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I read David Henderson’s review of the Finkelstein book. I thought he made some good points. The book not discussing the supply side is really an oversight. Also, not embracing any kind of cost-sharing is also an oversight. If you do not ration by money, you have to ration another way.
I have read several reviews of the Finkelstein book. My reservation about the book is this:
The authors of the new proposal are very naive about the actual workings of insurance. I do not think they have the slightest idea of how to design a national “basic coverage” policy that costs any less than private insurance today. Once you are committed to covering primary care, specialist care, outpatient and inpatient care, there is a high unavoidable cost.
In the real world, insurers use high deductibles to blunt the cost of ‘basic coverage’ policies. I doubt that this would sit well with these authors.
To paraphrase the great politician Sam Rayburn, I’d be a lot more comfortable if Einav and Finkelstein had ever worked for a real insurance company.
Item three: Out-party hate is more powerful than in-party love. That is one thing I have always thought that Trump got wrong about campaign politics. Once in office he should have been more of a uniter rather than empowering his opponents by antagonizing them. In the process of rallying his base, he also rallied his opponents’ base while making the median voter disinterested.
Let me be more specific on why I think that “basic insurance” would be hard to implement.
In any health insurance plan, the sickest 10 per cent of enrollees account for about 70-75 per cent of the claims costs.
Under a ‘basic insurance’ plan, these ten percent are still with you. It will be very hard to reduce premiums.
Now, there are cheaper insurance plans nonetheless. How are they cheaper? 1. Higher deductibles 2. Lifetime and annual limits 3. Underwriting — you don’t let some of the ten percent into your plan in the first place.
In-party love tends to be tempered by healthy cynicism, while out-party hate is easily exploited and exacerbated by various media in search of ratings, as well as by opponents.
A lot of this is made possible by our single-vote plurality voting system, which keeps a two-party duopoly in power. Under such a system, whenever there is a three-way race it is generally the centrist, if there is one, who fares worst because of the center-squeeze effect. This leaves the two fringe candidates to fight it out from opposite sides of the political spectrum.
It’s easy to see with a simple thought exercise: picture an electorate distributed evenly from 1st to 100th percentile along a policy dimension. Now picture three candidates, positioned at the 25th, 50th, and 75th percentile. Intuitively you might expect the centrist to have the advantage. But if voters all choose the candidate closest to their own position, the two fringe candidates will come out ahead with 37.5 percent of the vote each, while the centrist loses with only 25 percent.
Runoff elections, whether by traditional or ranked-ballot, are also subject to the center-squeeze effect. The centrist is still eliminated first, so they can only alter which fringe candidate will win.
Approval voting is not subject to the center-squeeze effect, and in fact may slightly favor the centrist, but is currently limited to municipal elections in Fargo, ND and Saint Louis, MO. Hopefully we will see wider usage in the future, along with more approval polling instead of the “choose one” kind.
“I do not think they have the slightest idea of how to design a national “basic coverage” policy that costs any less than private insurance today. Once you are committed to covering primary care, specialist care, outpatient and inpatient care, there is a high unavoidable cost.”
Not true. France does just fine.