One of the bigger problems with the ACA or any health insurance system which outlaws medical rating is its removal of the financial consequences of bad health habits. Progressives believe heavy taxes on cigarettes will reduce smoking and thereby reduce lung cancer and early death; a financial penalty on a self-destructive habit justified by the social welfare state’s future payment of medical expenses. (One issue is whether this is even true — it turns out most actuarial calculations show those who die early as a result of lung cancer have less spent on their medical care in old age and forego social security payments, so they save the welfare state money.)
But if you equalize the cost of medical insurance regardless of health habits, you are reducing the consequences of unhealthy habits and thus encouraging them. Accountability — having to be responsible for one’s actions — suffers under equalizing systems. Drivers with many accidents and drunk-driving convictions on their record will pay much more for (and find it difficult to even obtain) car insurance, and that’s normally considered a Good Thing because we want there to be financial penalties for habits that endanger others, like driving recklessly or under the influence.
The reasonable objection to charging for health insurance based on health record is that health status is only partly controlled by previous habits and behavior; a big chunk is genetics and chance. So it seems unfair to those who are sick because of bad luck in the genetic lottery — or even by accident, as cancers, for example, are thought in some cases to be created by accidental mutations, and only some cancers are caused by avoidable environmental exposures like smoking.
And many children begin life behind the eight-ball, having inherited problematic genes that make them more likely to suffer from conditions that cost a great deal to treat. Should insurance companies be able to use the results of genetic tests to offer low-cost policies to some, and much higher-cost policies to the unlucky?
In a laissez-faire world, insurance is an adversarial game with customers trying to hide any damaging information from the insurer as the policy is being sought, and the insurer doing their best to deny claims afterward. As a result, governments set up insurance commissions and regulators since it was impractical to adjudicate disputes over every consumer’s insurance policy in an expensive court of law. Arbitration and insurance commissions have done a fairly good job in the past of managing this conflict of interest, with some states being more pro-consumer than others.
One partial workaround for the medical rating problems is the idea of “continuous coverage.” The initial risk pool is assumed equal, and anyone who keeps paying for coverage continuously is allowed to stay in that average-risk category because some small part of their earlier premiums is true insurance — covering the risk that a health issue will turn up which makes them a bad risk in the future. Insurance contracts typically cover one year, and so if there is no requirement to continue coverage beyond that contract, rates could adjust upward or renewal could be denied based on negative events that happened during that year. Requiring renewal at the same rate as the rest of the risk pool makes the contract insurance against the long-term costs of treating any illness acquired during the period, not just that year’s costs.
What happens to people who allow their insurance coverage to lapse because they can’t afford the premiums or simply forget to pay? Most states had a high-risk pool with required must-issue, but rates were very high (of course — since the people seeking insurance under it were far more likely to need expensive care in the short term.) Some hybrids, like exclusions for pre-existing conditions for six months or a year, helped get people coverage at in-between prices.
The PPACA (“Obamacare”) tried to eliminate the problem with must-issue (no one could be refused insurance) combined with narrow time windows for seeking coverage and penalties for going uninsured. These were intended to force everyone to get insurance and to keep them paying for their insurance even if they were being charged much more than they were likely to receive in benefits. Younger, healthy people were expected to pay more to cover the costs of older, sicker people. In practice this did not work — even the subsidized rates were too high to get healthy young people to join up, and the penalties of going without insurance were small compared to the inflated new prices for insurance. So individual insurance coverage pools shrank and were dominated by new customers needing a lot of expensive, deferred care, and rates rose further as doctor networks were narrowed and more healthy people stopped paying.
The Supreme Court’s ruling deeming the ACA constitutional was only partial — the attempt to force states to increase Medicaid enrollments was deemed unconstitutional, so many states did not expand Medicaid. This left a bizarre hole in coverage in those states where a person could make too much to get Medicaid coverage, but too little to get private insurance subsidized through the exchanges. And the expansion greatly increased Medicaid enrollments in those states that participated, accounting for nearly all of the decrease in the uninsured in the US, but Medicaid itself has never been shown to improve medical outcomes or decrease mortality, and many people complained that they were forced to join Medicaid when they would have preferred to buy private insurance.
Also, the Supreme Court’s swing voter on the case, Chief Justice John Roberts, specifically warned that the fine for not having approved insurance was only constitutional if it was viewed as a tax, and an increase to the fine to an amount sufficient to force compliance would make it unconstitutional. This cuts off the ACA proponents’ attempt to raise fines to try to force more enrollment.
