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13 August 2016 @ 06:54 pm
Econ 101 and the Affordable Care Act  
The hardest course I encountered in my four years of college was Economics 101. In high school I had been one of those annoying students who was good at everything, and I assumed that, even if I didn't find basic economics thrilling, I would be able to get a decent grade and satisfy the distribution requirements (still in force in the 1970s), allowing me to pursue the history, literature, and the gods help me, philosophy, courses I preferred. Instead, from the get-go, it felt as if I had walked onto a friendly neighbor's freshly-mowed lawn and fallen into a cesspit of crazy.

The first lesson, supply and demand, was simple enough. But the next, "guns and butter," was totally mystifying. Naturally my first reaction was to think of the Indian Mutiny of 1857, when British Army sepoys were outraged to learn that their new Enfield rifles used cartridges (which had to be bitten open), greased with fat either from cows, offensive to Hindus, or pigs, offensive to Muslims.

But no, this wasn't what the Econ 101 lesson was about after all. Apparently it had to do with allocating funds. For me, personally, it's an easy choice. As a lifelong resident of New York City, I have no use for guns, and I think butter is one of the most delicious foods ever invented, right behind bacon and Haagen-Dasz ice cream. In fact, I can eat butter right off the spoon, like ice cream, and I'm happy with an allocation of 100% butter, 0% guns. But no, that's not what this lesson was about either. It was, I think, more of an analogy or a metaphor.

Anyway, by the time I had worked all that out, the class had moved on to five or ten other confusing lessons. I was lucky to get through with a C or maybe a C minus. I never went back to the "social sciences," and I figured I just didn't have the right kind of mind for them. I had never had problems with the hard sciences: biology, chemistry, mathematics. These had all been fun, although increasingly difficult over the years. Still, they were doable, understandable, with practice. They made sense. Only these "soft" sciences seemed to be making it up as they went along, changing the rules every time someone like me, someone with a good bullshit detector, examined them too closely. But plenty of my fellow classmates went on to major in and have successful careers in social science: politics, sociology, and yes, economics.

I rehash all this now because today's headline in The New York Times strikes me as an emperor's new clothes moment. "Cost, Not Choice, Is Top Concern of Health Insurance Customers," it says, in a discussion of how people who don't get health insurance from their jobs, and who don't qualify for Medicare or Medicaid, are choosing ... wait for it ... the cheapest health plans in the "marketplace" for the Affordable Care Act.


"It is not [about] finding a favorite doctor, or even a trusted company," the Times reports. "It is how much -- or, more precisely, how little -- they can pay in premiums each month."

Seriously? People who have to pay out of their own pocket, who earn too much for Medicaid, are too young for Medicare, and who have the kinds of part-time, low-paying jobs that don't provide health insurance, are choosing by cost? Get out of here!

And let's take a moment to relish the absurdity of referring to a "favorite doctor" for people who have had to go without health insurance for years, maybe decades. As someone in this situation myself, I can say that my favorite doctor was Dr. Scholl. Or maybe Dr. Who.

And "trusted company"? ROTFL, or whatever the kids say today.

It's guns and butter all over again. Apparently no one else understood it either. Is it really a surprise that young and healthy people are paying the minimum for health care they don't "need" right now, or going without altogether and risking tax penalties, and that only people with "expensive medical conditions" are willing to pay more?

Exactly what part of "affordable" do people not understand about the Affordable Care Act?

A couple of years ago I wrote an atypical blog post (no mention of writing fiction or hot bisexual guys) about the absurdity of using insurance as a system for providing an essential, ongoing human service like healthcare. Insurance was invented to cover infrequent catastrophes, like shipwrecks, fires, and death. The idea was that by encouraging all members of an affected class (ship or building owners, merchants, healthy heads of families) into paying premiums every month, on the rare occasion when a ship went down, a building went up in flames, or a husband and father died, the insurance company could pay the survivors while remaining in profitable business because the thousands of other ships, buildings and working fathers did not sink, burn up or drop dead. Using the insurance model as a way to cover millions of people's necessary, daily prescriptions, checkups, surgeries -- and across an entire nation, emergencies, serious accidents and death -- is crazy. A whole cesspit of crazy.

Only in a country like ours that, to borrow from last week's post, went directly from barbarism to decadence without going through civilization, do we cover a human right like medical care through a profit-driven business like insurance, which can only exist by maximizing revenue and minimizing payments. That is, health care, a necessity, is being funded by an industry that tries to not pay, ever, and which employs whole armies of investigators and actuaries to decide which of its claims it eventually, under duress, has to, unwillingly, pay.

As a participant in the ACA myself, in the three years of its operation, I have been enrolled in four different health plans, from three different companies. And yes, I chose each time by cost: whichever plan had the lowest premiums. It didn't matter to me about deductibles, networks, which doctors wherever, whatever. I hadn't had any for years, so I was starting from scratch. But at the end of each calendar year, the premiums went up, and the cheapest plan was a different one, from a different company.

Let's also admit that "affordable" is very much in the income statement of the shareholder (oops, I mean taxpayer). The only reason I participated in the ACA these first three years is that it's mandatory. In New York State (and every state that has its own marketplace) the "real" cost of the monthly premiums was offset by an amount determined by one's tax refund. If I didn't pay those "affordable" premiums I would pay a penalty, and after the first year of the ACA, the cost of the premiums was, for me and most people, lower than the penalty. But for anybody working a low-paying job, these premiums are "affordable" only in comparison with unsubsidized premiums, i.e., what they cost before the ACA went into effect. They're still an added expense, every month, for people who wonder if they can cover the rent and buy food, every month.

Only this year, 2016, was a new group of "essential plans" offered, with genuinely affordable premiums and no tie-in to the tax refund. But of course the rates will all be going up next year, and I will be shopping around again. Who knows if the essential plans will still be offered? If the health insurance companies can't make a profit on low-cost premiums that allow people to actually "consume" health care, it's likely my "favorite doctor" will be Dr. Dre. Or maybe Dr. Love (the 1977 disco song). "He don't need no office light, 'cause he operates at night..."