Friday, March 17, 2017

Doctrinaire Paul Ryan – True Believer

Doctrinaire Paul Ryan – True Believer

A Washington Post editorial of March 16, 2017 quoted House Speaker Paul Ryan discussing the need to end the Affordable Care Act. With health care he said “You need to have an individual market where people care about what things cost, where people have real freedom, where those providers of health-care services, be they insurers, doctors or hospitals and everybody in between, compete against each other for our business based on value, based on price, based on quality, based on outcome.” . . . “We’re going to have a free market, and you buy what you want to buy.”

What Ryan said could be quoted from any college economics text of which I have read many in more than twenty years teaching university economics. Economics in American colleges walks a fine line between education and indoctrination; Mr. Ryan provides a doctrinaire rendition of textbook theory.

The need for health care varies with age, and depends on random risk of illness or injury. The expansion of private health insurance in the 1950’s caused problems with random risk. All free market insurance must have people pay premiums into a risk pool that generates a reserve fund to pay losses. Insurance companies employ mathematicians to analyze actuarial data on mortality: accidents, sickness, disability, retirement and other risks. Actuarial data are necessary to construct probability tables that will determine the premium payments to charge that will generate cash reserves to pay future losses.

Someone who already has heart disease or diabetes when they apply for insurance has a health problem, but they are not insurable in a free market private health care system because they are not a risk, they are a certainty. To use insurance jargon they have a pre-existing condition. In effect, their probability of loss is guaranteed and their premium would have to equal the cost of treatment to avoid draining the reserve fund.

In the early 1950’s insurance companies started marketing group policies in large numbers and defined a risk pool through the work place. People started buying health insurance and hence joining a risk pool through their employer. One trouble with a health care risk pool that depends on jobs comes at retirement, when people lose their employer sponsored health insurance. Age and the likelihood of pre-existing conditions assure it will be difficult or impossible for retirees to re-enter a risk pool and buy insurance.

A second trouble with a health care risk pool that depends on jobs is that not everyone has one, or has one they can keep until age 65 or into retirement. Layoffs and unemployment are not just loss of income, but removal from health insurance and a risk pool they may have entered long ago when they were young and healthy.

If everyone entered a common risk pool at birth and stayed in the same national risk pool until death then all Americans would share in the risks of all our injury and illness over their lifetime. The Affordable Care Act requires insurers to accept a national risk pool by offering at least one policy at a price that reflects a risk pool started after birth and continued to death. Ending the funding for policies under the Affordable Care Act in effect terminates the national risk pool.

It does not matter if Congress leaves the requirement that prevents insurance companies from turning down applicants with preexisting conditions because they remain a certainty of loss, not an insurable risk; charges will have to cover the cost of known treatment.

Others without pre-existing conditions, who are not insured through government assistance or an employer risk pool, apply for insurance at the mercy of an insurance company, which can put them in whatever risk pool they choose and charge any price they want.

Private health insurance companies do not have the ability to define a national risk pool, nor the incentive to use a national risk pool when so much health insurance has tax subsidies available through employer risk pools. Health insurers have the incentive to assemble risk pools with the healthiest people they can find, and avoid the sick, those with pre-existing conditions and those with low wages unable to afford health care. The Republican plan to end the Affordable Care Act has an especially crude and unethical side when millions of Americans enjoy substantial tax subsidies through their employer sponsored health care. However, the 24 million the Congressional Budget Office thinks will lose coverage will still have to pay income taxes that subsidize other people’s health care, including Mr. Ryan.

There is nothing in an economic system of private markets and free competition that will move private health insurance to provide health care insurance for everyone. I cannot tell if Mr. Ryan knows free markets fail in health insurance or if he is a true believer in the capitalist secular religion. I do know leaders in positions of responsibility and power take steps to benefit the larger society. In health care leadership Mr. Ryan and the Republicans fail. So much for Trump helping the down and out in the working class.

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