Advocates for funding or for in-kind provision of medical services through the state — some degree of socialization of medicine — frequently assert that there is a basic human right to health or to medical services. But there is invariably a bait-and-switch, because health cannot be provided as a right, basic or otherwise, universal to human beings or even held by all members of a large, naturally formed community such as a nation; and a right to medical services gauged in terms other than consequences for health would be grossly implausible and otherwise unappealing.

It should be immediately obvious that there cannot be a basic right to medical services, because a basic right exists in any context in which there is a person, even when that person is in isolation. One cannot make a claim to the services of others if there are no others, nor can one make a claim to the use of technologies that simply don't exist. That's why genuine liberalism understands that basic rights aren't claims to the services of others, but instead are claims to be free from various sorts of interference by others. Robinson Crusoe cannot see a doctor when he is alone on the island, yet can speak his mind whether he is alone or has neighbors.

Derived rights are another matter. Derived rights are founded upon basic rights, but may emerge in a social context and be informed by the available resources, including technology. And there might even be a derived right that, though only emerging in some context, were universal to some population and involved positive claims to goods or to services. To provide an argument that health or medical care were just such a right, advocates of socialized medicine would have to identify and explain a process of derivation. While some persons making the assertion that there were instead a basic right to health or to medical care are simply swept-up by emotion, doing so also short-circuits a recognition of responsibility for that identification and for its explanation.

There are advocates who speak and write of the social contract and propose to find support thereïn for socialized medicine at present levels, and perhaps at still greater levels. But what is here called the social contract is not the contract that Hobbesians or liberals once imagined to be adopted at the beginnings of civil society; rather, a set of expectations held by some members of a society is being called a contract, as if such expectations alone could somehow contractually bind everyone within that society. The need to identify and explain the derivation of an ostensible right to medical care remains unmet by the use of the misleading metaphor of a contract. (Perhaps Mr Crusoe expects Friday to begin studying medicine upon arrival, but what of it?) It might also be noted that reference of this sort to a social contract is profoundly conservative — in the original sense of conservative — because the principal informant of expectations about social outcomes is tradition. And, if such expectations did have the sort of moral force that is imputed to them by the invocation of the social contract, then practices such as the subordination of women in various societies could be defended by reference to the social contracts of those societies. Even if such defense is somehow progressive, it is utterly illiberal.

In any case, health itself cannot be delivered as a right universal to human beings nor within some smaller but still large and naturally formed community. Some people have dire medical conditions for which there is no effective treatment, so there is no right to health itself. One might acknowledge that indeed there is no right to health yet assert that there were still a right to medical care; but others have conditions that could be corrected only by diverting resources that would otherwise be used to provide medical treatment to different people; and it is incoherent to speak of rights as things that may be in conflict — indeed, the point of insisting that health or medical care were a right (as opposed to a lesser desideratum) is to make an over-riding claim. One might finally punt to an assertion that everyone simply had a right to medical care regardless of need; but, thus unlinked, there is no more reason to suppose an entitlement to some allotment of adhesive bandages and of aspirin tablets than to suppose an entitlement to an allotment of bubble gum.

The actual provision of medical goods and services under socialized medicine cannot be about rights, and so it isn't about rights; it is instead a matter of politicized collectivist calculations. Essentially, popular opinion is motivated by a naïve and incoherent utilitarianism — trying somehow to maximize an implicitly quantified sum of human well-being (with perhaps odd lexicographical properties), but making exceptions here and there driven by pity or by respect for some people and enabled by blindness to the costs to others; and officials of various sorts try to keep some share of the public happy but more generally pursue their own interests. Those who are not served under the programme or who find their access to medical care reduced or even effectively ended by socialism are waved-away as unfortunate victims of practical limitations, previous talk of rights not-withstanding.

