ACA Repeal/Replace: Progressives Face Moral Dilemma

[Bob Butler 54]

(08-14-2017, 06:01 PM)Kinser79 Wrote: There may be 25-30 decent models to base a system off of.  However as the PBS article I linked to demonstrates that there are only four main types.  The problem with the US is that even with Obamacare we are still using all four.  

With the VA it is a Beveridge type system like Britian or Cuba.

With Medicare it is a National Insurance like Canada or France.

With employer based care it is like Germany.  (They still essentially use the Bismarck model.)

For everyone else on out of pocket, well its like Cambodia or Rural India.

The goal should be for the US to pick one type (like other countries have done) and to stick with it.

As picking and sticking is definitely a good idea, I'll throw out a few notions.

There are many retired, unemployed, small employer employed, children, etc... that arguably can't pay out of their own or their employers pocket.  It would follow that out of pocket or employer based schemes are highly questionable.  That leaves Beveridge and or National Insurance types on the table, with the government as the obvious single payer.

Those who like to gamble, those wealthy enough to recover from a failed gamble, those young and healthy enough for favorable gambles, those who have convinced themselves that their ad-lib health system is better than the usual main stream approach, might all shun a cost and risk sharing approach.  Why share cost and risk if one's cost and risk are subjectively low?  One might quiet their complaints by giving them an option out of cost and risk sharing.

But the more these people opt out, the less effective the cost and risk sharing becomes.  We get Republican "health care" proposals that are optimized towards the healthy and wealthy, leaving fewer people covered and poor coverage.  One example of the opposite is Obamacare's mandates.  Under Obamacare, most are mandated to participate in cost and risk sharing.  You are not allowed to opt out.

When I was young, healthy and wealthy, I was willing to contribute.  I had an employer based health plan.  I assumed that my salary and others in my company was lower by the cost of the health care premiums.  Perhaps in another country, my salary would be larger, but my taxes would be higher.  In another country, my taxes would not be higher, but I'd have to pay for health care.  As Kinser says, pick one.  My values include Freedom from Want and HDHR 25, a positive right to medical care, so I would pick government sponsored Beveridge or National Insurance.  That said, I quite sympathize that the litigation and profit shaped US health system could stand some culture shift, though I don't see that system shifting if the system remains the same.

And I do welcome a conversation about it.  I guess the prime question is whether we allow those who see their odds as good to gamble, or whether cost and risk sharing is mandated.  Is the objective to share the cost and risks, or to optimize the odds of some gamblers while forcing others to gamble at really bad odds?

I keep coming back to auto insurance.  Most states mandate some coverage.  Often, those with good driving records get discounts.  Often those with bad records pay extra, or can have their licenses pulled.  Often, those with lots of money can purchase better insurance. 

How much of that do we want to do?  Do we punish the old for being old?  Do premiums get higher for practitioners of dangerous extreme sports?  Is there a non-smokers discount?  Or do we keep it simple, stupid?

Anyway, my gut feel is that more folk want to share costs and risks than want to gamble with their lives and fortunes.  I also grumble loudly at gamblers who suddenly want cost and risk sharing when their gambles fail.  Still, turning them away to watch them die seems extreme.