Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Shocking News: N-HSA Doesn't Subsidize Poor People.

N-HSAs can expect criticism that they don't subsidize the poor. That is, the Affordable Care Act intended to include everybody, but circumstances made it impossible to cover thirty million people, like prisoners in custody, illegal immigrants, and mentally defective. In retrospect, it might be a better idea to design special programs for such outliers, since their needs are so unrelated. But even if they must be placed in a one-size-fits-all program, it is complex to see where they would fit into a pre-funded program if they have no funds. Furthermore, children and elderly are themselves in need of subsidies from the working generation, so it is hard to see where to fit them in and still retain the architecture of the plan, without creating loopholes. These people were thought of as frequently underserved, not as the ones responsible for subsidizing others.

So it would be my proposal that the concept of subsidy is re-examined, such that it subsidizes recipients instead of intermediaries, that is, people instead of programs. That would permit such a funding agency to direct its payments to whatever the client designates, which would be an improvement, right there. It would encourage new programs to start up, and it would introduce competition to an area where monopoly is the more characteristic behavior. I'm afraid, however, that civil governments have not completely recovered from their contention with churches and civic organizations for control of the private charity. Government has pretty well pre-empted this function, and political responses will still follow old patterns. It's worth discussing, but it is the government itself which created this situation, and the government is unlikely to surrender its victory.

Originally published: Wednesday, October 14, 2015; most-recently modified: Wednesday, June 05, 2019