I'm not at all a fan of collectivist calculations; typically they assume quantifications that don't hold, and otherwise they seem arbitrary in what they seek to maximize. But, if those calculations truly made sense, then one would want to consider the long run, to include the well-being of people in the future in one's aggregation; and thereïn lies the rub. Unless one assumes that humankind is fairly soon to come to an end, there are more people yet to be born than are alive to-day. If there truly were a collective aggregate to maximize, then anything done to-day that impaired economic development in the future would be counter-indicated. If people in the future were generally wealthier, then they would enjoy better medical care and almost surely better health. If we allow for considerations beyond the medical, the case for economic development is greater still. And, because it cannot allocate resources with economic efficiency, socialized medicine is ultimately a drag on economic development and thus on medical progress.

Socialized medicine doesn't deliver a basic right; it doesn't deliver a derived right; in the long run, it means that more people suffer (though suffering itself has no aggregate across persons) and that at any given age a greater share of people die. Refusing to face these points doesn't make one a nicer person; accepting the truth doesn't make one uncaring. Forcing the innocent to swallow bad medicine is not kindness.

The Veterans Health Administration is a con job. I'm sure that many of those working as part of it do not recognize it as a con job. I'm sure that some of those working for it recognize that it is a con job but believe that it can be something more and better, and have been struggling towards that goal. But it is a con job and it will remain a con job so long as it has anything much like its present form.

The declared purpose of the VHA[1] is to provide health-care to military veterans. This mission appeals to those voters who see veterans as deserving reward or compensation for their military service, and it appeals to those contemplating entering such service.

In theory, the provision of this health-care could be entirely by a voucher system, allowing veterans to acquire health-care at state expense but through a market of private producers. The reason that a voucher system is not used is because of its expense.

To control costs, provision has largely been by state-run facilities. Some people imagine that costs will be kept in check because of elimination of profit, because of technical efficiencies achieved through vertical integration, and because of recruitment of superior personnel willing to work for lower salaries. But the elimination of profit means the elimination of the profit-motive, which elimination in turn inhibits the search for new and better ways of doing things. Vertical integration might be able to exploit technical efficiencies, but a greater problem of economic calculation confronts any attempt to administrate a large-scale allocation programme. And the state is simply not very good at recruiting superior people on-the-cheap.

The problem of economic calculation bites especially hard, and the VHA cannot actually get its costs down to those of private provision through the market. The VHA can, however, lower its evident pecuniary costs by reducing the quantity or the quality of the health-care that it provides. In other words, it can shift the cost to veterans, in the form of unmet promises; in the form of suffering and in the form of death. That is how the VHA can and does control costs.

When the VHA was launched, there was almost surely a sincere belief that it could deliver at a discount. However, there have since been many decades for state officials to observe that it has not; there has been ample time to recognize that it cannot. Yet instead of being forthright in explaining what it would take to provide veterans with the benefits that they were promised, and instead of preparing to meet the promises now being made to recruits, the deception continues. As failure continues to come to-light, there will be further reforms that fall short of what is actually needed to meet the promises, because fraud saves the state a considerable amount of money, and protects the mythology under which the state preserves and accumulates power more generally.

---

I have noted that health-care could be provided to veterans by way of a voucher system, but if one respected the sensibility and character of military veterans, and trusted the strength of voters, then a better thing to do would be simply to give veterans enough money that they could buy the same amount of health-care (in part by purchasing insurance), but to allow them to spend that money as they chose. At the margin, a bit more or less of something else may reasonably be more important to some veterans than a bit more or less of health-care.

If veterans are intelligent, economically rational, and of good character, then they will use the money appropriately. If they are stupid, irrational, or sociopathic, then they may spend the money inappropriately, and later seek a bail-out from the tax-payer in the event of an emergency, and voters might give that to them.

I leave each reader with responsibility for his or her judgment on that matter.

---

[1] The VHA is the best-known part of the U.S. Department of Veterans Affairs, aka the Veterans Administration, to the point that VA usually refers to the VHA, and that VHA and Veterans Heath Administration aren't much used. None-the-less, I'll employ the more precise term and abbreviation hereïn.

