Note: TQE has recently been advertised in The Friend of London, and now we have many British subscribers. So, I will no longer write as if this is solely an American publication. To be short, Cg/Plt means "Congress or Parliament." When examples are general (not involving sums actually paid), the British may read "£" instead of "$."
We have just witnessed the U.S. Congress all grown-up, presumably intelligent men and women bickering childishly over how much and what kind of health care older citizens should all have, as if "one size fits all." They have ruled that exceptions to their principles should be set by themselves, in advance and in the abstract, instead of by the patient and doctor at the time they occur.
In a rich society (such as ours), everyone should have adequate health care. In a free society (as ours presumably is) each individual should decide what kind of health care to have, how much, and how much to pay for it. Except for the poorest among us, health care ought to be no business of Cg/Plt, or of employers, but of the individuals who receive it. We do not insure our homes or our cars through our employers or through the government, so why health care? Employers should pay workers' wages, from which they should buy health insurance on the private market.
How much? Well, the minimum to be supplied by government is the one thing Cg/Plt should decide. But health care from the public purse should be paid only for those who cannot otherwise afford it.
In any insurance, we insure against catastrophes we could not otherwise afford. If our house burns down, we and thousands of other policyholders pay for building another (assuming we had the foresight to insure); if we have an automobile accident, we and hundreds of other policyholders pay to replace our car (after a reasonable deductible). Why is it not the same with health care?
The "free rider" is one reason why it is not. In a compassionate society, no one should die on the street for want of health insurance. Knowing that hospitals are required to take emergency patients, the free riders might skip private health insurance; they will be taken care of anyway. To discipline free riders, health insurance should be mandatory.
In the New York Times (11/18/03) Emanuel & Fuchs suggest vouchers for health insurance for the poor. I suggest the same in my book, The Moral Economy (1998), page 96: The government gives health-care vouchers to people with incomes below a certain amount. Through your representatives in Cg/Plt, you decide the income level and the amount of vouchers. The law should require everyone to spend so much on health insurance (including drugs), within the level of vouchers issued. If they don't get sick, or don't need drugs, they "lose" (the vouchers spent), just as you "lose" (the money for premiums) if your house doesn't burn down.
Robin and I bought life insurance in which we "win" (or our children do) if we both die tomorrow; we "lose" if we outlive a certain age. One daughter was kind enough to say she hoped it was the worst investment we had ever made. The same with health insurance. While you "lose" if you don't become ill or don't need drugs, in a social sense you are not losing; you are paying (with your vouchers) the bills of those who do become ill or who do need pharmaceuticals.
Here's an example (not a suggestion): suppose we decide to give health vouchers of $200 a month to households with incomes under $20,000, other amounts for those with incomes below other levels. In other words, through our Cg/Plt, the people would decide how much, and any reasonable amount is all right.
Emanuel & Fuchs put it this way: "Each family or individual would be given a voucher to purchase a policy that covered basic services, including doctor visits, hospitalization, pharmacy benefits, some mental health and dental care, and catastrophic coverage." Instead of the 43 million who lack health insurance in the United States today, no one would go without.
If the waiting in Britain gets too long (as it often does for non-emergency surgery), the British could cash in their certificates in France (or elsewhere), and the doctor would be reimbursed by the British government. If Cg/Plt awards more vouchers than necessary for the minimum policy, the recipient may spend them for additional health care or save them for another year.
Sure, people can cheat, as they will in any system (especially in Medicare). That's the insurance company's problem, just as it is when your house burns down. But policyholders would be encouraged not to cheat because vouchers not spent could be saved. Besides, we do have laws against arson and against fraud. No new laws are needed.
Furthermore, health care would become more economical, because people who spend their own money (vouchers) generally do so more efficiently than the government. They would think twice before going to the emergency room. In the US, patients have been known to call an ambulance instead of a taxi, because ambulances are covered by Medicare and taxis are not.
Likewise, in the US, some procedures are decided by the amount reimbursed, not by medical necessity. An operation known as laminectomy is often superior to spinal fusion for relieving back pain, but doctors may prescribe spinal fusions instead, because Medicare pays more for these (New York Times,12/31/03, page A1).
Some knotty questions must be resolved. Two days ago (12/30/03) the US government banned the use of ephedra, an herbal supplement linked with heart attack, stroke, and sudden death and probably causing the death of a well-known baseball player. But millions have been taking it, to build their bodies and control weight. The manufacturers say there is no risk if it is taken properly. Clearly the risks should be announced widely, but my question is: Who then should decide who takes the risk? the government, or the person concerned? There is no answer. You will have yours, and you can guess mine.
Similar questions could be raised about mad cow disease, for which government action has recently devastated British cattle raisers unnecessarily, many say and now threatens the United States. These questions also have no answers: yours is as good as mine. But we should think about them.
In the United States, under the voucher plan Congress would decide on total amounts for the poor, but it need not spend hours and months wrangling over this decision or that, which ought to be the responsibility of the individual. Nor should it pay anything for health insurance for me. I can afford my own, just as I afford my automobile insurance. I deeply regret the hours and hours that Congresspeople wrangle over decisions that I would prefer each person make himself or herself. Instead of politicizing until three in the morning, they might spend some quality time with their families.
