Health insurance and "individual responsibility"

It’s worth remembering that despite all the problems with our health care system, it could be worse.

Progressives have long criticized our system of private, employment-based health insurance, and advocated replacing it with universal public insurance. But many on the right dislike employment-based health benefits either. Their solution? Eliminate health insurance as we know it.

The conservative critique is logical enough. Health costs are high, they argue, because people consume too much health care, and the wrong kinds. They get expensive procedures they don’t need, visit the doctor too often, and take too many drugs. And why? Because of insurance. When people aren’t paying for health care out of their own pockets, they treat it as if were free, and don’t worry about whether they really need it. Or as Arkansas Gov. Mike Huckabee put it, One of the reasons we have a healthcare crisis is because, as a consumer, I don't have that much skin in the game.”

The right-wing solution is to replace traditional health insurance, with its focus on employer responsibility, with a system based on individual responsibility instead. While details vary, there are three constant elements: high-deductible catastrophic policies, health savings accounts, and individual mandates.

High-deductible policies require the individual to pay the first several thousand dollars of a medical bill before the insurance kicks in. This is supposed to turn health insurance into genuine insurance – protection against rare, unforeseeable events. Consumers are expected to budget for regular check-ups, drugs, and treatment for minor injuries the same way they would for any other routine, predictable expense. (Never mind that this discourages people from getting cost-effective preventative care.)

Health savings accounts are the tool for paying for those routine expenses, before the high-deductible policy kicks in. They allow people to set aside money tax-free that can be spent only on medical bills. (Never mind that like any tax-favored savings accounts, HSAs would overwhelmingly benefit the wealthy, who do the lion’s share of personal saving.)

Finally, the individual mandate ensures that no one “free rides” by scamming free emergency-room care. (Never mind that, desptie facile analogies with car insurance, most of the uninsured simply can't afford even high-deductible coverage.)

It’s not hard to knock holes in these ideas – do you really want the “freedom” to choose your cancer treatment the same way you choose a window treatment? Is the problem with health care in the United States really that people get too much of it?

But they not going away. And even if they have been stymied – for the most part – at the state and federal level, that has not stopped individual businesses from putting them into practice, as I’ll discuss in my next post.

So my plea to health care reformers: while you continue to point the better alternatives to employment-based health coverage, don’t forget there are worse alternatives too. And if we don’t do something to shore up employment-based health insurance now, we may soon discover just how much worse they can be.