I believe that I last wrote here about what became the Affordable Care Act — aka Obamacare — in an entry posted on 28 July 2008. I've been meaning to write about it since, but I paused to await the outcome of NIFB v Seleblius, and then again to await the outcome of King v Burwell.

---

To understand what really drove the Democratic Party to pass the Affordable Care Act, one may look at the experience of the Social Security Act (1935).

The programme of old-age benefits — which is what most Americans have in mind when they refer to Social Security — is one that had been failing slowly over the many decades of its existence. Population growth has slowed strikingly, and life-spans have been extended significantly, so that the number of people paying into the system has declined dramatically relative to the number of people to whom payments have been made. At the same time, in various ways the typical payment per individual has been allowed to climb. The tax used to fund it has never collected enough revenue to do so indefinitely. At times, revenues have been much greater than benefits; but, none-the-less, there has never been a moment over the last 50 years or more when the demographics did not show that, within the expected lifetime of a young person, promised benefits would exceed revenues and exhaust whatever had been saved under the revised programme.

Congress did not plan for the old-age benefits programme to fail, slowly or otherwise. Congress simply didn't take a careful look at the future. The immediate concerns of Congress were to exploit the political gains to be had from promising a pension programme, and to short-circuit political support for the ruinous Townsend Plan.[1] But this slow failure has proved to be hugely rewarding to the party most responsible for effecting the programme.

Because the programme has failed slowly, there was sufficient time for a large share of Americans to become dependent upon it. It was even, for a while, said to be the third rail of American politics — analogous to the rail delivering current to an electrically powered train, in the sense that touching it would prove fatal. As failure has recurringly loomed, Republicans (having increasingly become the party of opposition to the New Deal Coälition) struggled with how to respond to the failure of a programme with such broad support, while the Democratic Party has been able to position itself as rescuer. The slow failure of their creature has been an important part of the success of their party.

Although supporters of the programme often speak and write as if opponents would simply and abruptly withdraw benefits from all recipients, a more common suggestion has been to phase-out the present programme in favor of an overt poverty-relief programme. Thus, for example, those born after some point in time would received reduced benefits — perhaps in some cases no benefits — if they had income or wealth measured above some levels. This idea meets resistance not only from those who would lose benefits, but from those who would then find themselves on welfare.

Younger people, looking at a future tax burden, and perhaps doubtful that the next major reforms will prove sufficient to maintain the programme through their own retirements, are most often open to suggestions of reform. But, as time passes and they age, they find themselves having paid much of the tax that they might earlier have hoped to avoid, so that the principal pecuniary result of a phasing-out would be either to deny them benefits or to place them on welfare. Additionally, as they age, so do their parents, who go from being perhaps middle-aged to being elderly.

A sense may often be retained that they would have been better-off had the programme been phased-out when they were younger,[2] and that those now young would be better-off if the programme were phased-out now. There is, thus, something of the flavor of a sub-optimal Cournot-Nash equilibrium to it all. A lot of people would admit that the programme ought not to have been instituted; but, since it was, and since they would personally be hurt by an attempt to end the programme, they will not assist in an unwinding, and may even actively oppose an unwinding.

And, so, they are increasingly inclined to support the Democratic Party, which continues to promise to do whatever is necessary to keep the programme going.

---

The Affordable Care Act was intended to creäte another slowly failing programme with a large number of people dependent upon it. There was no illusion on the part of most of those who voted for the Act that this programme would be the one exception in the history of large state programmes. They might not know the core reason that such programmes perform so badly, but they've had plenty of observations of failures. As with the Social Security old-age benefits, each time that failure loomed for Obamacare, the Democratic Party could position themselves as rescuers of the programme and thus of the people dependent upon it in order to receive medical treatment. And the Republican Party would again be forced to choose between protecting their brand and protecting their jobs. The public might perhaps conclude that they would have been better-off had the programme not been brought into existence in the first place, but they'd see themselves now being made still worse-off in any unwinding, however an unwinding might benefit later cohorts.

