Tuesday, January 10, 2017

Obamacare

I thought I might write a few words (stop laughing: actually, I have been insulted many times, but sometimes with such creativity I had to admire them.  One of my favorites was someone quipping that if I ever decided to kill myself I could do it by jumping off my suicide note) about Obamacare.  First, I will link my two treatments of the topic.

Health insurance reduced to ten paragraphs: http://www.goodnessmovement.com/files/Download/Notes--31--healthcare%20in%20ten%20paragraphs.pdf

Obamacare, at length, and contextualized within a broader regulatory and business context, mainly for the benefit of leftists who won't read it, and redundantly for those possessing basic economic literacy: http://www.goodnessmovement.com/files/Download/obamacare.pdf

Now, to the topic of repeal, which is a present very real probability.

First, you have to separate the parts of it which were simply coerced charity--socialism--and the parts where it was claimed the government could deliver an existing service better and at a lower cost, which is always farcical.

Broadly speaking, Obamacare helps the poor, and hurts the middle class and affluent.  People who had been able to get insurance at a reasonable cost (at least by the standards now in force, after all this government "help") were hurt.  Their premiums went up (for obvious reasons I detail in my paper), and their coverage went down.

The people who WANT the repeal of Obamacare are these people.  What they want is the ability to set the terms of their deductible, to set aside money to pay that deductible tax-free (and in an heritable manner, which was a Trump innovation I had not thought of: you get your parents health savings if they outlive it), to be able to choose between many competing providers, and to buy their own insurance directly from the carrier, rather than being forced to use whatever their employer provides, because it is a fucking Blue State and the Unions run things, and losing their coverage when they lose their jobs, or be forced into a plan they hate, can't afford, and would not choose.

So: 1) require all States to allow all insurance companies meeting minimum standards to sell within their borders.  This is a proper use of the much abused Commerce Clause, since preventing de facto protectionism within the United States was seen as a proper role of the Federal government.

2) Make all money deposited in an HSA tax exempt, both on the way in, and on the way out, when used for medical expenses.  This will HUGELY incent savings, which helps everyone.  Also, make these accounts inheritable, or for that matter shareable, in that a parent could gift without tax consequence their 20 year old son the $5,000 he needs for his first deductible.

3)  Require all States receiving Federal money for anything (this is a cudgel, but it seems the most obvious option) to allow individuals to buy any individual coverage plans they see fit, that are offered by carriers in their States.  This means that, like your car and life insurance, your health insurance is your own, and can be continued exactly as you like if you change jobs, are fired, or move.

4) Self evidently, there is no market reason why plans could not and would not be developed to keep kids on their parents plan.  Why this was ever an issue, I don't know.

But what I foresee is that people could have $10,000 deductibles, and only pay $25/month.  This is obviously highly affordable.

5)  Make all insurance premiums tax exempt also, PROVIDED that coverage is maintained for the previous 12 months.  Make both HSA and premium exemption contingent on this.  On the one hand, basic coverage will become very affordable, but on the flip side we want universal coverage in the not too distant future.

Now, as far as the poor, a big part of Obamacare was simply an expansion of Medicaid.  We saw endlessly the tired meme "all the other kids have universal healthcare", but the truth is we ALREADY had a huge safety net for the poor and what market problems existed for everyone else were entirely the result of too much government.  The problem that could be solved with socialism had been solved, and the problem that could not was made worse.

One of the things we want with health insurance is to avoid the moral hazard of allowing people to avoid responsibility for their own health.  In terms of concrete health outcomes, one of the big reasons Americans compare poorly to many other nations is that our poorest pay no cost out of their own pockets for failing to maintain their health.  They just go to the clinic, and lots of stuff is paid for.  So, at any rate, is my impression. I am open to correction.

So what we need is a migration path for the poor.  Let us say that we require them, as a condition of receiving other social benefits, to maintain health insurance of a very minimal sort.  Let us say they pay $25/month for a $10,000 deductible plan which includes one wellness visit a year with a Nurse Practitioner, or Physicians Assistant.  If they get seriously ill, they won't have $10,000, but we can make them responsible for some portion of that, depending on how poor they are.  Even if they have to pay $1,000 out of pocket, that will be incentive for them to give at least one or two fucks.

And having to pay something, versus just being gifted it for being born, helps build responsibility, and with it, some measure of earned self respect. The alternative is remaining a perennially needy and grasping child.

And I personally would support health education programs.  Maybe, again, they can be made to attend educational seminars as a condition of getting other benefits. Ask them to take care of themselves, but make sure they have at least the basics regularly reinforced.

These are a few ideas.  Repeal and replace for the middle class and up is easy.  For the rest, a migration path.  But perhaps we could take this logic past mere repeal, all the way up to a pathway to get rid of Medicaid entirely for most of the population.  Medicaid is something, but nothing remotely as good as what the free market could and would provide if allowed to do so.

Medicare is another story I don't have time for right now.  I do think we all need to realize collectively that it is very selfish spending small fortunes to win small amounts of life extension, and that in very poor health.  We keep people alive with machines for months at enormous cost.  Their hearts may be beating, but that is not living.  It is of course enormously profitable for some companies, but they can just suck our dicks.

We could potentially allow people to opt out of Medicare when young, and have provisos written into their health insurance contracts that there are lifetime maximums on end of life care.  This, again, would allow Medicare to gradually fade away, although of course it will be needed for a while.  We COULD write lifetime maximums into current plans though.  These would not be "death panels", per se: the expenses alone would dictate it. This step alone would likely make Medicare solvent, and we should allow people to opt out at all ages.  Right now, in my understanding, you MUST take Medicare if you want Social Security.

We should allow people to opt out of Social Security, too, but again I don't have time for that.  Something like what they did in Chile would be good: required saving, but under the individuals direct control.

I have work to do.  Should have been somewhere a couple hours ago, but I can make it another late night.  It all gets done.

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