Four out of five outcomes ain’t bad

Last week, Tim Jost raised a very interesting point in comments regarding auto-enrollment. I’ve been wrestling with it for a bit and I’m still trying to organize my thoughts:

I would add yet another group that I am not sure is captured in the four categories listed–people who just don’t want health insurance. They rarely need health care and when they do go to the local community health center or free clinic or work out some arrangement with a local doctor or local hospital. They would be quite upset if they found out that someone had enrolled them in coverage even if they could opt out of it There are a lot of people here in rural Virginia whom I think would fit in this category..

I’m still trying to figure out how meaningful this group would be if we had a fully functional auto-enroll with a straightforward opt-out. I’m hand-waving operational challenges away to think this through. As I see it, most people in this group would not see anything different.

Four out of the five  pathways lead to a status quo outcome.  People with an insurance card in their wallet and no utilization don’t care about that insurance card all that much especially if their premiums are effectively zero as the policy is paid for by non-transferable tax credits.

The one pathway where there is a departure from current status quo is when someone does not opt-out and has utilization.  Here they can either present or not present their insurance card.  If they don’t present, they are back to status quo.  If they do present, they’ll probably be better off if the service is for cancer treatment but they may or may not be better off if the service is for something low level that they could afford to pay for with cash.  Odds are they will stay be paying for that service with cash as there is a large deductible that they need to satisfy.

And yes, I am using a material well being analysis to try to understand psychological anchoring so that might be my problem, but I am struggling with this right now to see how big of an issue it could actually be.




Finally, the appropriate musical response to future conditional reactions to gut-check hypothetical questions is below the fold:

12 replies
  1. 1
    ruemara says:

    I think I’m only here for the retro music because as much as I try, I only get the barest jist of your wonkery.

  2. 2
    rikyrah says:


    I think I’m only here for the retro music because as much as I try, I only get the barest jist of your wonkery.


    A lot of posts, I get…others…I feel you, ruemara.

  3. 3

    What happens in the US when the people who opt out get hit by a bus?
    Do they just quietly go bankrupt, or do they think they should be able to opt in while they’re on the way to the hospital?
    I’m not being facetious (well, maybe a little) — but I do honestly want to know how Americans think their health care system should work.
    In Canada, we’ve been in a government-payer system for almost my entire life, where everybody “opts in” because they are Canadian citizens (or landed immigrants, or refugees) who pay Canadian taxes. It wasn’t easy to get our system — a baby died during the doctors strike in Saskatchewan after the government introduced medicare — or to keep it — we still fight all the time about what should be covered and how much it costs. But nevertheless, we persisted.
    So I find it difficult sometimes to understand how Americans think about health care.

  4. 4
    TenguPhule says:

    @Cathie from Canada:

    So I find it difficult sometimes to understand how Americans think about health care.

    First, try after drinking yourself into a stupor.

    If that isn’t enough then congratulations, you’re more aware then a sadly large portion of our population.

  5. 5
    Unknown known says:

    I think I’ve spotted what your analysis is missing. These West Virginians still wouldn’t want it because FREEDOM, MURKA, USA! USA!

  6. 6

    People who are philosophically opposed to health insurance still have to be part of the risk pool.

    People who are philosophically opposed to car insurance…drive anyway. Sometimes they get caught. Around here, if they get caught, they lose their license. Fairly often, they didn’t have one to begin with. There is an analogy here somewhere, but it’s pretty well camouflaged.

  7. 7
    Mnemosyne says:

    @Cathie from Canada:

    So I find it difficult sometimes to understand how Americans think about health care.

    Americans think that if they do everything right, they will never get sick, die, or get into an accident. If someone gets sick, dies, or gets into an accident, it is somehow that person’s fault, and if it’s not easily identifiable as their fault, then it was caused by another person.

    It’s a weirdly medieval way of looking at the world, where anything that happens is directly caused by someone’s will, and it’s not just religious people who think this.

  8. 8
    Ruckus says:

    @Cathie from Canada:
    Well they don’t think about it. Americans are exceptional, haven’t you heard? They don’t need no stinking healthcare, right up to the very second they need it desperately. And as they don’t need healthcare, they don’t need to pay taxes for a system they don’t need. A fair percentage don’t pay for auto insurance because they are exceptional drivers and will never need auto insurance, right up to the second that some uninsured drunk hits them or they forget to ask someone to hold their beer and drive at 90 on the freeway. I feel so proud to live among all these very exceptional people. Now if I could only find one of them.

  9. 9
    ruemara says:

    @Cathie from Canada: Honey, both. And obviously, we think healthcare is run by magic elves. Except for the few who think it should be run sensibly and not for massive profits. But we lost.

  10. 10
    jefft452 says:

    “work out some arrangement with a local doctor or local hospital”

    i.e. Stiff the Dr. and Hospital causing the rest of us to pay more

  11. 11
    Another Scott says:

    @Cathie from Canada: In addition to what everyone else has said, there are lots and lots of people who can’t afford a health insurance policy because they make too much to be on Medicaid, they’re too young to be on Medicare, they don’t work for a company large enough to offer a group policy, or they simply don’t have enough money.

    WaPo from May 2016:

    The Federal Reserve surveyed more than 5,000 people to determine whether their personal situations were improving along with the economy. The results, released Wednesday afternoon, found that though households showed “mild improvement” overall, their perspective depended on their income, race and education.

    Take this one telling statistic: About 46 percent of Americans said they did not have enough money to cover a $400 emergency expense. Instead, they would have to put it on a credit card and pay it off over time, borrow from friends or family, or simply not cover it at all.

    Lots and lots of people don’t have $20 left over at the end of the month. Finding ways to pay for an annual ~ $12,000 health insurance payment is like thinking of flying to the moon to too many people.


  12. 12
    DHD says:

    The Netherlands has a historically significant population of these people, who are fundamentalist Calvinists who are opposed to all health insurance on supposedly Biblical grounds. This is, I think, different from the typical American religious exemption to the Obamacare mandate which is more along the lines of “horror of horror my dollars might go to pay for birth control”. Oddly enough there are some of these Dutch Darwin Awardists in Canada too, but not surprisingly, they’re in Alberta (and yup, they’re anti-vaccine, too):

    You can certainly opt out of the health insurance system in Canada by just never applying for a health card, in which case all doctors and hospitals will demand payment up front like God intended. I guess this is functionally equivalent to the auto-enroll, no-opt-out case.

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