Indeed, when the President acted to preserve the programme by ignoring the plain wording of the law, a large part of the defense of his action was that a substantial number of people had become dependent upon the programme. Even a great many people who had been insured, at lower cost, previous to the programme could have suddenly found themselves uninsured, and the programme was defended on the basis of a dependency that it had induced amongst those people. Meanwhile, the Republican Party, though returned to power largely because of voter discontent with the programme, has been widely criticized for not agreeing upon some view as to how health care ought to be allocated, and then presenting that view to the public. Many Republicans essentially propose adopting a position they are just stuck with Obamacare, since the Supreme Court has twice now refused to stop it.

However, Obamacare is not a slowly failing programme; it is a rapidly failing programme.

In my entry of 28 July 2008, I explained that the programme was effectively to tax the insurance policies of the healthy in order to subsidize the unhealthy; and that, in the absence of compulsion, the healthy would not insure, causing premia to spiral upward.

In order to make passage of the law politically palatable, the compulsion was relatively weak. The annual penalty for failure to buy insurance is well less than the cost of insurance, and the IRS is forbidden to attempt to collect the penalty (if not paid voluntarily) except by reducing the annual tax refunds of those against whom it is charged. I suspect that the Democratic leadership had some awareness that this penalty structure was going to be inadequate, but were thinking of this weak compulsion as the camel's nose — they planned to get the rest of the beast into the tent in some later session, with higher penalties and more freedom of action for the IRS. They didn't understand that they'd lose control of one chamber in the very next election.

So, indeed, many of the relatively healthy chose not to buy insurance, despite repeated extensions of the buying period. And, as a consequence, premia are going to rise by more than 10%. This increase makes insurance a bad buy for an even larger group of people, who will choose not to buy insurance next year. That will cause a further rise in premia. And so forth. Premia should be expected to increase by more than 10% every year, until the programme implodes as affordable insurance moves out of reach for a huge share of people. (With annual increases of more than 10%, premia would more than double over just eight years, but I do not expect the programme to survive to a doubling of premia!)

There was talk of how, if King v Burwell were decided against the President, Obamacare would go into a death spiral. In fact it was already in a death spiral. King v Burwell could have accelerated that sharply; if the spiral were faster, then the health-care system would have been less distorted by Obamacare, and the unwinding would thus be injurious to fewer people.

The sooner that it were admitted that Obamacare were in a death spiral, the sooner that a drum might be beaten for toughening penalties upon those who refuse to buy insurance. (Or for kicking the insurance companies to the curb, and establishing a more explicitly socialistic system.) But the President is not a man to admit to mistakes, nor do supporters want to admit to yet more deep problems in a programme that has already had many embarassments, as such an admission would increase skepticism. Further, the elected Republicans are unlikely to alienate their base by acting to pull Obamacare out of a death spiral any time soon, though most of them might do so from expediency were Obamacare to last-out a decade.

---

[1] The Townsend Plan, advanced by Francis Everett Townsend beginning in 1933, was that each person in the United States over the age of 60 years were to be given a monthly pension of $200, conditional upon a requirement that the entire $200 be spent within a month. The theory was that this spending would result in an increase in economic activity that would, in turn, effectively pay for the pensions.

I won't endorse simply claiming that, since the CPI is now about 30 times that in 1933, $200 then would be equivalent to about $6 000 to-day. (Comparisons of so-called price levels becomes increasingly problematic as time-spans become longer.) None-the-less, one should see that a $200 monthly pension would have been rather breath-taking.

The Townsend Plan was supported by a very large number of people, and was especially popular amongst those over or approaching the age of 60 years, and amongst those economically responsible for the support of older people.

