Monday, August 17, 2009

Rational Health Care Reform Discussions

Timothy Noah has written an indispensible guide to resources around the web: Health Care Reform: An Online Guide. Check it out.

I have recently discovered Bernadine Healy's regular column for US New and World Reports. She is a cardiologist, professor and a Republican that has served under both presidents Reagan and Bush 41--most recently as director of the NIH.

If your last three addresses were Cambridge, MA; Berkeley, CA; and Boulder, CO; then you might be aware that anyone that is against Obama's health care reform is evil and/or just plain deluded. ;-) Or you might think that Obama hasn't gone far enough. You probably haven't heard a fact-based, rational argument against some specific elements of the proposed reforms. You will get that from Dr Healy. I actually learned new things from her columns. For example:
The angry so-called mobs at these town halls may have sniffed out the Kabuki courtship dance taking place between Big Insurance and the Obama administration. Two months back, these two parties were holding hands at the White House, hellbent on getting health reform done fast—and before the public caught on to some pesky details.
She refers to the mandate that everyone buys "comprehensive" health insurance. Many healthy young people, if they are not covered under workplace plans, buy "catastrophic" insurance only. They are much cheaper than comprehensive plans, as little as $50/month. Under the house bill, everyone is required to buy comprehensive coverage, and the premiums are fixed such that young people will pay half as much as older people. That sounds reasonable. Presumably, younger people will pay much higher premiums for slightly more coverage because they will reap the benefits of lower premiums when they are older.

The proposed legislation does not require the insurance companies to adjust the premiums for older people downwards to reflect the larger and healthier risk pool.

That's a huge gift to the insurance companies. Obama has let the fox into the hen house. I am disgusted.

Dr Healy is more conservative than I am. I don't agree with her conclusions generally. (For instance, I think that bare-bones health insurance is a bad idea.) But she has written some interesting insights about the insurance industry here and here. And she is bringing up generational equity.

I am in total agreement with her that we should slow down, read the proposed legislation (!), discuss the implications rationally and respectfully, and accept that reforming this mess will be a long process with many corrections along the way.


  1. My take on Obama's strategy is that he "overlearned" the lessons from the failure of the Clintons in the 90s. That effort was brought down by industry groups, so this time Obama is doing whatever it takes to get them on board, perhaps assuming that the system can be tweaked to remove some of the plums he's granting them along the way.

    Perhaps the assumption is that competition will naturally drive premiums down? If there is an actual competitive marketplace for insurance, you'd expect some companies to offer bare-bones coverage at the lowest price at which they can still turn a profit and other companies to offer fancier coverage at a higher price- and consumers could choose what best meets their needs.

    Of course, right now, insurance companies compete not for consumers but for HR departments, and that competition is almost solely on price. My "choice" at open enrollment time is between the HMO and the PPO offered by the same company. If I want to go out and buy insurance privately, I pay a huge premium for trying to go outside of a group plan. I can't help but laugh anytime someone tells me that we have insurance competition now. We do, sort of, but it is a very unusual market!

    I do agree with Dr. Healy, though, that this is likely going to take a few iterations to get right. If everyone were discussing the options rationally and respectfully, I'd be very happy. Sadly, what we actually have is Republicans distorting the facts and telling outright lies on Fox News and Democrats who seem unable to muster a clear and honest defense of why we need reform and who seem to instead want to fall back on cheap bashing of entire industries. It makes me sad.

  2. Are you suggesting that people should get to choose between comprehensive and catastrophic insurance? If so, self-selection will keep catastrophic rates down (due to a healthier pool), while comprehensive rates are driven out of reach. Yes, mandating comprehensive insurance will mean that some young people will have to shell out more money; however, it will also bring the price of comprehensive insurance within reach to millions.

  3. No, I should have made that clear. I think catastrophic health insurance is a bad idea for society overall. They are another form of cherry-picking. And they can lead to people delaying treatment.

    Public long-term care facilities are full of young men who had bare-bones or no health & car/motorcycle insurance.


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