Sincerely your friend,
Thanks for the thoughtful writing on health insurance. As usual, you make many good points. As a (relatively) young person disabled by a terminal disease, this is a topic of great interest and concern to me. Current Medicare coverage inadequate, making it pretty much mandatory to buy a Medigap policy. In Virginia, where I live, the only real option is the ironically named CareFirst. My monthly premium has jumped sharply every year and is now over $400, placing it out of reach of many people. I don't know what the answer is, but your proposal strikes me as a good place to start.
Michael Jack, Friends Meeting of Washington (DC)
Bravo for speaking against our burdensome medical system and the recent legislation that will make things worse. Many are aware that our US economy commits a much larger share of our resources to "health care" than other peer economies, including the UK. However, when serious reform of the system comes up, the argument always seems to drift to how folks without enough money can be "taken care of". These costs represent a very small component of the system.
The travesty of our system is that 80% or more of the resources spent on primary and preventive care are committed to the care of the least at-risk members of society. Even worse, well over 50% of an individual's medical expenses are incurred within the last two years of their life in the US, often with dire quality-of-life consequences. This creates enormous incentives for the entrenched interests, and as classic economics would predict, a very inefficient allocation of resources.
Christopher Viavant, Salt Lake City (UT) Meeting.
I am on Medicare. The provider loses money on every service provided me. I cannot buy superior care. It is illegal for me to pay the providers so they realize their customary charges. I can donate to the charity fund of the hospitals that treat me so that I become a desirable customer and get better care. I teach at Bellarmine University in Louisville. Many of my students think I am doing an unethical thing. Do you?
Lee B. Thomas, Jr., Friends Meeting of Louisville (KY).
Your criticism of employer-based health insurance is right on. Did you know that the AFL-CIO opposed Truman's proposal for national health service because it thought that removing health coverage from union benefit contracts would reduce the incentive for workers to join unions. Talk about unintended consequences. ... More critically, your discussion on how health care should be financed can't be divorced from how it should be provided. I know that form often follows money, but the ingrained inequities won't disappear with different financing. But the discussion is one worth having.
Paul Landskroener, Twin Cities (MN) Friends Meeting.
Health care costs are driven in part, by all of the new technologies that have come on the market in the past 20 years. They are expensive technologies that save lives. But the expense has long been shielded from the consumer who never has had to face the questions - do I really need this procedure? Would I forego that nice home or that fine car or that faster computer in order to pay for this procedure? Because none of us have had to face these questions, we have merrily gone about our purchasing lives oblivious to what it really costs to do a heart by-pass operation or to have an MRI scan done. It has been a huge national delusion.
Twenty years ago, an older fellow worker told me that health care costs started going up once people stopped writing their checks to the hospital and handed over that responsibility to their employers or the government. I didn't believe him then but I do believe him now.
I think it is a great idea to put the responsibility for one's health back into the consumer's hands. Vouchers seem to be a viable way of making this happen. I too would rather see our congress people debating the dollar limits on vouchers rather than wrangling over which drugs or which procedures are going to be handed out by a national system.
Rich Ailes, Middletown Meeting , Lima, PA.
One of the issues that would need to be overcome in your system is that in the current system, an individual purchasing health insurance does not benefit from the acturarial purchasing power of a large group (i.e., an employer's group plan) which essentially averages out the cost for those who never get sick with those who require significant care. It should presumably not be hard to define a system where an individual with no prior adverse history can purchase insurance at a standard rate, but what about somone who enters into the system with a chronic, and costly, preexisting condition? Perhaps this is a matter of "transition"?
Jim Clovis, Newtown (PA) Meeting.
Why not just include the "poor" in the same fine health plans provided to legislators? Most doctors I talk with hate the costly and time consuming paperwork required by a multiplicity of insurers. Many health care underwriters see little profit in funding the day-to-day health needs of low and moderate income families, and prefer to cover the categories of people who are least likely to get injured or sick. Insurance gaps put a high premium on employment in agencies where fringe benefits continue in retirement, and are also the basis for litigation of personal injuries and medical malpractice.
Steve Birdlebough, Sacramento (CA) Meeting.
Health care must be considered a tax when comparing America to a country like Canada or France, as we pay insurance companies privately for the same thing the government does for healthcare in other governments namely the ability to collect money in order to provide catastrophic event coverage.
Chad Polazzo, Atlanta, GA
"Winning" or "losing" is entirely the wrong way to look at it! Insurance is not gambling! You no more win or lose by buying insurance than you win or lose by renting an apartment. When you rent an apartment, you pay somebody else (who can afford it) for taking on the risk that the apartment will remain empty. When you buy insurance, you pay somebody else (who can afford it) for taking on the risk that you will need to be compensated.
Russ Nelson, St. Lawrence Valley (NY) Friends Meeting
My sympathies about your osteporosis but you didn't pay for the test twice, if the test isn't given twice. If the HMO routinely denies such re-tests, they aren't built into the cost structure.
Jim Booth, Red Cedar Meeting, Lansing (MI).
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