[2] This sense will be especially acute amongst those who understand that the Social Security old-age benefits crowd-out investment-savings for retirement. With reduced investment, the economy grows at a diminished rate.

The self-styled SD Planning Committee, formed to fight cuts to state funding of education, health care, and social services, has posted flyers that declare

We face not a financial crisis, but a crisis of priorities,

I don't know why they end that with a comma, as it's followed by a sentence in which it cannot participate. In any case, it's a somewhat puffed-up way of saying that

Interesting concept, there, that there could be plenty of money in a budget, but that the money is not being well spent. They just might try applying that same concept to just those portions of the budget that are allocated to education, to health care, and to social services. Perhaps, even after cuts, there would be plenty of money, if only it were spent well. And perhaps even if funding to these programmes were increased to the greatest possible levels, it would be spent badly.

Okay, so there's no perhaps to it; that's just how it would be.

---

On the other hand, I have to grimace when I hear or read of linking teacher pay to performance.

I understand the desire to pay teachers based upon the quality of their teaching. And, outside of the teachers' unions, almost everyone understands that it's not a good thing to link teacher pay primarily (let alone directly) to years of service. But I'm pretty sure that real-world attempts to link teacher pay to ostensible measures of performance are going to increase

• disincentives for teachers to accept jobs working with less able students,
• incentives for teachers to teach to the tests by which student achievement is purportedly measured,
• student time tied-up in taking those d_mn'd tests, which themselves teach nothing to students beyond test-taking skills.

A profoundly different model of education is needed to get something that will work.

A part of that model would be to use markets to price teaching, recognizing (amongst other things) that different teaching contexts correspond to different markets.

Unfortunately, another part of that model is for parents to accept a significantly greater degree of responsibility for ensuring that their children are properly educated. The vast majority of parents seem willing to pass the buck to state-funded schools, regardless of their performance. It isn't sufficient to say Hey, I sent my kid to school! The school dropped the ball, not me!

There's a fair amount of annoying absurdity associated with the cotton swab.

The traditional use for these things is, of course, cleaning-out one's ear canal. Probably that's not a good idea, though. The back of the Q-tips® package at which I'm looking says

If used to clean ears, stroke swab gently around the outer surface of the ear, without entering the ear canal.

WARNING: Use only as directed. Entering the ear canal could cause injury. Keep out of reach of children.

(Emphasis theirs.) A swab could push cerumen (ear wax) deeper into the canal, and pack it more tightly. With or without the cerumen, the swab could be pressed hard enough to rupture the tympanic membrane (ear drum). And the swab might even promote infection.

But, though there may be some tiny number of people with such odd convolutions to their outer ears that a cotton swab would be helpful in cleaning them, most of the rest of us could get better or faster results with a cloth or tissue. If we're not going to put the swab in our ears, then it probably just shouldn't touch our ears at all. Granted that the box merely says If used to clean ears, but I remember a commercial from Cheesebrough-Ponds featuring Orson Bean, cleaning his outer ear with a Q-tip®, and advising us Never put anything in your ear, except your elbow. (Someone get that man a tissue.)

When doctors and medical advice columns tell their audience not to use these things in the ear, they frequently use a formula which gets my back up. Formally, it's Not-X. When X, then Y. which is to say that they claim something doesn't happen, and then tell us what to do when it happens. Jeez! More specifically, they tell us

The ear canal does not need to be cleaned, because it's a self-cleaning organ. […] When the ear canal needs to be cleaned, one should see a doctor.

Okay, the ear canal does need to be cleaned, because it is an imperfectly self-cleaning organ; let's not pretend otherwise while we're trying to keep the swabs out. And, as far as this see a doctor business, while it may seem like a mighty fine idea to the doctors, most people don't want to pay the cost of seeing a doctor. Even where medicine is socialized to the point that there would be no pecuniary cost in seeing a doctor, there will be the cost of waiting (which will typically be significantly higher where medicine is socialized). People want their ears unclogged quickly.

