I'm a simple man. And by simple I mean I seek the simplest solution to complex problems. At times that means I miss the nuance and detail that is really at the heart of many complex problems, but that doesn't stop me from offering simple analysis.
So here's my economist take on the national health insurance, health care mandate, Obamacare, socialism...whatever...debate....
It's all about the risk pooling.
Insurance markets work when non-systemic risks are pooled across a population. Let's use car insurance as an example. For the most part, the probability of me getting in an accident is independent of the probability of you getting in an accident unless you happen to be driving next to me at 75 mph while I eat a Whopper with one hand and check my Facebook status with the other. By pooling the independent risks, insurance companies can offer relatively low priced insurance against one or the other of us getting in an accident. So states require (mandate) that in order to drive, you must have insurance, thereby reducing the external costs of my bad habits on you. If you don't have insurance, you aren't supposed to drive and if you are caught driving without insurance you face stiff penalties. The result: Users of the product that causes the risk (driving) have insurance--most of the time. You can choose not to buy insurance and not drive.
So what about healthcare? Shouldn't it work the same way? In theory, yes. Users of health care could be required to buy insurance against catastrophic outcomes. By pooling the risks across large populations, the individual cost of health care will be lower than the expected cost to you if you bore the full risk of your own health. Risk pooling reduces costs and protects againsts catastrophic outcomes. And, just as with car insurance, if you choose not to buy health insurance, you lose the right to consume healthca...oh, wait.
Human decency has to be factored in.
In the absence of health insurance, individuals can still not be denied health care (at least emergency care, which is expensive). So what happens when an individual chooses to forego health insurance? The cost of the uninsured care, guaranteed by human decency, gets rolled into the premium of those already insured. In other words, health care costs rise. Further, if individuals know that health care will be provided regardless of the willingness or ability to pay or willingness or ability to be insured, there is a perverse incentive to underconsume health insurance and further reduce the size of the risk pool in the insurance market (we call that moral hazard).
So what are the possible solutions?
- Rely on people to 'do the right thing.' But each person's definition of right might be different. While I think it is right to participate in the insurance market, others might think it is right to take advantage of the rules of the game. And as we know, economic incentives are powerful things.
- Have the government act as the insurer of last resort. This is the model we currently have. The government offers subsidized insurance for those who are unable to afford health insurance (medicare/medicaid) and then acts as the insurer of last resort for the unisured. The result: the cost of providing insurance to the uninsured and underinsured are passed on to the insured through higher taxes and higher insurance premia.
- Mandate that everyone buy health insurance and play by the same rules, and penalize those who opt out. The results 'should' be more efficiently priced insurance premia for those already insured, reduce costs of providing health care to those unable to afford insurance, and a less morally hazardous (I made that up) risk pool.
So what am I missing?
Let me have it.