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.