John C. Goodman

Clearly this plan will be attractive to people who don't plan to enter a hospital and unattractive to people for whom a hospital stay is likely.

Race to the bottom on access to care. Think of an insurance plan as having three main components: (1) a premium, (2) a list of covered benefits and (3) a network of doctors, hospitals and other providers. Under the Affordable Care Act, there is very strict regulation of benefits ? right down to free contraceptives, questionable mammograms and non-cost-effective preventive procedures. At the same time health plans have been given enormous freedom to set their own (community rated) premiums and choose their own networks. They are using that freedom in yet another way to attract the healthy and avoid the sick.

In the ObamaCare exchanges, the insurers apparently believe that only sick people (who plan to spend a lot of health care dollars) pay close attention to networks. Healthy people tend to buy on price. Thus, by keeping fees so low that only a minority of physicians will agree to treat the patients, some insurers are able to quote very low premiums. They are banking on attracting the healthy and they may even have the good luck to scare away the sick.

Community rating is what makes this strategy work. In the ObamaCare exchanges, if I am healthy why wouldn't I buy on price? If I later develop cancer, I'll move to a plan that has the best cancer care. If I develop heart disease, I'll enter a plan with the best heart doctors. And these new plans will be prohibited from charging me more than the premium paid by a healthy enrollee. (See a more comprehensive analysis.)

As a result, we are getting a race to the bottom on access ? with private plans in the exchanges looking increasingly like Medicaid, just as they do in Massachusetts.

The Obama administration doesn't seem to be bothered by this development. In fact they have been touting the fact that the premiums have been lower than expected, even though the reason is that the networks are narrower and skimpier than expected.


John C. Goodman

John C. Goodman is President of the Goodman Institute and Senior Fellow at The Independent Institute. His books include the widely acclaimed A Better Choice: Healthcare Solutions for America and the award-winning Priceless: Curing the Healthcare Crisis. The Wall Street Journal and National Journal, among other media, have called him the "Father of Health Savings Accounts.”