There are real differences between us

There are many times when it seems politically savvy to highlight the similarities between the positions we and those who disagree with us hold. But there are times when we do that too much. I’ve been thinking about that as I’ve watched the recent debate about “catastrophic” insurance and how “higher copays” are what’s bringing down health care spending.

Let there be no hedging here. The RAND HIE showed that if you make people pay more of their own money for care, they spend less. Overall health care spending can go down. This is known, and no one here disputes that. The subtlety is that it turned out that people in the study were somewhat lacking in their ability to discriminate between necessary and unnecessary care. Sick, poor people had a higher mortality.

If your main goal is to bring down health care spending, then go with high deductible plans. The tradeoff is that the health of the population may suffer. If your main goal is to improve the health of a population, then lower the deductible. The tradeoff is that spending will go up. These are two different goals, with different tradeoffs.

As I have said many, many times: I believe the main goal of the ACA was to improve access. It was to reduce the number of people in the United States who lacked health insurance. I think in defining access, it was also a progressive policy in that it stipulated that insurance should meet certain minimum standards. The tradeoff for this is that it cost money, about a trillion dollars over a decade.

Anyone who loves high deductible plans usually acknowledges that they are awesome for young, healthy people. They are. No one disputes that. By definition, young, healthy people don’t need care, so getting them to spend less is a pure benefit. The tradeoff is that it removes those people from the risk pool for other plans, which makes the insurance for sick or not-young people that much more expensive. If your goal is to maximize the freedom of young, healthy people, then you probably favor more HSAs and HDHCPs. But if your goal is minimize the cost for the entire risk pool, then you probably favor the ACA. In fact, you probably favor a single-payer system. But we compromise for political feasibility sometimes.

If your main goal is to protect young healthy people from insurance that costs more than it could, then that’s fine. But I don’t think that’s what most people who supported or wrote the ACA held as a main goal. Maybe they weren’t clear about that. Take that up with them. That’s a political discussion. But from a policy perspective, it’s been pretty clear what the ACA was supposed to do.

So I’ll state this for the record: I think that some young, healthy people are getting the shaft right now. Not all, because some can still get on their parents’ plans. Some can still still buy catastrophic insurance if they want. Some will get Medicaid. Some will get subsidies. But if you’re a young, healthy 28 year old male who makes 400% of the poverty line, and you currently have really cheap insurance, it’s likely your rates are going up.

OK? I freely admit that my goal in health care reform was not to protect the status quo for young, healthy males. That’s wasn’t my goal for reform.

They will have to pay a bit more. The tradeoff is that if they don’t stay healthy, they’ll still be able to get insurance for the same price. If they get sick, there will no longer be any lifetime or annual limits. When they get older, they’ll still be able to get a plan, and it won’t cost nearly as much as it otherwise would have.

I think these tradeoffs are acceptable. You may not; that’s why we live in a democracy. But this was the plan. The law has not been rewritten. This blog, and many others, have been consistent in what they say about it. There is no “gotcha” here. The fact that young, healthy people are seeing a rise in premiums (without subsidies) as they transition from cheap, bare bones insurance to more comprehensive insurance is not a surprise. It’s not new, horrifying data about the failure of Obamacare. It’s an expected, and known, tradeoff to get a better healthcare system overall.

You’re still free to disagree that the system will be better. I’m sure that debate will continue for some time. But let’s acknowledge that we do differ in what we want out of policy and be honest about what we value.


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