Austin Frakt on John Goodman's proposals in Priceless:
Anyway, the main rule John doesn’t like is community rating. He explains the problems with community rating, leading to a seeming take-down of risk adjustment. One problem with risk adjustment is that no methods predict costs all that well. Of course, some of health care, probably most of it, is unpredictable, the very part John thinks we should insure against.
John’s proposed solution to risk adjustment is that, upon switching plans, an individual’s “original health plan would pay the extra premium being charged by the new health plan, reflecting the deterioration in health condition.” There are two things about this I do not understand. First, how would this extra premium be calculated in a way that is different from risk adjustment payments? If we knew a better way, we’d have better risk adjustment now.*
Second, this idea seems no different than risk adjustment by another name. Think about it from the new plan’s point of view. Would the plan manager act any differently if the payment is called a “change of health status offset” and paid by the original insurer or a “risk adjustment payment” and paid via a market administrator of some sort (funded, for example, by assessments on low-risk bearing plans)? A dollar is a dollar. The same limitations of risk adjustment apply, don’t they?*I see two issues here, both brought up in the comments. The first is that there is a huge issue with information here. Sorting out what the "lump sum payment" would be from the first plan to the second plan is a daunting task.
The other is the assumption that market players are immortal. What happens if a company invests in high risk assets with their reserves? Or if a company goes bankrupt? How does the consumer get to be reimbursed for the increase in premium now that the original company has no assets?
This is unlike a regular insurance company, because if a regular insurance company has to stop covering thousands of customers for fire, they do not incur instant liabilities. Nor does the underlying risk of fire make it harder and harder to insure a house over time (or at least this doesn't change as briskly as health between 20 and 50).
The closest analogy is pension funds, but notice the huge problems we are having with defined benefit pension plans. Notice how much discussion there is about breaking pension plan contracts due to bankruptcy; airline pilots seem to be the latest example.
Now consider the amount of personal risk such a system would create. At 18 you buy insurance and then hope that it lasts until you are 65 (if we keep medicare) or perhaps 80 or 90 if we don't. Even the 18 to 65 perod is 47 years. How many top companies of 47 years ago are healthy today?
So what is the solution to this risk and information problem? Well, with pensions we have government backing. That helps. But at what point does regulating the market and creating an interaction system between insurers reduce efficiency to the point where competition isn't going to improve gains? And recall, the real way to make money in this market is to be able to forecast risk (over 47 years) better than your competitors. But if you underestimate risk and mis-price your plans, you can't reduce services or customers will leave and bankrupt you instantly.
Isn't this just begging for an endless cycle of bailouts?