Friday, June 29, 2012

Health Care Predictions

Yesterday the Supreme Court upheld the Affordable Care Act.

On a meta-level, the decision made me happy-- it shows that at least one of the Supreme Court justices thinks for himself and doesn't always fit into the "Conservative" pigeon-hole that the media likes to put people into.

And I think the decision makes sense on a common-sense level; if it looks like a tax, smells like a tax, and sounds like a tax... then it is a tax.  Even if they decide to avoid the "t-word" and call it a "mandate."

But... I don't think the Affordable Care Act will succeed in making health care more affordable.

If you've read this blog for a while you know I like to calibrate my thinking by making testable predictions. I have a terrible memory, and by writing down what I think will happen then comparing it to what actually happens I teach myself that I'm not as smart as I think.

So besides not making health care more affordable, what do I think will happen in the next 10 years?

Well, I don't think the Republicans will actually repeal the Affordable Care Act, no matter what they say right now.  If Romney becomes president (I'm not even going to try to predict that, I have no clue) they'll repeal some little part of it and declare victory.  If he loses then there will be a huge, noisy debate in Congress that ultimately accomplishes nothing.

After 2014 I predict a whole lot of healthy people will figure out that dropping their insurance coverage and paying the no-insurance-penalty (tax!) is, financially, the best thing to do. After all, if you get seriously sick you can always buy insurance then (no denying coverage for pre-existing conditions, remember?).

If nothing changes, I'd expect a year or two after that lots of small employers decide that paying the penalty to their healthy employees and dropping their coverage is also the smart thing to do.

So in 2018 or so I'd expect there to be a health insurance industry crisis that, in typical Washington "We need Another Law to Fix This Law that We Passed Back Then" fashion, prompts Congress to first try to make it illegal for employers to drop health plans and increase employee's compensation.

When that doesn't work, they'll increase the no-health-insurance-tax so it is more expensive than the least expensive health plan you can buy.

But health insurance costs will continue to ratchet up every year, the IRS will spend ever-increasing money tracking down people who cheat on their no-insurance taxes (there will be laws passed requiring health insurers to report on who has purchased insurance, so the IRS doesn't have to rely on possibly forged documents from taxpayers), and the whole cobbled-together system will be obviously falling apart again in 10 years.

What happens then, I have no idea.  If the Democrats are in power, maybe we'll get a "Medicare for All" single-payer system.

If the Republicans are in power.... I have no idea what they'll do, they don't seem to have a coherent vision for what to do.

If I were King, I'd implement something like this for a national health care plan (inspired by a Megan McArdle proposal that I can't find right now):

1. De-regulate medicine as much as possible. At the very least, make doctor's and nurse's licenses portable across state and national lines and allow nurses to do much more routine health care. If I really were King I'd replace government medical licensing with private licensing, and give people the freedom to legally visit really crappy unlicensed doctors if they were willing to take the risk.

2. Eliminate tax breaks for the World-War-II-wage-controls-inspired "your employee buys your health insurance for you" system that most people are using now to get coverage. Every economist in the world agrees it is a stupid way to pay for health care.

3. Phase out Medicaid and Medicare. Replace them with a single, national, means-tested catastrophic health insurance plan that is simply something like "The US government pays for any health care costs that exceed X% of your adjusted gross income.

We could argue about what X is-- I don't think it should be zero because then people have no incentive to shop around for health care or weigh the costs and benefits of visiting the chiropractor twice a week (that's my problem with single-payer solutions).  Somewhere around 10% feels right to me; you pay out-of-pocket for day-to-day health care expenses, but if you are unlucky and get seriously sick and either lose your job  or have huge medical bills then we'll all chip in and pay for it.  (this is where my libertarian friends disown me as a rotten-stinking Statist)

A system like that should have the right incentives to actually make health care more affordable.