Is this why Republicans can't support health-care reform?

Imagine a world in which there are only 10 people. All of them want to buy health care. But some of them are sicker, or older, than others. Two of the 10 people cost $10 to cover. Two of them cost $2. And everyone else costs $5.

Like in our own world, insurers are pretty good at discriminating against the sick. They deny the two bad risks coverage. Average premiums are thus only $4.25 a person. That's not too bad.

But it is a bit cruel. After all, the people who need insurance most are locked out of the system. Recognizing the inequity, the 10 residents of our imaginary land elect Schmarack Schmobama president, in part because he's run on a platform of universal health care. He comes into office and passes a law saying insurers have to offer care to everybody at a similar price, and there will be subsidies to help those who can't afford the cost. What happens to premiums?

Well, as Michael Gerson says in his column today, they go up. With the two $10 risks included in the total, average premiums are now $4.40. The subsidies help people who can't shoulder the expense, but that's not quite the point. As Gerson writes, health-care reform has made "the average insurance plan more expensive." This is the first reason, he says, that "non-Maine Republicans object to the Senate Finance bill."

But the average insurance premium is now more expensive because insurers can't discriminate against the sick, and they can't discriminate as much against the old. Most of us -- even those of us in the middle class -- eventually become sick, and eventually become old. Our insurance plan might be more expensive now, and so we consider ourselves losers, but we won't be locked out later, which would have been losing on a whole other scale. Whether we come out ahead in a single year may well be different than whether we come out ahead over time. After all, insurance itself is a hedge against catastrophic bad luck. On some level, so too is this bill.

Moreover, this is emphatically not why non-Maine Republicans object to the bill, or at least it wasn't at one point. Republicans have bent over backwards to proclaim their openness to insurance market reforms. Sen. Mike Enzi, for instance, told AARP that, "I support fundamental changes that would prevent insurance companies from denying access to anyone needing health insurance coverage." If everyone can access coverage, then the risk pool will become more expensive because the bad risks will no longer be locked out. Enzi, in other words, supports the fundamental change that raises average premiums.

Conversely, the pieces of the bill that have driven the most partisan bickering have been the elements that would drop the cost of average premiums. You may or may not like the public plan, but the Congressional Budget Office and many other analysts have said it will lead to lower premiums for consumers. The individual mandate has sparked a fair amount of Republican opposition, but its purpose is to pull healthy customers into the pool so average premiums remain low. The level of subsidies has created some controversy, but it will offset the premiums costs for most consumers.

Republicans have adopted the insurance industry's talking point that health-care reform will "make the average insurance plan more expensive." The problem is, most of them support, or have previously supported, the elements of the plan that drive that increase. And most of them oppose both the insurance industry's ideas for mitigating the problem (a much stronger individual mandate) and the elements of the Democratic bills that would drive down premium costs.

To make this a little bit more concrete, the photo atop this post is of Jean Perry, a women who lost her job and could no longer afford health-care insurance. She was reduced to entering a lottery held by the Arlington Free Clinic. Average premiums go up because health-care reform won't let insurers lock people like Perry out of the system. Is that really the reason Republicans want to give for why they can't support this bill?

Photo credit: Mark Gail/The Washington Post