Method agnosticism and funding

I’m fairly agnostic about what method the United States uses to provide healthcare and health insurance to our population as long as the objectives of providing decent care at affordable prices in an equitable manner are either met or worked towards.

If that means Medicaid expansion, great. If it is Medicare for All, fine.

If that means Exchange subsidy exploitation, wonderful.

If that means Medicare Advantage proliferation, I’m fine with that.

If it means it means segregating the risk pool into a general insurance market and a high cost/high risk chronic condition management market via a high cost risk pool that is adequately funded, I’m on-board with that.

Once a method is chosen, we should seek ways to use that method efficiently and wisely. There are lots of ways that coverage can be configured that if they are adequately funded AND constantly tweaked to avoid perverse and negative incentives, they would accomplish my objectives as a means to an end in and of themselves. I’m effectively method agnostic if the end is accomplished. And this method agnosticism means I’m okay with spending a bit more money to achieve the goal as most of my writing on Silver Gap subsidy manipulations will lead to higher federal expenditures than Silver Spam strategies.

TPM has a good piece on a problem that the Republicans have right now on trying to come up with a Repeal and Replace bill. They don’t share an end as worthy in and of itself of trying to get people reasonably covered. Instead their end is minimizing federal taxation which is constrained by electoral consequences. So their policy writing space is limited:

“On paper, high-risk pools could work to lower premiums for healthier people and provide adequate coverage to those with pre-existing conditions, it really comes down to the money,” Levitt said.

A number of states operated them before the ACA, but because they were so expensive, most states offered coverage on them to a very small portion of people on the individual market, much smaller than the percentage estimated to be barred from insurance without the ACA’s pre-existing conditions coverage requirements.

“The issue, of course, is the people in the high-risk pool are going to be very expensive, so you’re going to have to have some sort of funding mechanism to subsidize or otherwise pay for the coverage that they get,” said Yevgeniy Feyman, a health care policy expert at the right-leaning Manhattan Institute.

Estimates for the average annual cost for the federal government range from $15 billion to $178 billion, while Ryan’s “Better Way” heath care reform white paper reserved an average $2.5 billion per year to subsidize state risk pools.

The big problem is funding. A lot of different systems could work if funded reasonably well. It won’t be funded reasonably well.

“Money is so central to all of this. If a replacement spent comparable amounts to the ACA you could come up with all kinds approaches that could probably get the same level of coverage in a different way,” Levitt said. “But Republicans have generally been very clear that they want the federal government to spend less than what the ACA called for.”

There could be a bunch of designs that could work towards a liberal end if they were funded. That won’t be the case so agnosticism is useless on mechanism design.

33 replies
  1. 1
    Baud says:

    Is there anything money can’t solve?

  2. 2
    Roger Moore says:

    You could probably also reduce government spending if you were willing to impose really strict cost controls- being really aggressive about drug price negotiations, reimbursement rates, etc. It would be hard to save a bunch of money right away, but it would bend the cost curve and save big in the long term. But, of course, the Republicans really, really don’t want to kill any sacred cash cows. It’s simply impossible to cut costs, maintain or improve coverage, and continue to funnel money to the people who have been profiting from the current system. At the very best, you can get two of the three.

  3. 3
    Fair Economist says:

    The basic problem is that the Republicans want to reduce direct federal spending so they can cut millionaire’s taxes, but the ACA is already about as efficient money-wise as any healthcare program can in terms of direct federal spending. Keeping the official deficit down was one of its biggest design goals, so it has lots of choices that are either politically unpopular (mandates) or socially inefficient but cut government spending (using private insurance). Even the Medicare expansion probably cuts government expenditures, because it’s for people who would need 100% subsidies anyway so the superior efficiency of Medicare is needed since they can’t offload expenditures via private insurance.

    So, to cut costs the Republicans have to cut healthcare, which people will notice. Worse, after whining about the specific mechanisms of Obamacare, if they change them they’ll increase needed federal spending and put themselves even further behind.

    Rarely has an unpleasant dilemma been more richly deserved.

  4. 4

    The fundamental reason there is no Republican plan for universal health insurance is because Republicans don’t want universal health insurance. I don’t know why this keeps getting lost in the reporting. Probably because there’s no real fun narrative, no warring ideas, and reporting on actual democratic vs. republican policy priorities would mean “a well-meaning but flawed proposal vs. fuck you” over and over and over.

  5. 5

    @Major Major Major Major: The major issue is that most of the Republican Party or at least the elements of the Republican party that A) Face potentially competetive general elections AND B) make up the marginal majority won’t say that “FUCK YOU” is the preferred Republican policy position.

    So that is why we’re here.

  6. 6
    gene108 says:

    There could be a bunch of designs that could work towards a liberal end if they were funded.

    Dude, seriously. Pretty much everything government does, outside of law enforcement, could work towards a liberal end, if funded properly.

