Coming clean on catastrophic

In an email exchange with Jed Graham about his post, I wrote,

I suppose if the catastrophic premium were low enough, the deductible is almost irrelevant. I mean, yeah, people may not be able to afford it, but in a case of a real catastrophe, at least the liability (whether the patient’s or, ultimately, the providers’ if the patient can’t pay) is limited.

It argues for universal catastrophic (with income-sensitive subsidies, both for the premium and the deductible), which I would support. Of course, some may want to fill in below that, which I wouldn’t object to either. But they should do that with their own funds.

I figured I ought to share this with readers since many seem to think I’m anti-catastrophic. Clearly, I’m not. It is probably fair to say that, once upon a time, I hadn’t thought things through enough to be sure how I felt about something like a universal catastrophic scheme. It’s also fair to say that John Goodman’s book deserves some credit (or he does, really) for helping me do that thinking. Although, to be totally fair, I deserve a lot of credit for wading through the heap of absurdities I found in his book before extracting the few nuggets I think have merit. And, finally, he also deserves credit for taking licks like “heap of absurdities” in stride. Say what you will about John, but he’s a good sport.

But enough with the Goodman love fest. I’ll conclude by noting two things. First, a pro-skin-in-the-game (to the extent  affordable, in some sense) position is not the same thing as a pro-repeal-Obamacare position. Far from it. These are reconciled by the recognition of political constraints and realities. (Where’s the coalition for a replacement?)

Second, employer-sponsored insurance is gradually moving toward higher deductibles anyway. I think this is inevitable. The big question is the extent to which other publicly subsidized programs from Medicare to Obamacare will be modified to follow and support this evolution, and even help it work better.

I’ll quit now and take my abuse in the comments. Let’s see just how thick my skin is.


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