A better alternative to the swab for cleaning the ear canal is the syringe. For a few bucks, most druggists will sell you a syringe that's basically a rubber ball with a nozzle. If you went to the doctor, then he'd probably use a more impressive syringe, made of metal and with a plunger. You could order one of those for yourself for about US$20, but it's unlikely to be more useful for you unless you start syringing not only the ears of everyone in your household but also those of all your friends and neighbors.

If you read the instructions on the syringe package, it will basically tell you to dribble water into your ear. You will probably find this dribbling signally unhelpful unless you've used other fluid to dissove the cerumen and are now just rinsing the mess out. You can buy expensive fluids from your druggist, or you can use the dilute hydrogen peroxide that he'll sell you for much less, or you can use a mixture of vinegar and baking soda, each bought from the grocer. In all three cases, that's going to tickle maddeningly.

I once had my ear canals cleaned by a Doctor Villavecer, in Westerville, OH. He used one of those impressive metal syringes. He didn't dribble the water into my ear; he blasted it. That worked pretty well, though I might have felt differently had a tympanic membrane ruptured. In any case, subsequently, this blasting is how I clean my canals, except that I use a rubber ball syringe, as I am leaving the ears of my friends and neighbors clogged but unmolested.

Backing-up, let's return to the warning on that Q-tips® package:

Keep out of reach of children.

Now, unless we're prepared to tell people to keep lollipops and twigs out of reach of children, it doesn't make a whole lot of sense to put the Q-tips® with the pornography and assault rifles. We can instead tell junior not to put anything into his ear, and reälize that a swab would be less terrible in disobedience than many other candidates. I reälize that Cheesebrough-Ponds is not really to blame for this specific bit of nonsense (responsibility lies in the hands of lawyers, of state officials, and of the fools who empower them), but nonsense it is, none-the-less.

I recently read someone defending socialism on the ground that socialism has the same root as does society. Well, I don't object to society. And I venture to guess that she doesn't object to fathers, yet I go further to guess that she does object to what's called patriarchy. One mustn't over-reach with etymology, with dear old dad, nor with society.

I've previous explained the economic calculation problem of socialism: Rational allocation of resources requires trade-off signals that reflect as much relevant information as practicable. Most of the relevant information is highly decentralized, and some of it (such as the expectations and preferences of participants) is intrinsically so. A market brings that information into play by way of prices (trade-off signals) developed by the give-and-take of would-be consumers and of would-be sellers. Socialists haven't developed an alternative; they correct the market only at the cost of over-all misallocations with their own costs in human welfare.

This point is as true in the delivery of health care as anywhere else. Almost everyone agrees that American health-care delivery is in appalling shape, but there are those who ignore that the problems have grown as state interventions have increased. Commentators frequently note that costs have exploded in the last fourteen years, but then most of these commentators are silent on the fact that the period followed upon the last round of reforms. Of course, the period before those reforms wasn't itself some sort of golden age; the reforms were effected because many things were seen to be worse than once they were, and getting worse still. But, again, due attention was not paid to the rôle of prior state intervention in effecting that worsening. This routine of blaming what remains of a market for the mounting problems of an increasingly state-controlled system began well before I was born.

Many people, even defenders of socialized medicine for the United States, admit that the socialized systems elsewhere have some dramatic flaws. The belief of the defenders is that the United States can develop a better system, perhaps in part by learning from the problems of other states. But the deep problem is, again, that of trade-off signals. And one of the seldom-recognized implications of that is that greater state control here has led and will lead to a worsening of systems elsewhere. A state-controlled system can somewhat compensate for its own inability to formulate rational trade-off signals by being guided (directly or indirectly) by prices generated elsewhere. (This solution is imperfect because the prices of one region cannot be expected to be ideal for another; and, if they were, using them fully would generate exactly the same out-comes as would be effected by a free market, rendering the socialism absurd.) Implicitly, production and distribution of health care in the industrialized nations with more socialized medicine has been significantly guided by the choices made in the United States. To the extent that our prices as well continue to become the guesses of bureaucrats rather that the outcomes of interaction between free consumers and free producers, socialized medicine everywhere will be shooting in an ever-growing darkness.

