Tuesday, April 12, 2016

Health Insurance - Right, Responsibility, or Luxury?


A lot of what I write is just me processing stuff, attempting to work through information and to navigate a variety of well-informed and honest perspectives.  The following thoughts started as some scribbling on how to think about the various components of health care just to better understand it.  It evolved, for me, into something of a framework through which I could better understand the relevant issues.  Thought I'd post it here.

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Many across the political spectrum can agree that there are significant problems with healthcare in the US, both before and after Obamacare.  Ever have to go through a medical bill line by line to see if you’ve been billed correctly?  How would you even know one way or the other?  Ever tried to get info on costs before service is incurred?  Or try to get an insurance company to work directly with a healthcare provider?  It’s not pretty.  The quality of care suffers for all of this.

I’m not convinced that anybody really knows what’s in Obamacare (including Obama).  We can only guess at the unintended consequences that may lie in wait – consequences both good and bad.  This is no different than most other bills, though, and I don’t see any reason to single it out in that regard.  The bloated nature of it aside, the MOST controversial part of Obamacare is the so-called mandate.  THAT is what people argue most about.  THAT is the root of the accusations of so-called “socialism”.  (To be accurate, the enforcement of the mandate is a monetary fine.  The penalty of any failure to comply with the mandate is not criminal in nature.  Thus the Supreme Court ruling of it as a “tax”.)

I personally think that in talking about the mandate, we have to back up and talk about pre-existing conditions.

Actually, let’s back up even further.

Recall the 2008 election year debate between McCain and Obama over whether health insurance was a “right” or a “responsibility”.  And I’d like to add the term “luxury” as a 3rd option.  So “right”, “responsibility”, or “luxury”.  Obama said that it was a “right”.  McCain said that it was a “responsibility”.  (I think that the position Obama supported is more of “right to be responsible”, the debate itself being centered around access to health care.)

Now I think it fair to say that both candidates wanted everyone to have access to health care, so I think it fair to frame the disagreements within that paradigm.  Among other things, they disagreed about the role of government in promoting this access, particularly within the context of the privatized health insurance market that characterizes our current health care system (note that there ultimately was no public option within Obamacare).

I’d like to focus specifically on McCain’s answer – that health care is not a “right” but rather is a “responsibility”.

Now clearly it is not a “right” in terms of the constitution, and I don’t think anyone would argue that it is.

So the idea behind using the term “responsibility”, I presume, is to indicate (1)a level of personal accountability and (2)that government should have as minimal involvement as possible.  The philosophical idea that underlies this, I believe, is that these two things are necessary for long term success and “prosperity”, and that the government granting excessive “rights” undermines that.  Opponents tend to frame such a “right” as a “handout” – a form of political pandering to lazy and irresponsible individuals who will do nothing more than ask for more and more.  Ultimately in this view, legislation to ensure a credible and transparent marketplace is needed to ensure that “individual responsibility” has a fighting chance (though some are opposed to any sort of regulation AT ALL, I suppose - these people are delusional), but that the government can and should do the bare minimum and then get out of the way.

But I want to pause and, rather than get caught up in the inflammatory rhetoric of laziness and entitlement when it comes to “rights”, instead look at that word “responsibility”.

Now, if a person is going to assert that having health insurance is a “responsibility”, it MUST follow that a “responsible” person would have the ability to fulfill this “responsibility”.  It must be reasonably achievable.  Right?  If this is not the case, then the word “responsibility” is a misnomer and should be discarded.  Agreed?

And this happens to be where the assertion of “responsibility” begins to fall flat.  The freedom of private insurance companies to withhold access to a health insurance product due to pre-existing conditions has ensured that millions (it is undeniably in the millions though estimates vary as to how many) will be unable to get any type of health insurance AT ALL.  None.  No amount of “responsibility” on the part of these individuals is going to change that fact given the current nature of the system. 

This is THE essential point.  The system itself prohibits people from being responsible when it comes to acquiring healthcare.

This is indisputable.  And if the language of "responsibility" is to be retained, something has to change.  Period.

With the ability to deny coverage based on pre-existing conditions, health insurance can only be characterized as a “luxury”.

What is also beyond dispute is the reason that pre-existing conditions are grounds for ineligibility.  Money.  Period.  Pre-existing conditions mean more costs for insurance companies, less profits, and/or higher premiums for everyone else.  It's unnecessary to get into the ethics of insurance in order to understand the issues (though the conflicts of interest are obvious).  IF the U.S. is married to a model in which private insurance companies manage health care (which it is), it is essential that these BUSINESSES remain viable.  Their operations, efficiency, and viability is necessary to the health care system.  Period.

