The Corner

Health Care

Where to Go on Health Insurance?

The rap on Americans is that we are inward-looking and don’t know very much about the rest of the world. Of course there are good reasons that Belgians know more about American affairs than Americans know about Belgian affairs. That’s just the way it is. But the criticism is not entirely baseless, which shows from time to time in our endless debate about how to regulate health insurance and health care.

Jamie Daw’s column on the German model of multi-payer health care in the New York Times today is a useful antidote to a little bit of that.

Progressives sometimes talk about health care in “Europe” as though there were a single European model, and few of them seem to appreciate that national-monopoly provision on the British-Canadian model is fairly unusual in Europe and elsewhere. That isn’t how Sweden, for example, does things.

The German system has some elements that progressives would admire and that conservatives would not, though they might prefer them to the national-monopoly model.

In my earlier column about what we could learn from the Swiss and how that might help to inform a genuinely bipartisan compromise proposal, I wrote about the way that the Swiss enforce their individual mandate, achieving a very high (practically universal) rate of compliance. The United States never managed anything like that, and the individual mandate was effectively repealed as part of the 2017 Republican tax bill.

Here’s the thing: Republicans, and most Americans, say they want a system in which insurance companies are obliged to cover expenses associated with preexisting conditions. They also want insurance to be provided privately in the market. I have a very hard time seeing how you can have both of those things without having an individual mandate, without which the underlying incentives all but ensure a dysfunctional insurance market. You’d have no incentive to sign up for a plan and pay premiums until you came down with something expensive.

This is the Republicans’ dilemma: They hate the Affordable Care Act, but they want certain benefits (choice of private insurers, coverage of preexisting conditions) that more or less necessitate something like the basic structure of the ACA — which is to say, a necessarily complex regime of mandates, regulation, and subsidies.

Such systems are more the norm in much of the world than is the national-monopoly model. They have significant deficiencies of their own, and some strengths, too, which would be worth understanding as we proceed.

If we are proceeding.

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