Negotiating Risk Factors: notes from the 2nd presidential debate
Well, now we know how the election turned out. I should have posted this much earlier, but for record keeping sake I'm posting it now.
Below is an excerpt from the second presidential election debate. It is Hillary Clinton's response to a citizen's question about health care namely, his lament that it is very expensive despite the efforts of the Affordable Care Act. The dialog is an example of negotiating the risk we face. In this case, the public is upset with health care costs that presumable reflect some estimate of risk. The policy maker response is to help the public develop an idea of risk that supports public values.
I've added emphasis to some relevant text. I've left Donald Trump's comments for my records but I haven't highlighted anything for two reasons. One, he doesn't often speak in complete sentences and ideas are disjointed. Two, some of his comments are proposals to revamp insurance through competition, removing state boundaries in health care insurance, and designer policies (my words). The former two solutions come up against historical issues with state rights and concerns about the optimal level of competition for an insurance market. The final issue is in effect the opposite of what I think Clinton is arguing and speaks to a larger issue in insurance about decomposing risk pools which poses difficulties for insurability and social values of equitability.
CLINTON: Well, I think Donald was about to say he’s going to solve it by repealing it and getting rid of the Affordable Care Act. And I’m going to fix it, because I agree with you. Premiums have gotten too high. Copays, deductibles, prescription drug costs, and I’ve laid out a series of actions that we can take to try to get those costs down.
But here’s what I don’t want people to forget when we’re talking about reining in the costs, which has to be the highest priority of the next president, when the Affordable Care Act passed, it wasn’t just that 20 million got insurance who didn’t have it before. But that in and of itself was a good thing. I meet these people all the time, and they tell me what a difference having that insurance meant to them and their families.
But everybody else, the 170 million of us who get health insurance through our employees got big benefits. Number one, insurance companies can’t deny you coverage because of a pre-existing condition. Number two, no lifetime limits, which is a big deal if you have serious health problems.
Number three, women can’t be charged more than men for our health insurance, which is the way it used to be before the Affordable Care Act. Number four, if you’re under 26, and your parents have a policy, you can be on that policy until the age of 26, something that didn’t happen before.
So I want very much to save what works and is good about the Affordable Care Act. But we’ve got to get costs down. We’ve got to provide additional help to small businesses so that they can afford to provide health insurance. But if we repeal it, as Donald has proposed, and start over again, all of those benefits I just mentioned are lost to everybody, not just people who get their health insurance on the exchange. And then we would have to start all over again.
Right now, we are at 90 percent health insurance coverage. That’s the highest we’ve ever been in our country. COOPER: Secretary Clinton, your time is up.
CLINTON: So I want us to get to 100 percent, but get costs down and keep quality up.
COOPER: Mr. Trump, you have two minutes.
TRUMP: It is such a great question and it’s maybe the question I get almost more than anything else, outside of defense. Obamacare is a disaster. You know it. We all know it. It’s going up at numbers that nobody’s ever seen worldwide. Nobody’s ever seen numbers like this for health care.
It’s only getting worse. In ’17, it implodes by itself. Their method of fixing it is to go back and ask Congress for more money, more and more money. We have right now almost $20 trillion in debt.
Obamacare will never work. It’s very bad, very bad health insurance. Far too expensive. And not only expensive for the person that has it, unbelievably expensive for our country. It’s going to be one of the biggest line items very shortly.
We have to repeal it and replace it with something absolutely much less expensive and something that works, where your plan can actually be tailored. We have to get rid of the lines around the state, artificial lines, where we stop insurance companies from coming in and competing, because they want — and President Obama and whoever was working on it — they want to leave those lines, because that gives the insurance companies essentially monopolies. We want competition.
You will have the finest health care plan there is. She wants to go to a single-payer plan, which would be a disaster, somewhat similar to Canada. And if you haven’t noticed the Canadians, when they need a big operation, when something happens, they come into the United States in many cases because their system is so slow. It’s catastrophic in certain ways.
But she wants to go to single payer, which means the government basically rules everything. Hillary Clinton has been after this for years. Obamacare was the first step. Obamacare is a total disaster. And not only are your rates going up by numbers that nobody’s ever believed, but your deductibles are going up, so that unless you get hit by a truck, you’re never going to be able to use it.
COOPER: Mr. Trump, your time...
TRUMP: It is a disastrous plan, and it has to be repealed and replaced.
COOPER: Secretary Clinton, let me follow up with you. Your husband called Obamacare, quote, “the craziest thing in the world,” saying that small-business owners are getting killed as premiums double, coverage is cut in half. Was he mistaken or was the mistake simply telling the truth?
CLINTON: No, I mean, he clarified what he meant. And it’s very clear. Look, we are in a situation in our country where if we were to start all over again, we might come up with a different system. But we have an employer-based system. That’s where the vast majority of people get their health care.
And the Affordable Care Act was meant to try to fill the gap between people who were too poor and couldn’t put together any resources to afford health care, namely people on Medicaid. Obviously, Medicare, which is a single-payer system, which takes care of our elderly and does a great job doing it, by the way, and then all of the people who were employed, but people who were working but didn’t have the money to afford insurance and didn’t have anybody, an employer or anybody else, to help them.
That was the slot that the Obamacare approach was to take. And like I say, 20 million people now have health insurance. So if we just rip it up and throw it away, what Donald’s not telling you is we just turn it back to the insurance companies the way it used to be, and that means the insurance companies...
COOPER: Secretary Clinton...
CLINTON: ... get to do pretty much whatever they want, including saying, look, I’m sorry, you’ve got diabetes, you had cancer, your child has asthma...
COOPER: Your time is up.
CLINTON: ... you may not be able to have insurance because you can’t afford it. So let’s fix what’s broken about it, but let’s not throw it away and give it all back to the insurance companies and the drug companies. That’s not going to work.
COOPER: Mr. Trump, let me follow up on this. TRUMP: Well, I just want — just one thing. First of all, Hillary, everything’s broken about it. Everything. Number two, Bernie Sanders said that Hillary Clinton has very bad judgment. This is a perfect example of it, trying to save Obamacare, which is a disaster.
COOPER: You’ve said you want to end Obamacare...
TRUMP: By the way...
COOPER: You’ve said you want to end Obamacare. You’ve also said you want to make coverage accessible for people with pre-existing conditions. How do you force insurance companies to do that if you’re no longer mandating that every American get insurance?
TRUMP: We’re going to be able to. You’re going to have plans...
COOPER: What does that mean?
TRUMP: Well, I’ll tell you what it means. You’re going to have plans that are so good, because we’re going to have so much competition in the insurance industry. Once we break out — once we break out the lines and allow the competition to come...
COOPER: Are you going — are you going to have a mandate that Americans have to have health insurance?
TRUMP: President Obama — Anderson, excuse me. President Obama, by keeping those lines, the boundary lines around each state, it was almost gone until just very toward the end of the passage of Obamacare, which, by the way, was a fraud. You know that, because Jonathan Gruber, the architect of Obamacare, was said — he said it was a great lie, it was a big lie. President Obama said you keep your doctor, you keep your plan. The whole thing was a fraud, and it doesn’t work.
But when we get rid of those lines, you will have competition, and we will be able to keep pre-existing, we’ll also be able to help people that can’t get — don’t have money because we are going to have people protected.
And Republicans feel this way, believe it or not, and strongly this way. We’re going to block grant into the states. We’re going to block grant into Medicaid into the states...
COOPER: Thank you, Mr. Trump.
TRUMP: ... so that we will be able to take care of people without the necessary funds to take care of themselves.