  The problem with it is that anyone, no matter how young, healthy, or responsible, can be hit with a catastrophic illness or injury that there is simply no way to have saved for.  The chances are not high,* but the possibility is real.  Therefore, R/C/L's as a practical matter do favor health insurance that is a real insurance system, i.e., not a systematic subsidy, but a bet on a rare event.  Everyone who fears the expense of catastrophic illness or injury will pay in and the unfortunate few who actually have such an experience will receive payment.

But ordinary healthcare will always be paid out of pocket.  R/C/L's generally believe that medical costs these days are so high because health care has been artificially subsidized by insurance.  This applies to both government and private insurance.  However, R/C/L's blame mostly government since without government regulations, health insurance would cover only catastrophic care and would therefore be affordable.

But what about people with chronic medical problems, you may ask.  People with chronic medical problems will have higher medical expenses than healthy people, often through no fault of their own. Often** people with chronic medical conditions will have lower earning capacity than healthy people.  Sure, we can discount people whose chronic medical problems are the result of unhealthy choices, but there are lots of people who were simply unlucky in the genetic lottery.  The proper R/C/L response, so far as I can tell, is that while it is unfortunate that some people are unlucky in the genetic lottery, it simply does not rise to the level of a legitimate public policy concern.  The purest R/C/L response would be to recommend private charity and if private charity proves insufficient, well, it still is not a legitimate public policy concern.  The less ideologically pure will concede a limited role for government here -- county indigent funds to pay medical bills for people who cannot otherwise afford necessary medical care.

Pregnancy and birth also deserve some attention.  This has been a major point of contention since R/C/L's have objected to the collectivism of making men pay for coverage of pregnancy and birth when only women use such care, while liberals say that, since every pregnancy and birth involves a man as well as a women, it is reasonable that men should subsidize women in this respect.  I assume that if you asked R/C/L's whether men should subsidize women's expenses for pregnancy and birth, R/C/L's would say of course.  The baby's father should marry the woman in question and share the medical expenses of her pregnancy and birth.  But no man (or woman, for that matter) should be asked to share the expenses of the birth of someone else's baby.  In other words, the medical expenses of pregnancy and birth should be paid out of pocket by the parents and no one else, except perhaps grandparents and other close friends or relatives who want to help out.

At the same time, not all pregnancies and births cost the same amount.  Some women have medical conditions (including being near the beginning or end of their reproductive life) that make pregnancy and birth more risky and higher maintenance.  And sometimes completely unforeseeable complications arise.  I assume that R/C/L's would approve of the couple getting pregnancy and birth insurance to deal with the sort of unexpected catastrophic complications that sometimes happen, just like health insurance against catastrophic illness and injury.  But any foreseeable problems caused chronic medical problems are like other chronic medical problems -- unfortunate for the individuals in question, but not anything that rises to a legitimate public policy concern.

This is the hypothetical ideal for R/C/L's.  Obviously, there are real-life problems in getting there.  Hypothetically, the ideal R/C/L health policy would be to take a time machine back to the time during WWII when health insurance was first linked to employment and stop that from happening.  Then pass a federal law allowing insurance companies to compete across state lines. This will allow them to move to the states with the least regulations and ensure that health insurance is essentially unregulated.  Then take a time machine to 1965 and block the enactment of Medicare and Medicaid.  At this point you will have a healthcare system untainted by government and will presumably serve all well.

Like all counterfactuals, this one cannot be proved or disproved.  But removing government from all role in healthcare overnight, though theoretically the ideal R/C/L policy now, is not politically feasible.  Indeed, as it turns out from the Obamacare repeal debates, dismissing the higher expenses people with chronic (or acute) medical problems would have as not a legitimate public policy concern is not proving politically feasible.  Too many people with ongoing medical problems would get upset. So Republicans are conceding a legitimate government role in health care.  Private insurance companies will cover healthy people.  For people too sick to be insurable, government will provide high-risk pools.

So it turns out that R/C/L's are conceding government a legitimate role in healthcare after all -- paying for people the private sector does not want.  And theoretically there is no reason why this couldn't work.  As a practical matter, it is so much window dressing.  Running high risk pools of this kind would be extremely expensive.  Republican alternatives to Obamacare do not allocate anywhere near enough money to pay for such pools.  The high risk pools Republicans are proposing are not much more than a sleight of hand allowing them to wave the chronically ill out of the way and say that they do care about the sick, while actually not taking anywhere near enough action to matter.  This can be airbrushed away during debate on the bill.  It cannot possibly be concealed if their plan is actually implemented.

*Of course, one's chances of dying eventually are 100%.  And while a few lucky duckies will be killed in a plane crash while in perfect health, for most people dying will be an expensive proposition. Currently most people die after the age of 65 and Medicare takes care of that, but R/C/L's don't approve of Medicare either.  I am not clear how they favor dealing with everyone's ultimate and generally expensive mortality.  Thus far they have managed to avoid the question.
**Not always.  I realize there will be many exceptions.  But often.

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