I had a thought about our current fish-bicycle style employer-based health insurance system where good chunk of the American public’s health insurance is tied to their place of employment. The two things aren’t really connected intuitively. There is no real reason one has to be tied to the other. And I think it results in some unintended consequences – for example, sick people or family members are sick people are likely to stick with a job that’s otherwise unsuitable for them simply so they can keep living and stuff.
But, it does have one salient feature that’s especially resonant in the United States – it at least gives some assurance that we are not insuring lazy people. Laziness might be the cardinal sin in the U.S. And, I do believe, we’d rather have a screwed up, expensive system of health insurance that gives us less for our dollar if it means that no one who is lazier than us gets more than us.
Which might explain why Medicaid is fairly unpopular. Even I’m guilty of it. Within the last month, I’ve grumbled to my wife about some expensive procedure received by someone with whom we’re acquainted. It was something that would possibly wipe us out financially despite being insured if we were to find ourselves in that position. But, since the recipient has Medicaid and nothing to lose, in some ways, they’re better positioned to receive medical care.
They are also in a position to be less healthy, because they are living well below the poverty line without the skills/means to get anything better. That puts them in a very unfair situation from the get-go – and it also makes it harder to find a doctor who will take you, and makes you more likely to depend on hospital services than regular doctor’s care. It’s not a great system, but you won’t catch me grumbling about it.
I’m willing to pay extra so someone else can not die.
For every person I know out there that considers it a “free ride,” I know two if not three who struggle to make ends meet and insurance some times takes a back seat or is not available. I have a friend who still works 70- 80 hours a week, does have health insurance, but is still paying off emergency gall bladder surgery from years ago because it happened right out of college and he could not get a job that offered insurance at the time. Plus this was before Obamacare which would have allowed him to stay on his parents insurance. He just got screwed by timing. I’m okay if my tax dollar helps someone like this. Does that mean a “lazy” person might be able to take advantage of a system? Sure. Its a trade off, but one I can live with.
Why would it matter? It’s not like “lazy” people are entitled to any less of a share of social wealth than anyone else.
Why is a lazy person entitled?
I’m more persuaded by the idea that allowing slackers to take advantage of the system is a trade off for ensuring that the system works in a rational, efficient way that doesn’t screw people who are basically trying to do the right thing.
Because he exists.
Although, I will admit to sometimes having a knee-jerk reaction when hearing about someone receiving services through Medicaid, especially when I am forking out money for both insurance AND all of the procedures and medications that insurance simply does not cover, I truly believe Amy has nailed it in the first sentence. If you cannot afford quality living conditions, including good, fresh food, complete medical and dental preventative care, and a solid education so that you can obtain decent employment and continue to support yourself and your family above the poverty line, you will not be healthy enough to make it without a lot of immediate-line medical care.
Not really. Some of the hardest working people I’ve seen are working in fields that usually don’t have insurance (construction, waiting tables, lawn work, etc). Positions where you sit at a desk all day and may or may not be productive almost always have insurance.
That made me think. The cardinal sins in the US. A lot start with the letter “L”. You mentioned one, but also, Liberal, Lesbian, Libertarian, Lobbyist, Learned, Leftist (which is distinct from Liberal, before the nutcase gallery chimes in), and (drum roll, if you please) Lawyer.
It’s as if some never made it past one episode of Sesame Street, in which that particular show was brought to you by the letter “L”. As a bonus, one can count the above terms using the voice of the late Jerry Nelson’s “Count” character.
Loser.
Paul C.,
Come back in twenty years and revisit your answer.
Carlito…. that was a reference to L words. You obviously didn’t get the reference.
Ok, I understand.
What about the idea that healthcare is a basic human right? In my opinion, it doesn’t matter if someone is lazy or just has bad luck, they deserve not to die prematurely when care is available that will heal them. No one should have to make the decision whether they will be able to eat this month or fill necessary prescriptions, and for too many people that is a regular conundrum. I’ve been lucky enough to have insurance through surviving cancer more than 7 years ago, but it was pure luck. I wouldn’t want anyone to have to forego any of the surgeries, chemotherapy, or radiation that I went through, just because they weren’t insured. Without those treatments, I might not be here to raise my 9 year old right now. Healthcare is necessary.
A valid point. But, assuming health care is a human right, is it fair to charge me more or less than someone else for that human right? In other words, if we accept that health care is a basic human right, can we at the same time permit the practice of charging higher or lower premiums for health insurance?
If we don’t allow insurance companies to charge different rates based upon health, we are then subsidizing unhealthy people at the expense of healthy people. In short, we are incentivizing people to be unhealthy (or removing an incentive for people to be healthy – same thing). Does that really sound like good macro policy to you?
I’m not sure if that’s a huge concern. Maybe it is. But, on some level, the point of health insurance is for the healthy to subsidize the unhealthy. It spreads the risk. Seems like being healthy should be incentive enough to live in a healthy fashion. Or, if it’s not, then money probably would not be a sufficient incentive either.
