The fundamental hindrance to achieving the goal of pooling comes down to the following policy conundrum: How can policymakers get younger, healthy adults to essentially cross-subsidize older adults with pre-existing chronic conditions? There are ultimately two separate methods policymakers could adopt to tackle this problem: a set of regulation-oriented arrangements that would compel cross subsidies, and a market-oriented arrangement that would establish voluntary cross subsidies.
This market-oriented arrangement of voluntary cross subsidies would be based on guaranteed renewability of insurance and would require a modification of the tax code to extend the tax break for health insurance beyond the employment-based market into the individual market. If that tax inequity were removed, people would obtain guaranteed-renewable insurance while young and healthy, and the pre-existing condition problem would eventually barely exist. This market-oriented arrangement could be superior to the set of regulatory arrangements that have been either tried or suggested to help people with pre-existing conditions.