Even assuming that morality can somehow ignore such practical problems, the morality of the claims for socialized medicine strikes me as utterly bogus. Many people declare health care to be a fundamental right, but that's plainly incoherent as one could exercise any fundamental right without the presence and assistance of other people. There have been very few attempts to build ground-up cases for a moral entitlement to health care — identifying some actual fundamental right from which a right to health care is derived in a social context — and every one with which I'm familiar has been exploded on logical grounds. Mostly people just confuse the appealing proposition that it would be a very fine thing if no one was denied health care for simple lack of resources with there being a right to health care. There are a great many hypotheticals that would be very fine things. I know people such that it would be a very fine thing if they had the companionship of someone of the desired sex, and such that they would like that even more than access to medical care; I hardly think that we should force someone else to provide that companionship though.

Some very fine things become very vile things when delivered by virtue of confiscations, regardless of whether we imagine that the confiscation is effected by society, or recognize that it is by a state or by a gang or by a mob.

Let's walk through what it would mean if insurers could not deny coverage to any applicant and could not charge higher premiums on the basis of preëxisting medical conditions.

The out-lays of insurers would of course increase, so the they will do one and likely both of two things:

• Increase premiums for all subscribers: Those without preëxisting conditions would pay more than previously, to off-set the out-lays for those with preëxisting conditions.
• Reduce coverage for all subscribers: The contractual liabilities of insurance companies would be reduced in the case of conditions that could be preëxisting, so that subscribers who developed such conditions after subscription would receive less treatment or face greater out-of-pocket expense.

So the buck-per-bang price of insurance (and probably the absolute price) would increase. This would occur regardless of whether subscription were mandatory, but I think that the consequent increase in price would be greater were coverage not mandatory.

In the absence of requiring people to purchase coverage, fewer people would buy insurance voluntarily. Those most likely to reduce their demand for insurance would be the less affluent and those who perceived themselves as relatively healthy. A significant share of the latter would indeed be relatively healthy, and their departure would mean that the average out-lay per subscriber would increase, which would push-up costs. The departure of the less affluent would tend to push-down out-lays, as the less affluent tend to lead less healthy life-styles, but it would be unreasonable to expect the less affluent to depart in sufficient numbers to restore the lower price, and I'm not aware of anyone advocating a strategy of pricing the poor out of the insurance market.

In fact, without compulsory subscription, it becomes less reasonable to subscribe until one actually needs treatment. Coverage would no longer function as insurance because it needn't be purchased on a precautionary basis. Instead, subscription would simply be a buy-in for some programme of medical care. When the expected cost of needed medical care were less than the buy-in price, one should not purchase a subscription; when the expected cost of needed care were greater, one should buy a subscription.

The proposal is to make subscription compulsory, in which case it's not clear why insurance companies should continue to be involved at all. Insurance premiums would have been replaced with a tax (regardless of whether it were called a tax or called a user fee or called a premium), and the insurance companies would be functioning as extensions of the state. Possibly a bona fide insurance could be offered to supplement coverage provided under the proposal, but it remains none-the-less unclear what legitimate reason there might be for using insurance companies to collecting a tax or to reïmburse those who provided state-mandated coverage. I'm inclined to interpret the intent in part to be to buy-off the insurance companies, giving them what will seem a guaranteed source of revenue, and in part to give a private-sector façade to a state monopsony.

Returning to the issue of the increase in buck-per-bang price, a consequence is going to be that most people who would insure in the absence of the proposed measures are going to have less coverage in their presence, unless they are required to have as much or more coverage than before, at the greater prices implied by not imposing higher fees on those with preëxisting conditions.