Gene Steuerle writes,

Here is the bottom line on how employers and employees together can maximize what they get from government. Many employers who don’t provide insurance today will probably just choose to pay the tax ($400-per-employee under one scenario in the Senate Finance bill) for not carrying health insurance. Some small employers might be enticed back into the market by yet another subsidy they would get. Large employers will react by outsourcing more low- to middle-wage jobs and switch more workers from full-time to part-time employment. Such incentives toward a two-tiered labor market, partly segregated by income, aren’t new, but they will expand under this type of reform.

Health care reform along the lines being contemplated currently faces too many constraints.

1. The average cost per family of the sort of health insurance that Congress wants us to have is $15,000 a year.

2. Even for families above the median income level, $15,000 seems like a lot. Hence, Congress wants to subsidize families up to relatively high income levels.

3. Congress cannot possibly hand out these subsidies to everyone. Therefore, it wants to deny subsidies to people with employer-provided health insurance.

The result is a Rube Goldberg scheme of penalties and inducements, creating a system that is ripe for gaming. For example, many workers may find it to their advantage to change their relationship with their firms from “employee” to “independent contractor” in order to enjoy the subsidy. Others, particularly high-income workers, may be better off keeping their employee status.

As the system gets gamed, the costs will be much, much higher than CBO is estimating.

The obvious solutions, which are politically infeasible, include:

1. Change the concept of insurance to something closer to real insurance. See Crisis of Abundance if you do not know what I am talking about. Real insurance would pay only in the event of an illness that is going to require large cumulative expenses over a period of years. As with fire insurance, claims would be rare but large, and premiums would be affordable.

2. Change the way that government subsidizes health insurance. Remove the tax subsidy for employer-provided health insurance, and instead replace it with health care vouchers. The vouchers could be determined by a formula that reflects income and medical history. Vouchers would eliminate the gaming that will take place as people choose their employment status to optimize the benefits they receive from different regulatory regimes.