Now, prior to the “mandate” it’d possible to group the uninsured into two groups of people – (1) those who wanted insurance and couldn’t get it and (2) those who could get it but didn’t want it.

Supporters of the law generally focus on group #1, whereas opponents of the law either focus on #2, or are so opposed to the general idea of a “mandate” that, for “slippery slope” reasons, it outweighs anything else including the benefits to or the moral claims associated with group #1.

Which group do YOU focus on?  Which is the law focused on?  As an aside I might also ask, which is the Christian focused on?

I will say that my primary concern is with group #1.  If there is, in fact, a way to provide coverage to group #1 without a mandate, then I would support that.

Indeed, shouldn’t it be possible to eliminate the ability of insurance companies to deny coverage to those with pre-existing conditions while simultaneously not legislating an insurance mandate?  Why both?  Why not just ensure that all who want coverage can get it rather than also require that those who don’t want it have to have it?   Needless to say, there was general agreement across the political spectrum about the harmful effects and injustice of the unavailability of health care insurance due to pre-existing conditions.  Thus the bipartisan goal to provide access to coverage to group #1.

But in short, no.  You can’t do one without the other.

Why do I say that?

Without getting into the similarities (or lack thereof) between mandating a company to sell a product and mandating a consumer to buy a product, the possibility that individuals could wait until they’re sick to acquire insurance shouldn’t be minimized.

In fact, without the ability to deny coverage, the occurrence of such a situation is a virtual certainty.  And that’s a problem.

Now it could be argued that the vast majority of people with pre-existing conditions wouldn’t acquire coverage ONLY when they needed it.  Nevertheless, insurance copies couldn’t take that risk.  Nor, given the key role that they play within the health care, could society risk their bankruptcy.  This becomes (gasp!) a social issue.  This could either bankrupt insurance companies or drive up premiums to the point that more individuals forego coverage (or devastate the economy because people have less disposable income) thus perpetuating the problem.  Or perhaps individuals just don’t want their OWN premiums to go up because the patient pool just got sicker – ideology being a smokescreen.

Now THIS is where the mandate comes in.  This isn't some random “big government” power grab as it’s often framed.  “Government death panels” and all that.

If insurance companies were going to be required to provide insurance to ALL people regardless of any pre-existing conditions (as both sides of the political aisle wanted), then the insurance companies themselves WANTED the mandate.  They effectively DEMANDED the mandate.  Otherwise, what prevents people from gaming the system and signing up for insurance only when they’re sick?  How is that fair?  What about profits?  What happens to premiums?  Could it bring these insurance companies down?

So in large part, the mandate relates to the “rights” of group #1 vs. the “rights” of group #2 as identified above.  Someone is having their “rights” infringed.  Either group #1 is having their “right” to purchase health insurance infringed, group #2 is having their “right” to NOT purchase insurance infringed, or insurance companies are having their “right” to profits infringed.

How do we navigate this?

A quick side note before I wrap up.  Health care costs themselves are a separate issue.  An important one, but a separate one.  Lower costs don’t change the nature of this particular problem AT ALL.  Lower costs may lower the potential cost ceiling, but it doesn’t materially change the nature of the problem to be solved.

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I recognize that this is an extremely brief commentary about a complex and polarizing topic.  To conclude, I’ll simply return to a set of questions that precede the mandate.

Is health insurance a right, a responsibility, or a luxury?

Can a system in which millions are denied access to coverage due to pre-existing conditions rightly be characterized as one in which health care coverage is  a “responsibility”?

Can those with pre-existing conditions be offered private insurance coverage without a “mandate”?

To restate, I think that an appropriate starting point for talking about health care, including the so-called mandate, is asking that first question – right, responsibility, or luxury?  I’ll argue that without access to coverage for those with pre-existing conditions, the characterization of health insurance as a “responsibility” is flat out wrong.  Period.  And I also contend that there’s no way to offer that universal access without a mandate for the reasons I highlighted above.  This, of course, is THE big question.

I understand why people don’t want a mandate.  My intent isn’t to argue the merits or lack thereof, the legality or illegality of an insurance mandate.  I simply don’t know.  I’ll leave that to others.  You are free to argue that a mandate is a dangerous crossing of the line.

If that is the case, however, I WILL argue that you’ve no right to characterize health insurance coverage as a “responsibility”.  Stand up tall you politicians and pundits, confess that a rightly functioning federal government cannot and should not do ANYTHING about health care access, and call it what it is – a “luxury”.  Speak those worlds clearly, and then let those implications sink in.  Or if you have an alternative, bring it to public discourse.  Either solve the problem (and I'm very open to hearing alternative solutions to the pre-existing conditions issue) or disclose that it is well outside of the jurisdiction of the government ("here is the problem, and here is why government shouldn't solve it").  That’s all I ask.

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