President Donald Trump’s core principles for health care include ensuring that Americans with pre-existing conditions have access to coverage, and that Americans should be able to purchase the health insurance plan they want, not one forced on them by the government. Each of these goals is laudable and achievable, taken separately. But President Trump and others are about to confront what others have learned the hard way: Achieving both goals simultaneously is extremely challenging.
Those attempting to implement the Affordable Care Act (ACA) have faced the dilemma under easier conditions and, even after years of trying, have not solved it. Unless President Trump’s technocrats can fix something known as “risk adjustment” that has bedeviled the Obama administration, his dual principles cannot coexist.
The problem arises from the peculiarities of insurance markets. If insurance policies can vary greatly in their coverages and networks, people will tend to sort themselves into the coverages and networks that fit them best.
On the surface, this sounds great: Americans get the plans they want, not uniform plans put together by some government bureaucrat who knows best or is attempting to use insurance to achieve political goals. But in the unique case of insurance markets, there are adverse consequences.
With a great diversity of plans available, people who believe themselves to be high-risk usually purchase policies that have great coverages and broad networks. People who believe themselves to be low-risk usually purchase policies with lesser coverages and narrower networks. This separation means that the policies with great coverages are going to start to get really expensive, because they are full of higher-risk policyholders.
Neither Democrats nor Donald Trump want to let insurers charge people buying the same policy different rates based on their health conditions. And they don’t want to let insurers impose pre-existing condition limits that would make the more generous policies less expensive for insurers to service. The result, under these constraints, is that only one group of people will buy the premium policies: People with really, really expensive medical conditions. The price of these policies go up until they essentially no one can afford them.
In the end, almost everyone else would migrate to lesser policies, and we would end up with an unstable environment in which only policies with poor coverages and narrow networks are really able to survive. So, yes, insureds and insurers on paper have freedom to design policies that they actually want, but the market this freedom produces is fatally unstable.
HENRY KOTULA 