Choice: Presidents and Health Insurance


Leonard Zwelling

         Americans like choice. In cars, breakfast cereal, health plans and presidents. And why the heck not?

         When I was a kid, there were three choices of cars—GM, Ford and other. Most people did not choose other except the few who drove Nash Ramblers (Google it). Today there are scads of different makes and models of automobiles—most aren’t really cars, but computers with wheels and fuel tanks. Some don’t even have the latter, just batteries. And they’re included!

         I no longer eat breakfast cereal. When I did I used to collect the boxes. I had scores in my freshman dorm room at Duke. I have no idea why I collected them and some I collected are now collectors’ items as the shelf life of the box clearly outlived that of its contents. Of course, I threw them out and I can’t even blame my mother for those as I could for the long ago discarded baseball cards and comic books, now worth thousands.

One of the dilemmas of the recent news reports of rises in the premiums for health plans under ObamaCare (see NY Times editorial of October 26: is that many of those who signed up for the ACA exchange plans are sicker than was anticipated by the insurers. The young and well who had no insurance have sat by the sidelines and have chosen to pay penalties up to $700 to NOT have insurance. Americans without employer-based insurance had a choice and they took the one that drove up prices because the ACA preserved supply and demand in the insurance industry. Well, what did you expect? The well and young are invulnerable and so choose to spend as little as possible. This has necessitated (rationalized?) the premium rises, or in some cases the leaving of entire markets, by insurers. That’s America. That’s choice.

If you want to prevent the health insurance price rise you will have to incentivize the well to buy insurance (increase subsidies or increase penalties—carrot vs. stick) or remove health insurance from the realm of the marketplace by creating a single payer system for all as we have for those over 65. 

You simply cannot blame Americans for making the choices from among those they are given. Note that the premium rises, estimated at 25% in ObamaCare, are not matched by similar rises in the premium rates of employer-based policies which are uniformly reported to be in the single digit range. Why? Greater distribution of risk because more well people are in the pool.

On the subject of risk, the choice most of America is immediately focused upon is the one for President of the United States. There are four choices and two don’t matter—Gary Johnson and Jill Stein. These two are fringe candidates who will not shift the outcome as some fringier candidates have done in the past (Ralph Nader and Ross Perot).

Next there is the flawed Mrs. Clinton. She represents the status quo. She’s a pretty mainstream Democrat with deep roots in the party and in Washington. She’s not a wild card even if she looks like one of my 1957 baseball cards did the last time I saw it in 1967 before Mom tossed them when I was at Duke studying. Worn. Not quite worn out yet which is remarkable considering what she has been through. The frequent flyer miles alone when she was Secretary of State would have done in most of us.

Mrs. Clinton is opposed by Mr. Trump who Tom Friedman called a “legal alien” today ( That seems about right as he sounds like he’s from Mars though born in Queens.

Frank Bruni outlines the choice ( Make it, America. And then live with it. I wish Mr. Trump would stop whining about the “rigged” election. The election is not rigged. He’s just run a lousy campaign and will probably lose. Tough!

Finally, there are situations in which Americans have no choice. In this I call MD Anderson exhibit one. Very few faculty or staff members were involved with the selection of the president of MD Anderson. He need not run for re-election and appears accountable to no one capable of assessing his performance. This is unfortunate, but alas, reality. While Mr. Trump operates in his own reality which he can do for a number of reasons—billions of them, most of us cannot and so are stuck with the choices we have, or in some cases no choice at all.

For most Americans, their choice for health insurance is made for them by their employers. That’s not a bad thing. For those who must use the exchanges or other market vehicles to acquire health insurance, things are a little bleak for now. Maybe Congress can revisit this if Mrs. Clinton sweeps Dems into both houses, an unlikely event.

As Mr. Bruni points out, the choice for POTUS could not be starker. While Mrs. Clinton is a flawed candidate, she is civil most of the time and deeply experienced for the good and the bad. Mr. Trump is simply unsuited for such a job as the profile in today’s NY Times demonstrates (

As for the faculty and staff of MD Anderson, you are stuck. You are forced to either vote with your feet by leaving, as many great clinicians and scientists have done, or suffer in silence.

Maybe next time, better luck. Maybe not!

Leonard Zwelling