As we begin to recover from a pointless political detour (I'll take that one on elsewhere) - and I try to resume regular blog posts - it's clear that health insurance is about to become the topic of our next long, mostly fritless political debate.
Around here, let's try not to call it Obamacare. Please.
The lumpy rollout of Healthcare.gov, the federal website designed to implement the "healthcare exchanges" - or more precisely, build a state by state marketplace for purchasing insurance outside of employer offerings - could have been all the right needed to sell their notion of the Affordable Care Act as an abject failure. As it is, they stepped on their own story with a needless shutdwn of government functions and brinksmanship that's probably ruined them long term. Now, Republican politicians are attempting to refocus attention on the ACA and the exchanges in an attempt to do what they meant to do weeks ago. And so far, that's not working out so well, either.
In desperation, political talking points seemed to have moved to a new target: the healthcare exchanges, we are told, will be a disaster if the "risk model" is destroyed by young people, in large numbers, failing to sign up on the exchanges for insurance. This, the apparently well meaning argument goes, is happening because the website is so problematic, and because young people "feel invincible" and see no need to be insured. If these young people stay away in droves, insurers will have huge problems and the world will end. Or something.
Like pretty much all of our "national" conversations around healthcare, this one has a lot of people who don't really understand what they're discussing making points that, on close examination, make no sense. Part of the real problem here is that conservatives have little or no good policy expertise on their side when it comes to healthcare issues, and while there's a better knowledge base on the left, there's a disconnect between the pundits who make the arguments, and many of the people and places armed with facts.
When it comes to the Incredibly Scary Problem of Uninsured Youth, as with previous mirage issues (death panels? Medicare decimation?), there's maybe a grain of true fact surrounded mostly by nonsense. The problem with the insurance exchanges getting up and running is real and concerning, but not because of some notion of insurers risk and some mythical group of young people. The problem has to do with who buys insurance, how poor they might be, and how sick they really are.
First, let's remember that we started with a problem most people don't fully understand. Most people have medical insurance - something like, still, 87% or so of the population. The elderly are in Medicare. People employed by most big businesses have insurance through their work. Most children are covered (especiallly since CHiP, the expansion of Medicaid to cover most poor children and their mothers). Our biggest problem, really, is that we used a model for insuring people based on employment, which is problematic for those who do not have a job or cannot hold one.
Second, to the extent that there is a youth problem, it's really misunderstood. Statistically, as with the whole population, most younger adults are insured - 58% of those under 34, 69% of those between 19 and 29. It is true that more young adults are uninsured when compared to the population of adults over 30, or 34. The trouble is, what best defines these uninsured people is not so much their age as it is their employment and income. Young people happen to be suffering most in the economic downturn, with higher rates of unemployment or partial employment. And the social safety net happens to be especially thin for a young, single, able bodied person.
The problem with the "youth argument" is the way that many conservatives cast it, the mythical young person without insurance is educated, wants insurance... but mysteriously, can't get it and finds it hard to budget for. Then, we are told, since they are young and healthy, they see no need for it, and therefore, don't see the point of the expense. None of that, really, is true. Young, educated, white collar professionals are insured, and pretty much have been all along. They are, in fact, the most desirable customers for health insurers, and are the definition of "cherry picked" in our old system of pre-existing conditions and other strategies meant to exclude the older and sicker from insurance. Though their rates may rise under the ACA, few will forego insurance all together, even when the case could be made economically that the premiums are more than the penalty ($95 in year one). As educated young people, they are also the most likely to understand the risk of going without.
Indeed, the most challenging aspect of insuring young people has to do with those with young people well below the poverty line - their coverage doesn't actually come from the exchanges, but rather was built into the notions of expanding Medicaid, the one part of the ACA no one talks about or notices has been decimated. While the Supreme Court upheld the penalty for lack of insurance, they also made the forced expansion of Medicaid voluntary, which means many states, especialy south and west, are not offering expanded coverage to able bodied, poor adults. This may well be the real problem that spells long term trouble for the ACA.
So the group of young people who are left, then, are young adults on the economic fringes - some may be students or young workers unable to tag onto their parents' health plans, some are in the jobs that traditionally have been worst for getting insured - waiters, bartenders, retail and other parts of the service economy, especially food service. These people may well benefit from the exchanges, and so far, they seem to be moving towards it, however slowly, and even with the website's problems.
The problem with risk, as insurers suggest, is that we really don't know, and won't know for a while to come, if insurance rates really do cover the flood of new people into more regular health services. It's been obvious that many people with serious medical problems were the first to obtain insurance, often far more affordbale than previous option. Their care is not free, and their needs are substantial. What's long been suspected is that much more of the uninsured are, in fact, sicker than we might think, and that more regular medical care will put strains on providers, but especially turn out to be more expensive than anyone dreamed. Insurers are worried about this. Therefore, it suits their purposes to push a notion, much like conservatives, that there's a mythical cohort of healthy young people evading the system entirely. Instead, the real problem may well be that the young people who do finally come into the world of insurance turn out, in fact, to need care - and a substantial amount of it. At least initially.
It's worth remembering that the Affordable Care Act is really a cobbled-together solution which few really love. It's our biggest attempt yet to construct a workaround in a series of cobbled together workarounds, none of which address the fundmental problem in American healthcare: a system driven by employment makes no sense and should mostly be ended, or replaced. Polling on opposition to the ACA rarely takes into account that while the right instinctively loathes "Obamacare", there's substantial, thoughtful opposition on the left. And that's why "defund or repeal" is not working as a right-wing slogan - lefties may not like the ACA, but they know there's really no going back.
By agreeing to focus on the Fallacy of Youth, liberal pundits once again ignore the best way to both reject the right's manufactured outrage and focus on the real problem: the problem for expanding health insurance is about insuring people in poverty, and separating insurance from employment. If we don't make those things happen, then the ACA is no more a solution than the previous one's we've tried. And even the collapse on the American Right Wing won't help.