Surprise, surprise the intellectual geniuses at the Wall Street Journal editorial pages have decided that they like the HSA concept and that HSAs could help address problems in the U.S. health care system. Well they are entitled to their theoretical opinion, and they are right in that the unfair tax treament of health care insurance purchasing should be rectified. There are unfortunately two major problems with their views.

First, the way that tax break should be rectified is to remove it from everyone not extend it to those who don’t get it now. There is no reason that health care premiums should be bought with pre-tax dollars (and for that matter there’s no reason that housing loans should be too). It’s a fundamental violation of that free-market that the WSJ claims to support–not that many of its conservative fellow-travelers are very interested in it these days. It also means that we spend marginal dollars on health care when we should be spending on something else. But I guess they missed that day in micro-economics class when MR=MC was brought up. In reality it means that Americans take their marginal compensation in health care benefits rather than in taxable income–and this amounts to a direct subsidy to higher level taxpayers (the rich) from lower level ones (the poor)–but it amounts to the same effect.

Secondly, while the theory of HSAs may look all very nice, in practice they are breaking down in the only place that’s ever really used them. That place is the directed free-market dictatorship (with a human face) of Singapore. What’s happening to HSAs in Singapore? Well funnily enough according to the Health Minister Khaw Boon Wan they’ve encouraged risk-shifting and cream-skimming:

There are now 15 other providers of a similar medical insurance scheme, causing the risk pool for insurance to be fragmented. Instead of competing to provide better services at lower premiums, Mr Khaw said private providers are cherry-picking by providing coverage to certain groups only to maximize profits.

Does this sound in the least familiar? Could you possibly imagine that kind of behavior amongst American insurers, which might, just might, not be quite as well-behaved or as subservient to the government as their Singaporean brethren? I suspect so, and that’s why Kaiser Permanente is getting aggressively (for it) involved in the campaign against HSAs, partly by advertising loudly this press release about a study its researchers did using Humana’s data. The study, which was published a few months back in the journal Health Services Research and has been featured before in THCB, concludes that a CDHP offered to Humana employees attracted enrollees 25% to 50% healthier than those in traditional plans. Kaiser of course can’t just create another insurance product without taking money out if its own risk-pool. So CDHP/HSAs, and the prospect of the adverse selection death spiral they bring with them, terrify Kaiser–as they should.