I'm not sure of the entire context of this, but what do you mean by "another example?" We have lots of examples of programs being undercut, or the system being gamed, by people who want to screw poor people. If that is all you mean, I agree. But the people behind the ACA did not have this as their goal. Instead, look to somebody like Marco "babyface" Rubio, whose concerted effort to damage the ACA would threaten certain states more than others, without any tangible benefit to the poor (beside reciting the space fairy parable of a neoliberal market intervention, I mean). I'll explain what I mean about Rubio later.quash wrote:The issue arises if you actually have to use that insurance, which he has. He would have been better off if he hadn't been working and been covered under the state. Yet another example of how these programs designed for the poorest of people make life that much harder for those trying to move up.
"Can?" I hope your theory of the healthcare market has some room for people who *do* use their insurance. There are different ways of funding many projects - so some states don't have everybody pay for the roads, even if they should, given the roads benefit absolutely everybody. Even the hermit in the woods got propane tanks and Pokemon thanks to roads. Yet as expensive as roads are, regressive taxes are often enough, because you're just paying the cost of gas for a fraction of resurfaced road, or a few filled potholes. Some could go broke due to shitheaded state politics on road funding, sure. But for health insurance, even with the ACA the market does not spread costs around like this, and even though healthcare ultimately benefits everybody, we have this view that you should pay for what you get.What is there not to see? People who aren't likely to use their insurance can choose a company that covers other people who aren't likely to use their insurance, which in a competitive market would (in theory) keep premiums low.Ed Oscuro wrote:I don't really see it, but I'm sure there are some good rationalizations for having a basket of different insurance pools (and, therefore, companies) to spread the risk around, instead of just one organization. Of course, those arguments won't work well for states without competitive insurance markets (or good healthcare providers, for that matter).
The point isn't what healthy people are buying - we want everybody to be healthy, and this is a great way of keeping costs down, including external costs which can bounce right back into your face. A person with adequate health and mental care is possibly less likely to scale a campus tower and shoot at people like Charles Whitman with his brain tumor; a person with adequate health care is more likely to be prevented from passing out at the wheel of a car aimed at a school x-ing. Every time you read some news about an outrage, remember that this represents an opportunity that may well have been caught with better social services - of the sort that insurance can pay for.
In the quote my first sentence is confusing, unfortunately. Risk is like manure - no good unless spread around. What I'm questioning is the view that companies are the more cost-effective, "better" option. Insurance is mainly offering a financial service. By analogy, Muslims have managed to make no-interest banking work for many years now. There is still overhead, and maybe even profit and stock holders, but the bank apparently succeeds in managing the risk of loaning while keeping costs and many types of risks down compared to the typical bank model. Maybe a particular halal bank might be rotten to the core - but it just seems like a very appealing model in many respects. Seeking to minimize its own costs while maximizing the costs of customers for profit - that is a phrase describing a natural goal for private insurance companies.
My second quoted sentence should be clear. The market can be divided up into different levels:
Nationally, the question doesn't change for single-payer compared to private insurers: What is the cost for all Americans, together and individually? Single payer's answer is easier to discover, and better if we can keep overhead down. If insurance is seen as a right, and also a worthwhile public good, arbitrarily dividing up the national market is ultimately robbing Peter to pay Paul. I will try to show why.
Next consider the state level. We have an insane hodgepodge of healthcare systems in the US; different states have different needs - and ability to pay - and politicians. Any of these things can put the monkey wrench in without single payer. So, just because he lives in the wrong state, the guy who wants and needs just the most basic healthcare plan is still screwed (see the NPR case at the bottom). Systems and insurance offerings vary on a per-state basis, so many private insurers have no way to spread out risk enough. We have let the laboratories of democracy play with this one long enough. It's the same old shit: Once it was the Permanent Secretary of Agriculture who starved the blacks in his state (I don't mean this guy), while today it's still easy to find a politician starving a man back onto the dole out of confusion, spite, and for the purpose of pandering. I should note Jamie Whitten was a Democrat, of the old segregationist school originally. His early career was not exactly typified by "programs designed to help the poor," but even he eventually came around.
Rubio's wrinkle in the ACA are the "risk corridors." This attempts to keep insurers - and the populations they serve - whole when they are screwed over by circumstances. This is, essentially, the government's form of finding a way to avoid robbing Peter to pay Paul - it ends up feeling the same way, because of certain Republican efforts to, well, collect "golden eggs laid by somebody else's goose," as Justice Brandeis might have put it. While some people get a relatively decent deal, other people do not. If you are unlucky enough to be an insurer in the "wrong" state, or cannot finagle certain wrinkles in the system that competitors have, you certainly aren't well placed to provide those low cost insurance plans while competing, even if you make a very good effort, even if you are a nonprofit.
Speaking of theory, with single payer we could still have individual health plans. You just wouldn't have companies strategically selecting what markets, states, and individuals to cover; you must also current view the issue at the per-company level (which may be identical to viewing an individual state, or practically so).
Finally, the company level. The big picture for each company is looking at their risk in total - but, of course, they will look at "more risky" groups and try to avoid them, thus we have the ACA. Yet even though the intention was that this be outlawed, it still happened.
The reality is there are markets where some insurers won't go, and there are also markets where insurers already did go, but not through the exchanges. Here's the key:
Wellmark Blue Cross Blue Shield opted not to offer ACA plans on the exchanges.
Instead they seem to have followed two strategies in these states:
1.) Keep old, non-compliant plans going. People who already had these tended to keep them, and Wellmark BCBS wanted them to continue because they were already cheaper with healthier applicants that had been screened.
2.) Keep off the exchange, where everybody else was going. This included a lot of people who weren't healthy enough for Wellmark BCBS before the exchanges, but it also includes some of your theoretical people who should be able to buy a cheap plan because they are healthy - like a young person who needs insurance for the first time.
Result: Competitors got fucked, and the people who went to the exchanges also get fucked. Can we still believe this fairy tale theory about competition and low rates?
It goes without saying that this wouldn't have happened in a single payer system, or even if the ACA had simply not allowed grandfathering in of plans. Yet they did, stupidly, and the result is that the poorest and sickest people got extra screwed.
How am I supposed to take this sort of talk the least bit seriously?
