Romney is wrong on healthcare

On his campaign website, Romney says he will “pursue” the following policies:

Prevent discrimination against individuals with pre-existing conditions who maintain continuous coverage

Ensure flexibility to help the chronically ill, including high-risk pools, reinsurance, and risk adjustment

Ensure flexibility to help the uninsured, including public-private partnerships, exchanges, and subsidies

In order to accomplish them, Romney will have to do precisely -- nothing.  Obamacare already includes provisions for guaranteed issue, community rating and the widest possible risk pools, which as of January 1st, 2014 ensure that people can get health insurance at the same rate as anyone else regardless of pre-existing conditions.  It also includes exchanges and subsidies.

Yet, if elected, Romney would seek to repeal each of those provisions. 

Romney is wrong.  In the ultimate irony, his vague promises don’t even fully address what’s needed in the individual insurance market:

(1) They would not solve the adverse selection problem.

(2) They mean that applying for insurance would still involve medical underwriting, a time-consuming process that I know from personal experience to be both humiliating and bizarre.

(3) They mean those with pre-existing conditions would still pay more for insurance.

(4) They provide little comfort to those who have difficulty getting insurance.
(5) They would not solve the freeloader problem.

Obamacare fixes all five of these issues.

Moreover, just what does “flexibility” mean?  People want insurance, not ambiguity.  The need is clear: guaranteed issue, community rating and the widest possible risk pool.  On January 1^st, 2014, that is what we will have, provided Romney does nothing.

How adverse selection destroys insurance markets

I have not seen an adequate explanation of adverse selection, a key issue in the debate over Obamacare, so I am offering one here. Consider a simple scenario: one insurance company, Acme, with three potential customers. Alice, who is very healthy, has only $30 in medical expenses in a typical year. (I’m making the numbers small in the interest of simplicity; if it makes you feel better, add some extra zeroes to every number.) Bob, who is of average health, has $90 in medical expenses in a typical year. Caroline, who was born with a genetic defect, has $300 in medical expenses in a typical year. To account for the unpredictability of medical expenses, here’s one additional twist: one of these unlucky souls will have an accident that leads to an additional $210 in medical bills.

While each person knows their typical medical expenses, and knows they face a one-third chance of an additional $210 in expenses, all Acme insurance knows is that the total costs for all three are $630 ($30 + $90 + $300 + $210). That’s $210 per person; Acme decides to charge $220 per person (the extra $10 goes for administrative costs) for a policy that covers all medical costs. Is this a smart decision?

No, it isn’t. Take a look at the financial landscape from each person’s perspective:

	Minimum possible costs	Maximum possible costs	Insurance premium
Alice	$30	$240	$220
Bob	$90	$300	$220
Caroline	$300	$510	$220

Insurance looks like a fairly good deal for Bob and Caroline, but Alice is skeptical. Insurance would be a whopping $190 higher than her minimum expenses, and $120 higher than her expected costs of $100 ($30 plus one-third of $210). In the worst scenario, she only saves $20. Alice decides not to get insurance. This is the tragedy of the insurance business: the most profitable customers have the least motivation to buy insurance.

With Bob and Caroline as customers, Acme collects $440 ($220 from each), but can expect to pay out a total of $530 ($90 + $300 + two-thirds of $210), for a loss of $90.

Acme must set a higher price for insurance. If it knew Bob’s and Caroline’s costs, it could, for argument, set a price of $270 per person, 22% higher than before. Take a look at the adjusted financial landscape:

	Minimum possible costs	Maximum possible costs	Insurance premium
Alice	$30	$240	$270
Bob	$90	$300	$270
Caroline	$300	$510	$270

It’s an even worse deal for Alice, but now Bob is also skeptical. Insurance would be $180 higher than his minimum expenses, and is $110 higher than his expected costs of $160 ($90 plus one-third of $210). In the worst scenario, he only saves $30.

Bob decides to skip insurance too, and Acme can expect to lose $100 on Caroline’s policy. What’s happening here is called the adverse selection death spiral. For all intents and purposes the market for insurance has disappeared, and Caroline is left to deal on her own with the financial consequences of her genetic defect. Absent external forces (such as subsidies or government regulation) Adam Smith’s invisible hand cannot establish a price for insurance at which the market will clear. The way this market is defined, Acme cannot offer insurance at any price.

James Suroweicki: Was the health-care decision good for Republicans?

http://www.newyorker.com/online/blogs/newsdesk/2012/06/was-the-health-care-decision-good-for-republicans.html

Atul Gawande on "wicked problems" and the "perversity," "futility," and "jeopardy" theses.

http://www.newyorker.com/online/blogs/comment/2012/06/something-wicked-this-way-comes.html

If Medicare Is OK, Obamacare Should Be Too

http://www.tnr.com/blog/jonathan-cohn/101970/obamacare-mandate-like-medicare-payroll-tax-social-security

When will medical underwriting be illegal?

Medical underwriting will be illegal in the U.S. in:

Dirty Harry remake of Chrysler Super Bowl ad

For fans of Dirty Harry, here’s the script for the remake of Clint Eastwood’s Chrysler Super Bowl ad:

I know what you're thinking.

Did we just play two quarters, or four?

Is it halftime, or is it game over?

Well, to tell you the truth, in all this excitement I kind of lost track myself.

But being as this is America, with the most powerful engines in the world, you’ve got to ask yourself one question:

Do you think we’ve run out of gas?

Well, do ya, punk?