What Avik Roy won't tell you about healthcare in Switzerland and Singapore

Avik Roy so despises the Affordable Care Act that he wants it to swallow Medicare and Medicaid.

According to Roy's latest sketch of a conservative plan to offer universal health insurance, Medicare and Medicaid are the chief culprit in the United States' uniquely expensive healthcare system -- notwithstanding that they pay less per procedure than private insurers and patients, and that most experiments in alternatives to fee-for-service payment are located within them.

In Roy's free-market healthcare vision, Medicare and Medicaid patients would be transitioned onto deregulated health insurance exchanges, where insurers would be free to offer even skimpier insurance than the current exchange bronze plans, designed to cover just 60% of average patient costs. They might also be free to expand the ACA's age-rating, which limits the ratio of older patients' premiums to young patients' to 3-to-1, and be freed from offering the ACA's minimum essential benefits.

To flesh out this vision, Roy touts the virtues of his two favorite national systems: those of Singapore, which features mandatory individual health savings accounts (HSAs), and  Switzerland, in which everyone buys insurance on private exchanges (subsidized for about a third of the population). But as is his wont, Roy fails to mention the feature that enables each of these systems work: strong government influence over pricing.

Take first Roy's sketch of Switzerland's free market system:

For state GOP officials, a manual for undermining Obamacare

In 2011, the National Association of Insurance Commissioners (NAIC) produced a report cataloging risks of adverse selection in the ACA state insurance exchanges and provisions in the ACA designed to avoid or mitigate those risks. (Adverse selection occurs in plans that chiefly attract less health and more expensive customers, e.g. when younger, healthier customers have other options more attractive to them, including remaining uninsured.)

One key ACA measure to mitigate adverse selection is as follows. Those who offer insurance on the exchanges must treat all their customers in that state as one risk pool and must offer silver and gold plans -- the middle options in a spectrum that runs from bronze to platinum. If "young invincibles" choose bronze plans, their choices won't affect pricing in more expensive plans, which may be more attractive to older and sicker customers.

A continued risk is posed, however, by the ongoing existence of an individual market outside the exchanges, where insurers may still sell cheap high-deductible plans that appeal to healthy young people, albeit subject to many if not all of the same rules governing plans offered in the exchanges. In yesterday's New York Times, Eduardo Porter outlined that risk:

In which Ezra Klein makes Avik Roy acknowledge why U.S. healthcare costs are so high

Avik Roy and Ezra Klein had a long --very long -- conversation about Roy's beefs with the Affordable Care Act. They covered "rate shock,"  minimum coverage standards, and Roy's dreams of a more fundamental system overhaul that would push everyone onto healthcare exchanges by privatizing Medicaid and Medicare and ending the employer tax deduction for health care benefit provision. 

Roy has been a relentless critic of the ACA. Having read some of his writings about it but by no means all, I was surprised to learn, as Klein probed his reaction to feature after feature, that he "do[esn't] have* a problem with standardizing benefits" and that "guaranteed issue [no refusals or cost bumps for preexisting conditions]is fine." His objections really boiled down to three: 1) he objects strenuously to "community rating," i.e., the ACA's limiting of the price differential between the youngest and oldest age cohorts to 3-to-1, as opposed to the roughly 6-to-1 ratio that Roy says the market would dictate.  2) He would like the exchanges to offer plans that cover even less than the lowest cost plans in the current design -- plans covering, say, 40% of a member's average yearly costs rather than the 60% that the exchange's lowest-run "bronze" plans are designed to cover. 3) As mentioned above, he would like more radical reform -- health exchanges for everyone.

As Klein eventually made Roy implicitly acknowledge, though, none of his favored solutions get at the root of the United States' disproportionate healthcare inflation.

Look what the GOP can get for $300 billion

In July 2011, Obama was reportedly ready to sign off on a grand bargain for deficit reduction that would include $800 billion in new revenue and somewhere in the neighborhood of $3 trillion in spending cuts over ten years. David Brooks said that Republicans would be crazy not take such a deal.  And that decision may pay off for them.

If Republicans can stomach the sequester and withstand pressure from defense contractors and other constituent groups, they can close the books on ten-year deficit reduction with some $2.7 trillion in spending cuts and the measly $600 billion in new revenue that Obama unaccountably settled for on Jan. 1 (plus additional interest savings).

The double catch is that even Republicans profess to dislike the sequester's indiscriminate swing of the meat ax, and Republicans also purportedly want to cut and "reform" entitlements -- though they would prefer to induce Obama to do the dirty work on that front.  And the funny thing is that he will -- if Republicans would only give ever so little on revenue. My educated guess is that if they would agree to say $200 billion worth of tax loophole closures or tightenings, Obama will go quite far in altering the structure of Medicare, Medicaid and Social Security.

There's one other catch. Republicans would have stop doing their utmost to strangle Obamacare in the crib. That's their ticket to privatizing Medicaid and Medicare.

Consider the Rubicon on Medicaid that's been stealthily crossed in the last month. Sarah Kliff explains: