So now, after long debate, it seems like the solution may be health care co-ops.  Perhaps I'm missing something, but it seems like we've undergone a lot of stress to invent . . . Blue Cross/Blue Shield.

Interesting questions remain.  Will the health-care co-ops be exempt from the tangle of state regulations that have resulted in near-monopolies in many areas?  I presume that Democrats still want guaranteed issue and an individual mandate, but aren't these the parts that are actually going to anger constituents?  In Massachussetts, more people seem to think they've been hurt by the plan than helped by it.  Meanwhile, the costs are skyrocketing, and control has so far been elusive.

The core problem is this.  You have four groups of uninsured people:

  1. Immigrants, who probably aren't going to get insured anyway.  This is presumably why Massachussetts spending on the uninsured has only fallen by 40%, even though the number of uninsured people has plunged about 80%.
  2. Young healthy people who don't need much health care
  3. Working poor sick people
  4. Affluent people who are uninsurable because of some pre-existing condition

Advocates of reform believe that the number of people in Groups 3 and 4 who are not receiving needed care is large. The idea of a mandate, combined with guaranteed issue, is to force Group 2 into the insurance pool.  This is supposed to pay for the care of the people in Groups 3, 4, and (arguably) 1.  But the people in Group 2 don't have that much money; most of them are working marginal jobs, which is why they don't have insurance.  They're also Obama voters who think that health care reform will give them cheap health insurance, not force them to shell out $500 from a meager paycheck to cover someone else's high-risk pregnancy.

That means we have to dip into the pockets of Group 5:  people with insurance.  Either they have to pay higher premiums, or they have to pay higher taxes, or they have to get less stuff.  This makes them anxious.  Unfortunately, most of them are satisfied with their insurance, so the only thing that you can offer them is the relief from the fear that they'll lose their job and their insurance coverage.  That's not nothing.  Options are valuable.  So is peace of mind. But is it worth hundreds of dollars a month to the average family? 

There's a further problem if you have guaranteed issue:  unless the tax penalties for failing to carry insurance are draconian, the dominant strategy is to drop your insurance, then buy insurance if and when something bad happens.

I actually agree with the progressives that health reform will be a disaster unless you can find some way to control costs.  But the senior lobby freaks out when you suggest it.  So far the only that Massachussetts has actually managed to pass has been shaving benefits for immigrants.  That doesn't bode well.

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