GEORGE No, but you… you… you’re thinking of this place all wrong. As if I had the money back in a safe. The money’s not here. Your money’s in Joe’s house…(to one of the men)…right next to yours. And in the Kennedy house, and Mrs. Macklin’s house, and a hundred others. Why, you’re lending them the money to build, and then, they’re going to pay it back to you as best they can. Now what are you going to do? Foreclose on them?

This proposal also doesn’t appear to address one of the biggest problems with non-group insurance now, the indiscriminate exclusion of care based on medical history. When I was applying for individual health insurance last year the biggest problem was not the cost, it was the exclusions. One company wanted to exclude all neurological problems that might occur in my 6 year old because she had fallen while running 4 years earlier and we had taken her to the ER. Everything was fine except a big knot on her forehead, but the exclusion would have gotten the insurance company out of all sorts of unrelated diagnoses like viral meningitis. I had had a pinched nerve in my low back successfully treated, but the insurance company wanted to exclude everything spine related including a traumatic cervical spinal injury. What good is catastrophic health insurance when the companies use every trick in the book to avoid actually insuring people?

But then, if national competition at least makes inferior insurance coverage more affordable, it’s a step in the right direction. Combine the two, and those who want (or need) decent comprehensive coverage can get it, those who want bare bones coverage can get it, and those insurance companies that want to price themselves in the middle will have to provide a set of benefits which justifies their price point.

Without community rating, if you have a history of health problems, perhaps a few breast biopsies without clear findings so far, insurance with decent coverage is likely to range from pricey to unaffordable no matter where you look..i.e. what company really WANTS your business?

A 3-part interview involving a conservative Republican member of the House Ways and Means Committee (Jim McCrery, LA) and a centrist Democrat (Jim McDermott, WA) was published in 2000 (October, the Atlantic Monthly). The 2 Representatives, coming from very different political perspectives, basically dreamed up what they thought was a politically palatable system to expand health care coverage, proceeding on the political understanding that neither a single-payer nor an unfettered free market were going to emerge any time soon.

The Republican argued that community rating was the obvious, least complex way to assure that persons with history of health problems had a viable place in the insurance market. Community rating can result in problems, however, particularly if the young healthy persons are not insured in the same system as those who have a history of illness (or if the young healthy people drop out). The writer explained that this happened in 1993 in the New York insurance market, where community rating was applied to the individual market (only), the few healthy individual insurance purchasers dropped out and it set off an insurance death spiral as plans became increasingly expensive for fewer and fewer sick people.

On that basis, Representatives McCrery and McDermott argued that a self-purchase system (tax breaks, subsidies for the poor) would have to require mandatory purchase of insurance by all….
McCrery argued for a system that actually put all comers in the same market, i.e. no employer-based purchases, no Medicare, no Medicaid…just everyone purchasing policies on the basis of community rating, and a requirement that they purchase.

It may seem radical for those of us who are used to either receiving care or offering care in protected sectors of the market, but it may be worth thinking about how everyone can be “protected” against being uninsured without a forced single-payer system.