Which brings us to the subject of this essay — how do we decide what is fair when consequences of simple bad luck and genetics are mixed with the downside of behavior under a person’s control? Suppose a well-off person (let’s say the son from a wealthy family who left him a trust fund) drinks, smokes, and plays video games all day throughout his life. In his 40s now, he’s obese and unhealthy, with emphysema and cardiac problems imminent. Should his expensive future healthcare be subsidized by middle-class families who have worked hard, exercised, and been careful to avoid bad habits? That is the way ACA policies are now set up. Even unsubsidized, policies for wealthy people in poor health are much cheaper under the ACA than they would be in a free market, and those who have restrained their appetites and sacrificed to maintain their health pay more than they otherwise would to make up for those costs.
But there’s no easy way to separate those “bad unhealthy” people whose illness is due to their own choices from those “deserving unhealthy” people who are ill because of chance or genetic inheritance.
The ACA plan tried to compel more equality of premiums regardless of actual risk or likely use of medical services, which removed some of the incentive for healthier behavior and burdened those who made the effort and sacrifice to keep themselves healthy. This tried to protect those who were simply unlucky, but many of those people are worse off than they were under previous high risk pool plans provided by the states, and have had their care disrupted or cut off by the high prices and narrow networks.
Every complex system is adaptive, and human systems especially so, with people quite capable of understanding the rules and seeking out every loophole to their advantage. The ACA has failed because people aren’t easily herded by programs designed by committees, and by finding the loopholes (paying for one month and using it for three, staying off until actually ill then signing up under the many loopholes in enrollment windows to get expensive care then dropping out again), the ornery people have ensured the ACA cannot be sustained in its current form.
The ACA, which was promoted as saving everyone money, has ended up being much more costly for most than the old system. It has helped a few, but cost far more tax and premium dollars to help those few than a direct subsidy to the existing high-risk pools would have. The redistributionists have again discovered that unintended consequences will make nonsense of their social engineering schemes.
Philosopher John Rawls is usually cited by progressives intent on redistribution; his thought experiment suggested we view a system as just if we would choose it willingly, not knowing in advance what advantages or disadvantages we would be born with. You can argue that much behavior is also dictated by fate — our example of the obese videogamer may well have been doomed by being born into his particular family with parents who could not guide him toward a better way of living. But under that view, no one is responsible for anything, and we know that people can change to overcome even the worst background and genetic inheritance. Removing rewards for modifying one’s behavior toward the socially-valuable means a society which is less civilized and poorer in every way.
The classic Vonnegut story “Harrison Bergeron” takes equality to the extreme. The government has decreed that all must have equal abilities and outcomes, and so those who are more intelligent or talented are handicapped to bring them down to average. Of course, this becomes a nightmare with tragic outcomes as society grinds to a totalitarian halt.
But suppose we already have a little bit of this deadening effect introduced by the government’s emphasis on hiring by ethnicity or sex rather than ability. Would we even realize that the but-for world where only merit is considered would be wealthier, happier, and more fulfilling for most if not all people? If one has never seen a ballet performed to perfection by the most talented dancers on Earth, would we notice that the dancers are being dragged down by lead weights they have been forced to carry — or selected for political reasons rather than talent — making their performance less satisfying?
Socialists and redistributionists tend to think diversity and choice and product improvement are not as important as providing the poorest an equal quantity of goods, and the central planners of the USSR counted quantities of production, not quality; the stories of great quantities of useless, poor-quality, ugly products available from state stores while people schemed and bribed to get better-quality goods from abroad show how central planners failed to understand what mattered to the people. Even Bernie Sanders, who should know better, suggested there was too much choice in deodorant and shoes, and restricting choice would somehow allow more poor people to be fed, clearly missing a lesson or two of the socialist past.
So if you had never seen a perfect ballet or operatic performance, you might not notice how the ones you have seen have been compromised for the sake of political goals. Similarly, if you’ve never seen a world of free enterprise without identitarian politics or Party corruption, you will never realize how much freer and more productive your society might have been. The US overcame a history of race and sex discrimination to more closely approach the standard of merit alone — then has been backsliding incrementally as race- and sex-conscious employment policies took hold. While it appears the US is now limiting progressive overreach by not electing Hillary Clinton president, there has been a lot of damage already, with government agencies especially dysfunctional. It will take a lot of work battling entrenched special interests to reverse the educational system’s failure to teach children civics, history, and economics.
For more reading goodness:
Materialism vs Purposeful Life: Trump, Bannon, and Teilhard de Chardin
Sekrit Reform Agenda: Untangling Government: Medical Deregulation
No More Elections or Campaigns: Liquid Democracy
“Death by HR” – High Tech Threatened by Social Justice Activists