    Adequately funding government, in America right now, is a radical liberal-lefty-socialist-borderline-full-blown-communist idea.

  7. 7
    Chris says:

    @Major Major Major Major:

    The fundamental reason there is no Republican plan for universal health insurance is because Republicans don’t want universal health insurance.

    This is a more straightforward and honest report than anything I’ve read on the topic from any media outlet since the ACA debate started.

  8. 8
    John Revolta says:

    @Baud: Well, apparently it can’t solve stupid.

  9. 9
    HeleninEire says:

    @Baud: No. Money smooths the way. Every. Single. Time.

  10. 10

    @Baud: It can’t buy everything but you can’t buy much without it.

  11. 11
    pj says:

    I have called Cong. Ryan’s office a few times asking for their estimate on how many people they expect to be enrolled in high risk pools. No answer yet.
    One of the lowest estimates I can find is from an American Enterprise Institute paper. 2 to 4 million enrolled.
    Let’s give Ryan that conservative estimate: 3 million people.
    His 2.5 billion a year for 3 million enrolled works out to $69.44 a month per person.

  12. 12

    No, it is not about money. It is about risk pooling. Republicans want risk segmentation. Partly this is for pseudophilosophical reasons; partly it is because they think it is what the insurance industry wants. And there are players within the insurance industry who do want risk segmentation, which is only another way of saying that businessmen are too stupid to breathe, because risk segmentation leads ineluctably (and, as we may find out even yet this year, with unimaginable speed) to the collapse of the market. This is why there must be a Federal role, because the only workable risk pool is exactly the human inventory of the country. If any kind or amount of risk segmentation is permitted, then it does not matter how much money is thrown at the problem or where that money comes from; the outcomes cannot be good.

  13. 13
    Thru the Looking Glass... says:

    They don’t an end as worthy in and of itself of trying to get people reasonably covered…

    In other words…


  14. 14
    mai naem mobile says:

    I’m affected by this shut but I can do other stuff if I have to but fuck the people who got conned by Dolt 45 and the lazy fuckers who couldn’t be bothered to show up. Those people are going to get hurt just like me and I just don’t give a shit about them anymore. And I don’t want to hear about voter suppression because even with voter suppression we just need a very good turnout on our end to beat these aholes.

  15. 15
    mai naem mobile says:

    And,no high risk pools don’t work.

  16. 16
    gene108 says:

    @Thru the Looking Glass…:

    It’s not just poor people. It is anybody, who is not independently wealthy, or has a spouse with good benefits.

    Why a spouse with good benefits?

    Let’s say Mr. Middle-Class-Chemical-Engineer one day ends up with kidney failure and cannot work regularly, without the option of his spouses insurance, the whole family is SOL.

    Now if Mrs. Chem-E gets laid off, the family is SOL.

    There were (are?) plenty of middle class families, who are one or two serious health problems and/or economic down turns away from financial ruin.

    Obamacare saves lives.

    Obamacare saves family’s finances.

  17. 17
    jl says:

    If whatever is chosen is very poorly funded, should we be agnostic about which is worst, or will all of them be equally bad?

  18. 18
    MobiusKlein says:

    @Baud: Being buried under a million quarters?

  19. 19
    Betsy says:

    @Frank Wilhoit: Can you go into what you mean by pseudophilosophical reasons? That sounds interesting.

  20. 20
    Sasha says:

    At the risk of sounding stupid, what happened to Richard Mayhew?

  21. 21
    Turgidson says:

    Estimates for the average annual cost for the federal government range from $15 billion to $178 billion, while Ryan’s “Better Way” heath care reform white paper reserved an average $2.5 billion per year to subsidize state risk pools.

    Yeah, this is one of the Granny Starver’s go-to moves. Pretend to be trying really hard to make the numbers work, but purposely underfund the program so severely that he can turn around in a few years and say “gee, look, we’re spending billions of dollars on this and the results are really poor. We should unleash the benevolent power of the invisible hand on this dilemma.” Then release another Path to Prosperity for Billionaires but Nobody Else budget document which block grants or privatizes the whole shebang.

    Nobody other than a few people like Elizabeth Warren or St. Bernie of Sanders is likely to point out that Ryan starved the program to death on purpose so that he could get it off the federal government’s books, and no one outside the political junkie crowd will hear them.

  22. 22
    Hoodie says:

    @Betsy: freedumb! Market segmentation aligns with the belief that bad outcomes are always the result of bad choices and that bad choices are only the product of moral inferiority. Affluent whites make good choices because of superior character, not because that have better options to begin with.

  23. 23
    Jerry says:


    At the risk of sounding stupid, what happened to Richard Mayhew?

    Richard Mayhew was a lie.

