While agreeing with the need to harness market forces and to incentivize individuals to maintain their own health, I fear your plan goes far enough towards increasing health insurance coverage.

One of your goals is:

1. Access to affordable health insurance for all Americans.

Since you oppose mandates, “affordable” will be interpreted by each individual and interpreted differently depending on individual circumstances. The young, healthy, and financially struggling will be likely to declare health insurance unaffordable. Older Americans struggling to pay bills may opt out if their health is currently good and they are feeling lucky. Universal coverage won’t be achieved and the insureds will tend to be relatively ill and, therefore, expensive. Decades of insurance rates rising faster than incomes have encouraged individuals who are healthy to opt out of insurance coverage leaving the insured pool increasingly ill; this high risk insured pool has lead to recent premium increases of 20% or more exacerbating the flight of the currently healthy from health insurance.

Why does the US so uniquely among rich nations not mandate universal coverage to assure that the currently healthy are insured? This would not require single payer coverage. Germany has less government involvement in health care than the US in that its insurance companies, its providers, and its hospitals are all private. They don’t have an equivalent to our huge “socialized” Medicare, Medicaid, and VA. But, they mandate that private insurance is bought by everyone with the fee split by employee and employer via payroll deductions. The government helps out during periods of unemployment.

Our government already does its fair share of mandating. We mandate that everyone gets some education and it’s available in a public form, we mandate availability of legal representation, we mandate auto insurance, we mandate universal sufferage but, unlike all our peers, health insurance is optional. As premiums rapidly rise and are increasingly considered unaffordable we run the risk of totally wrecking our health care system. Why not mandate universal nealth insurance in a healthcare system made more efficient by the Medicare reforms, HFA’s, preventive medicine, and health insurance redefinitions that you propose?

Scott

Steve responds:
I don’t know, Bob. Bunion surgery can be pretty serious. Many thanks for the closer perspective. My experience in serving my country was limited to fighting forest fires in Idaho for the U.S. Forest Service.

Re the question about why limit HFA contributions at all, tax policy would be the only reason.Without limits on tax exempt contributions, HFAs would become an unlimited, much-abused tax shelter.

Bob is correct that both the House and Senate versions of the proposed health insurance exchange are over-regulated, paternalistic nightmares that would only bend the cost curve further upward. While the changes I propose will fix these problems, the necessary brevity of my blog precludes the detailed explanation provided in my book (thanks, Bob, for the opportunity to blatantly plug it).

I agree with the comments about getting employers out of the insurance selection business. The same holds true for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

The question about Phillip Longman’s “Best Care Anywhere” apparently refers to a 2005 article that lauded the dramatic turnaround of the VA medical system from one of the worst to one of the best. While the casualties of two wars have more recently caused some fraying around the edges, the VA experience does suggest that a single payer system might actually work (1) at times, and (2) if the American people are willing to shelve their untidy individual preferences and accept a military model of medical care. The biggest problem with VA-like systems is that they can only be as good as their leadership at any point in time. The neat thing about consumer markets is that, while they are essentially leaderless, they have always outperformed top-down systems over time.

Re Rep. Paul Ryan, his proposal (co-sponsored with Coburn, Burr, and Nunes)meets five of our eight goals, but falls too far short on free-rider prevention, sustainable affordability, and prevention effectiveness to provide a complete solution. See my blog that rated it against several other approaches (including my own)at http://www.hydeonhealthcare.com/hyde-review-health-reform-proposals.html.