No matter how many payers

By now no one should be surprised by this:

[A]ll systems of paying for and providing healthcare suck; all of them suck worse if you’re poor and none of them are especially bad if you’re rich. There is no happy, Disney-movie solution and on many levels, the more lawmakers mess with it, the worse it gets.

Before all this started, if you were poor and didn’t have insurance, you were perfectly free to die in a ditch; if you chose not to, showing up at a hospital emergency room would get you treatment (hospitals are generally not allowed to turn away anyone who is genuinely ill or injured) and a whopping huge bill. Under ACA, you could also die in a ditch or walk into a hospital uninsured, but you were going to be fined in addition to the big bill*; under ACHA, the uninsured get the same two choices and skip the fine, but if they choose the hospital and survive to buy insurance they will pay a 30% surcharge on their premiums — and so will you, if you go more than two months without insurance. This is all very interesting, but if the initial aim was to reduce the number of uninsured citizens who die in ditches, exactly how does either plan accomplish that goal? They don’t, no more than a low-flow showerhead in Seattle or Indianapolis helps droughts in California or a shrinking fossil aquifer in Arizona.

The line I keep hearing is that “everyone has to be insured so the risk pool is large enough,” which will come as a surprise to the statisticians and actuaries who work for insurance companies. It does not take a huge pool to make the risk usefully predictable and there’s a lower limit to the rule that adding more people makes the risk more predictable and therefore allows reducing the amount of “just in case” money the insurer needs to keep for off-the-prediction surprises: you do have to pay all those mathematicians, adjusters, attorneys, salesmen, managers, top brass and support staff — and the investors are hoping for a little profit on the money they have put up to get the whole thing rolling, too. The thing people seem to think they are saying boils down to “if everyone pitched in a dollar, we’d all be able to afford healthcare when we needed it,” a charming sentiment that skips blissfully over what right the rest of us have to demand a dollar from every random stranger.

As always, there’s a footnote:

* The fine is (if I remember correctly) under $2500, which is just about big enough to be insulting and for the the person without two dimes to rub together, might as well be $25,000 or $250,000.

I’m awaiting the first proposal that calls for filling in all the ditches, so no one can die therein.


  1. McG »

    21 March 2017 · 8:01 am

    Before all this started, if you were poor and didn’t have insurance, you were perfectly free to die in a ditch

    Two words: “charity ward” — something the insurance model and the welfare model have conspired to flush down the memory hole on the assumption that people would rather die than accept charity.

    An actual look at history suggests what charity-ward patients really did was take it and complain, which now everybody gets to do. Never underestimate the power of gripe envy.

  2. Holly H »

    22 March 2017 · 8:49 am

    “…..what right the rest of us have to demand a dollar from every random stranger.” Why do we Americans hate socialism so much? Should we dump our public libraries/schools/highways because we all pay for them and even poor folks get to use them?

  3. Holly H »

    22 March 2017 · 8:56 am

    Last night, I heard a Republican senator stating that he certainly does not expect anyone else to pay for his family’s health care costs. I shouted at the radio, “Yes you absolutely do, you hypocrite! The public pays for a gold-plated health care plan for you and your family.”

  4. CGHill »

    22 March 2017 · 10:11 am

    Congress wasn’t at all interested in ACA-level policies for itself, and I doubt any of them are looking forward to whatever emerges as TrumpCare.

    The big argument against single-payer is that it will result in rationing, and of course it will. Then again, if you have to pass up a treatment option because you have to meet your yearly deductible first — to me, anyway, that is a distinction without a difference.

  5. fillyjonk »

    22 March 2017 · 12:22 pm

    I suspect part of the “solution” is going to have to be requiring Congress to live with whatever plan they choose to foist on the American public. Goose, gander, sauce, and all that.

  6. Roy »

    22 March 2017 · 4:56 pm

    “Why do we Americans hate socialism so much?”

    Because it gets out of hand too soon and too easily. Where does it stop? How much is enough? Answer: There’s *never* enough.

    “Should we dump our public libraries/schools/highways…”

    In a word – yes. But only in that the people who use those amenities should be the ones who pay for them. Libraries – except to a child, a library card doesn’t have to be free. Charge a fee for the library card that is commiserate with the cost of the library.

    Schools – in most districts not everyone pays now. Usually only property owners pay the local school tax regardless of whether you have children in the system or not.

    Highways – should be payed for by taxes levied on the users of the highway – taxes such as on motor fuel, vehicles, and tolls, etc. I know it’s not that way today, but only because the taxes that motorists pay today are dumped into the general fund and the highway upkeep and maintenance are then paid for out of that.

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