Obamacare – ok the Affordable Care Act, is that better? – is collapsing, state by state. Younger healthier potential enrollees are not enrolling. The incentives – how much premiums you pay and what kind of deductible you face and what kind of coverage you get – are making them choose to stay away and defer their choices. Perhaps you can construct a longer term economic model based on the expected costs of a health crisis with the likely percentages and the expected cost. And decide that they should enroll, just in case. But by many metrics, younger and healthier people are making a reasonably rational choice.

As are sicker, older people who have rationally decided that Obamacare is a good deal for them. Those two subsets of health care consumers means that Obamacare is currently unsustainable without several things:

  • Higher premiums
  • Higher deductibles
  • More bailouts/subsidies courtesy of you the taxpayer

And even with all three of these responses factored in, many insurance companies are finding Obamacare unprofitable to say the least. That means that the next president will have to clean up the mess and either reform Obamacare or create a new health care plan. Hillary Clinton likely has plans all set up to effectively dump Obamacare through a vigorous reform program that preserves it only in name and broad outlines, all the while praising her former boss’s flawed plan.

Of course Hillary’s reforms will certainly involve lots more regulations. But different regulations. By new agencies or renamed agencies, or re-configured government departments working for you, the health care consumer. Regardless of what state or county you live in. That will work out wonderfully won’t it?

Thank goodness we have an alternative with Paul Ryan’s Patient Choice Act. Right??

Uhm. Have you actually looked into the PCA? Have you scanned the long-form summary, for example? Found at Ryan’s house.gov site? Here’s a few gems:

If you are on SNAP (what used to be called Food Stamps) then forget about buying junk food with your SNAP card. That means you might have to fork over hard cash for that bag of Nachos that gets you through the weekend. You will be told what to buy with your SNAP card. Or the clerk will be told what you CAN’T buy. How? Who knows? Will there be brawls at convenience stores between clerks and SNAP card people?

Seniors who adopt “healthier behaviors” will be rewarded with lower Medicare premiums. Makes sense, in terms of improving health outcomes. But it also adds another layer of paperwork for retired people and means the government is even more involved in your daily life, telling you in minute detail how to live. Of course you could live free … without Medicare. Not an option for many.

The CDC would create a web-base prevention tool based on your private data: your health records, how fat you are (sorry! body mass index), your sordid family details (sorry! your family history) which will all go into an Orwellian little app-thingy that will tell you exactly how to eat, drink, sleep, have sex, exercise, and any other part of your personal life the CDC feels is relevant.

There are some less invasive ideas in the PCA to be fair. Like reworking the tax code to incentivize health outcomes instead of health insurance outcomes. Like the HDHP (High Deductible Health Plan) combined with HSA, the Health Savings Account. This bundled option offers affordable catastrophe insurance with a tax-free way to save towards your health care costs.

But the point is that there is no perfect optimal solution. There are only tough trade-offs. The best you can do with health care is to offer smarter trade offs. And Ryan’s PCA does do that. But it also promises care for everyone AND affordable premiums. Sorry, but somebody somewhere is going to have to pay for that. The bills always come due. Just like with Obamacare.