The problem comes when the need for health services is no longer “risk,” but has actualized – or at least when there is sufficient information to know that the “risk” is more likely than not to land on a particular person. For example, old people get sick or injured more. It’s just a fact of life that bodies deteriorate. Or, to get more exotic, the more we know about genetics, the more an insurer can isolate those segments of the population with greater predispositions to certain expensive ailments.
A thought experiment: what if every citizen came out of the womb with a price tag, showing exactly how much they would incur in health care services over their life time. What obligations, if any, would we have, one to another, with such perfect knowledge?
Your thought experiment suggests that medical expenditures are in large part inevitable. I just don’t believe that is accurate. Sure, a child born with a debilitating disease is going to incur large medical expenditures. But so is an adult who develops diabetes because of poor diet. We spend $140 BILLION DOLLARS A YEAR on type 2 diabetes. Much of this cost could go away if people took better care of themselves. These lifestyle factors also apply to lifestyle issues such as cancer, high blood pressure, and many of our most troublesome diseases.
I can get behind subsidizing the medical treatment of those that lose the medical lottery and are not at fault for their health condiditons, but providing an overall subsidy for these other health conditions does not seem wise.
Different rates are charged based upon actuarial risk. Adverse selection poses a greater risk of inefficient cross-subsidization than people “choosing” poor health. And cross-subsidization is what insurance risk pools are all about. That is why the bigger the pool, the better the medical risk prediction.
Arguments that we are incentivising people to be unhealthy have some merit, but generally a minor issue driving costs. Most people seek to be healthy but a few are not because of chronic or emergent conditions.
Some people do engage in unhealthy behavior, but it is often because of addictions. For addicted people, health concerns are usually not a concern and their addiction makes their life style choices for them.
I’d suggest that unhealthy behavior can also be motivated by over discounting consequences that are too far in the future. Smoking or eating chips is going to cause me big problems 20-30 years in the future? Screw it.
Absolutely, human beings are not good prognosticators about their futures and tend to project current conditions out until some vaguely imagined “old age.”
It doesn’t even have to be that far in the future. As a college student, “night Doug” used to routinely screw “morning Doug.”
The problem with the “basic human right” argument is that it completely ignores scarcity of resources. If there is a procedure that could save my life, but it will cost $10 million dollars, do I have an automatic right to that procedure? What if it costs $100 million dollars and around the clock care for the rest of my life?
If I have a basic human right to a procedure that only one person can perform, can the law require this person to perform that procedure?
I don’t think health care should be seen as a human right. That language is over used. We have the right to be free from certain things, we have our bill of rights, but to say we have a right to healthcare goes too far. Effort of third parties and tremendous cost is involved in providing this right. It can’t be a right.
This is coming from someone in favor of a universal payor system.
OK, if we don’t have the right to health care, don’t we have an obligation as humans to take care of those others of us that are sick? Or is it every person for themselves, screw anyone else?
Just like everything else, it depends on the cost-benefit analysis . If I can help you live another 20 years by giving you an aspirin, that’s reasonable. If I can stretch your last 30 days of life into 40 days by spending $1,000,000, is that reasonable?
Probably not. But that decision should be left to the good sense of the doctors and patients involved, without the influence of the marketplace.
Doug, no, I don’t think it is fair to charge varying premiums based on whether someone is employed or not.
Paul, those are tough questions. I think all medical decisions should be made between the patient and his or her doctor, or the family/medical POA if the patient isn’t capable of making a decision. The doctor should be able to determine, using his or her professional judgment, whether a particular treatment is likely to be effective or not, and whether the cost, in either time or resources, is worth the benefit that such treatment would gain the patient. We should trust doctors to counsel their patients and make the right decisions.
April,
The US medical model usually takes physicians out of the cost-effectiveness loop. That puts the payor in the position of roughly determining the care to be provided based upon “medical neccessity” and not reimbursing care based upon “expiremental, investigational and unproven care exceptions.” They are, as a practical matter, the people that say “no” based upon economic constraints.
There is a model for determing the economic value of care. QALYs, Quality-adjusted life years. (1 QALY for a year of good health, .7 for some mobility issues, .3 for being bedridden, I do not have the schedules right now) If a cost figure is attached to a QALY, life improvment per dollar spent can be roughly measured.
In a rough sense, a QALY usually costs about the annual per-capita income amount in the UK, and interesting, about the same in the US. However, over time the US QALY number has creeped up, especially for Medicare patients. I have never heard an explanation about why this rough correlation exists.
That’s the problem with the US medical model–doctors and patients aren’t able to make those decisions.
April,
Paul C. makes good points about cost-benefits analysis, which can be roughly analyzed through QALYs. Someone has to be in a position to say “no,” there are limits to what we will spend on patients. when the cost is unreasonably high or the outcome is questionable.
I would call this reasoned rationing. The way we ration care now is that if you lack healthcare benefits, you get little or nothing. That seems the most cruel and irrational type of rationing. But if you have a benefit card, turn on the treatment and spending hose.