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The Agenda

NRO’s domestic-policy blog, by Reihan Salam.

The Sabotage Argument



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While left-liberals fret that conservatives are trying to “sabotage” the Affordable Care Act, Ramesh Ponnuru argues that there is no need for conservatives to sabotage the law, as it rests on an unsound foundation. The sabotage thesis rests on a two central ideas, both of which Ramesh knocks down. The first is that encouraging young, healthy Americans that they should pay a tax in lieu of purchasing medical insurance is tantamount to telling them to break the law, despite the fact that the Supreme Court has found that Congress cannot order people to purchase medical insurance. The second is that encouraging young, healthy Americans that they should pay a tax in lieu of purchasing medical insurance is to encourage them to court danger, as these young people in dire straits once they are diagnosed with a serious medical illness. But of course the Affordable Care Act stipulates that people “will be able to buy insurance once they’re sick at the same rate they could have gotten it for when they were well,” and so the costs associated with delaying the purchase of medical insurance might outweigh the benefits.

To convince young, healthy Americans to purchase medical insurance, you have to convince them either of something that is mostly false — that you won’t be able to purchase insurance after being diagnosed with an expensive ailment at the same rate you would have paid as a healthy person, and so you protecting yourself against catastrophic medical expenditures – or of something that may or may not be true, namely that the value of medical insurance will outweigh the cost. If every young, healthy person who purchases medical insurance under the ACA gets more out of insurance than she pays into the system, they system as a whole is in trouble, as young, healthy people are expected to cross-subsidize older, sicker people. It could be that one ought to purchase medical insurance out of a sense of solidarity with older, sicker people. But we shouldn’t be surprised if this argument doesn’t prove very compelling.

The ACA strikes me as an unstable equilibrium. My guess is that we are either going to gravitate towards some version of universal catastrophic coverage or Medicare-for-all.

P.S. To be clear, there is a limited enrollment period for purchasing ACA exchange plans — initially, the enrollment period will last from October 2013 through March 2014, but the plan is to shorten it to October to December in the future. If you develop an expensive malady outside of the limited enrollment period, you will not be free to purchase an exchange plan. This means that going without an exchange plan does entail taking some risk — the question is whether this risk is worth taking, given the wedge between the penalty and the price of an exchange plan.  



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