E. J. Dionne Jr., yesterday:

[Republicans’] core proposals–especially their call to expand health savings accounts and to overturn state regulations in favor of nationwide “association” health care plans–push in exactly the wrong direction by further fragmenting the insurance market.
Doing so might cut insurance costs for those who are not ill, but at the expense of raising the already prohibitive costs for the sick. The marketplace is good at providing options for the well-off and the healthy, but they are not the ones with problems. That’s why Obama wants the government to change the health care market.
What this means is that most Republicans want to take themselves out of the health care discussion altogether. For reasons of principle as well as politics, they want to rail against the costs of government action and assert–against what I would insist is overwhelming evidence to the contrary–that somehow we can find a way for the market to solve our health care problems.

I think there is some circularity to Dionne’s argument at the end of this passage. If the discussion is defined to exclude people who believe in market solutions to health care, then yes, such people are indeed outside the discussion. But I don’t think the nation is insisting that the debate restrict itself to these parameters, nor do I think that “overwhelming evidence” suggests that it should–but like Dionne, I’ll save that argument for another time.

Instead I will concentrate on the first paragraph I just quoted. Larger HSAs, he claims, will further fragment insurance markets. How can anyone know that? People who work for small employers and currently are in an insurance pool with their fellow workers could, with individually-purchased HSAs, be in a national pool of people with similar characteristics. So the effect could be more pooling of risk rather than less. But it’s the bit about association health plans that I find the most puzzling. Allowing small businesses (among other groups) to band together in associations to provide health insurance to their employees seems like the exact opposite of a fragmenting move. Yes, it bypasses state regulations. But moving toward a national market is, again, the opposite of fragmenting. Large business plans governed by ERISA get out of most state regulations as it is, and their exemption has not hurt sick employees–and has allowed for more pooling than our health-care policies would otherwise make for.