  24. 24
    FlipYrWhig says:

    The problem is that Republicans at this point are all either hateful, greedy, amoral, or stupid, and, most commonly, all four at once. If you voted for a Republican government, you should start to feel the painful results any day now. If you don’t like the pain you feel, you can either start voting for Democrats, or you can pressure the Republican Party to grow a conscience. If you don’t feel like doing that, then learn to enjoy your misery. Some sick people don’t want to be cured. I’m not interested anymore in doing it against their will.

  25. 25
    Shinobi says:

    One thing that stuck with me from that article is the underlying desire to have people be smarter “consumers of healthcare.” And I think that’s a fundamental problem, health care is not a consumer good. It’s something everyone will need at some point in their life regardless of their desire to need it. It’s just such an absurd point of view. “Well then don’t get cancer if you can’t afford it.”


  26. 26
    Mark Regan says:

    A reason not to be agnostic about how things are organized is that some schemes are easier to undo than others as a political matter.

    Luther Gulick’s account of a 1941 conversation with FDR is instructive here:

    In the course of this discussion I raised the question of the ultimate abandonment the pay roll taxes in connection with old age security and unemployment relief in the event of another period of depression. I suggested that it had been a mistake to levy these taxes in the 1930’s when the social security program was originally adopted. FDR said, “I guess you’re right on the economics. They are politics all the way through. We put those pay roll contributions there so as to give the contributors a legal, moral, and political right to collect their pensions and their unemployment benefits. With those taxes in there, no damn politician can ever scrap my social security program. Those taxes aren’t a matter of economics, they’re straight politics.”

    FDR also mentioned the psychological effect of contributions in destroying the “relief attitude.”

  27. 27
    Betsy says:

    @Hoodie: Oh right, of course. Puritanism plus plutocracy, propped up with the “Just World Hypothesis.”

  28. 28
    Bob Hertz says:

    I have never met a Republican with a serious chronic health problem. Republicans stand for the interests of healthy people, who would get dramatically lower premiums in the individual market if we went back to medical underwritng.
    This is just a type of straight up class conflict.

    As tor the high risk pools…….the intent of Ryan et al is to minimize any federal contribution, and then leave it up to the states to provide the rest of the funding. This is partly just selfishness, or maybe mostly selfishness, and partly from the Republican philosophy that it is just fine for the states to differ wildly in benefits.

  29. 29
    Shinobi says:

    @Bob Hertz: I have. My mother is disabled from a car accident and a stroke. At one point 10 years ago my parents were paying over 20k a year for her health insurance, plus huge supplemental bills. I made the mistake of pointing out to my father one day that if we weren’t well off, my mother’s quality of life would be much lower. The yelling that followed was fairly tangential and unrelated but clearly expressed what he thought of my statement. (Mostly that it had to be wrong because he didn’t want it to be right.)

    Do not underestimate the ability of Republicans to delude themselves so they can keep their Elephant Daddy. They just want Daddy’s approval, logic and self interest doesn’t enter into it.

  30. 30
    BBA says:

    So I’ve communicated with some thinking conservatives (stop laughing, I’ll wait) and one common thread is opposition to the ever-rising cost of care beyond any kind of diminishing returns. The amount of money spent on the last six months of a terminally ill patient’s life, for instance, is pure waste to them and not worth spending public money on. But since there will always be political opposition to rationing care or imposing “death panels”, any “universal” system will ultimately be required to pay for all of these ridiculous costs, increasing taxes on the rest of society until the whole thing inevitably collapses. Thus it’s best not to go “universal” at all.

    I don’t agree with the conclusion, but I think there is maybe half a point to it. There is rationing in any system, and “universal” systems tend to be stingier with benefits than a typical American employer-sponsored plan, let alone Medicare. That’s why health insurance still exists there – if you can afford it, you can get a Blue Cross Canada policy to pay for what Canadian Medicare doesn’t, likewise the UK’s Bupa and NHS. But that kind of two-tiered system will never be politically acceptable in America.

    They also like to bring up that Oregon Medicaid study that “proves” that whether or not you have health insurance doesn’t actually affect health outcomes.

    I think their preferred “plan” is to just deregulate everything and let the market take care of it. End the tax exemptions for employer-sponsored health plans, abolish Certificates of Need and the AMA’s monopoly on med school accreditation to let more new providers into the market, and prices will naturally become affordable once everyone has to pay for their own doctors instead of going through lots of middlemen. I’m skeptical – has any country actually tried this? Singapore doesn’t remotely count.

  31. 31
    Buskertype says:

    @jl: this is a really interesting question.

  32. 32

    @Betsy: How lucky you are, to have somehow escaped saturation-bombing with “conservative” pseudophilosophy over the past decades! Let me not put words in their mouths (as if I could, with so many flowing out in the opposite direction). Simply look at any of the justifications for high-risk pools. Google something like “unfair to young healthy people”. You will be eyes-deep in travesties of rational discourse in no time at all.

  33. 33
    Sasha says:

    @Jerry: I assumed he simply disappeared back into London Below.

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