The other day I saw one of my regulars for a follow up visit. Cindy is a an attractive woman in her twenties, a young mother with several young children, who works long hours in retail to make ends meet. During the course of the examination, I leafed through her chart and noticed that she had no health insurance. Health insurance is a personal concern of mine, and when I meet a patient without it I often ply them with gentle financial counseling.
“Does your employer offer health insurance?” I asked.
“Yes. I looked into it, but it was too expensive.”
“How much was it?”
“They were going to take $300 a month out of my paycheck. I can’t afford that.”
I did not intend to persuade her to change her mind, but I wanted to plant the seed of an idea in her head. “I can appreciate that,” I said, “With the kids, money must be tight. Just keep in mind that insurance does nothing but go up. This is as cheap as it is going to get. And if you get sick, they could exclude your new condition, or deny you altogether.”
Then I talked to her about the CHIPS program, an arm of Medicaid especially for children. “The financial qualifications for it are pretty lax,” I explained to her. “Often working mothers can get it for their kids, so make sure you look into it.” I also told her that Medicaid loosens its qualifications for single mothers with more than one child, and that she needed to look into that for herself.
What I didn’t tell her was this: $300 is not all that bad a monthly health insurance premium. Some employers offer better, especially in situations where a union is in play, but for an hourly wage earner, $300 for a quality plan is at least competitive. If she was waiting for a better deal, she would probably be waiting forever.
This bothers me. It is one thing if a person has a job that does not offer insurance, or if the person has a pre-existing condition that precludes getting good insurance, or if the person is too sick to work at all. But when the insurance is there, and at a fair market price, and the person does not take it, what do we do about that?
I am in no position to say if Cindy could or could not afford $300 a month. Though it is worth noting that this $300 would be deducted from her paycheck pre-tax, meaning the cost to her would probably be less, maybe $250. Still, the offer is probably the cheapest she will ever get, unless she gets Medicaid. Complaining that a health insurance premium is $300 is like complaining that gasoline is $2.50 a gallon. You can complain all you want, but that is the price, and it is not going down.
If we have a class of people who will not buy health insurance even when the price is reasonable (and I think, considering the protection you get from health insurance, $300 is not all that outlandish), then it is clear that private insurance will never insure everyone. We need to throw that myth out the window.
Is it acceptable to allow people to choose to be without health insurance? I say no. There are too many common, potentially devastating medical illnesses lurking out there. If Cindy were to find a lump her breast, for example, she would probably lose her job and her health, go bankrupt, and eventually, after prolonged suffering, end up on Medicaid. She would also, with her pre-existing condition, be uninsurable for the rest of her life. It should not be the public’s job to pick up the pieces when an individual takes a risk and loses out. While one Cindy is a small risk for a society to take, a million of them is a serious risk, and one the public has a right to weigh in on.
Unfortunately, most people who choose to skip health insurance are people like Cindy. People who are young and have very little money; people who are in good health and do not feel they need regular medical care. This is the worst possible reason not to buy health insurance. The time to get it is when you are young and healthy. You have no pre-existing conditions, and you are free to choose a high-deductible plan that costs less money. If something comes up, you can usually switch plans with the same insurer. But if you don’t get your foot in the door and something happens, you are excluded forever.
Waiting until you get sick to get health insurance makes about as much sense as waiting until you smell smoke to get fire insurance.
What do we do? We can require people to carry health insurance by law. I am not a fan of forcing people to do things, but clearly society bears a great risk when people choose to go without insurance. If Cindy gets hurt and can’t work, we will pick up the bill, one way or another. It may be a fair argument to say that the price of living in society is that you must carry health insurance. We say the same thing about auto insurance now.
Another solution is to liberalize Medicaid so Cindy can get it, but then charge her at least nominally for the service. That puts Cindy on the taxpayer’s dime now instead of later, but at least it would give her access to health care. If she does get sick or injured, with prompt care she might avoid disability and get back into the workforce. An often-missed argument in favor of universal healthcare is that it means a healthier and more productive work force. People who get proper care do not languish on the sidelines the way people who get inadequate care so often do.
One thing is clear – tax breaks won’t work. Cindy is already in a low tax bracket, and her insurance would be paid with pre-tax money. This is not the issue. She could get a tax credit, but then the government would be paying her to buy insurance. This would spin off a new legal battle about how much of the bill the government should pay, and why not pay it for everyone? And it also assumes Cindy knows enough about tax law to claim this credit. This is not a given. It is estimated that 15-25% of people eligible for the Earned Income Tax Credit do not claim it because they do not know how. Since health insurance eligibility could be harder to prove than simple income, it might be more difficult to claim.
As a general rule, I have always opposed using the tax system to create health care policy. Taxes are supposed to be a way for the government to raise revenue, not an instrument for public health. God help us if the tax code is our hope for universal health care. There are simply too many opportunities for lobbyists and politicians to play with tax law and distort medicine for financial gain. My belief is that if the government is going to pay for health care for people like Cindy, it should treat health insurance like it does the police force. Just pay for it. Imagine what the police force would look like if it were a system of private contractors that were encouraged to do a better job through a system of tax incentives.
Whatever the solution, for it to work Cindy has to pitch in. Either she pays for private insurance through her employer, we give her Medicaid and charge her for it, or the entire U.S. goes single-payer and everyone pays in taxes. The great problem with health insurance in the U.S. is that it is a complex shell game in which everyone passes responsibility on to the next person. Patients rely on employers to subsidize premiums. Employers lean on insurers to lower prices and cut benefits. Insurers raise copays and expenses for patients and try to dump high-risk patients on Medicaid and Medicare. The federal government supports Medicaid and Medicare (as well as tax subsidies for private insurance) by irresponsible borrowing instead of raising taxes.
Healthcare is not like a war. Eventually (0ne expects) a war will end, and war debts can be paid off. Healthcare is an ongoing expense, a cost that only goes up. We have to pay for it as we go. Borrowing to cover an ongoing, ever increasing expense is insanity. Like it or not, patients like Cindy have to be brought into the system and made to pay at least something. This puts them in the position of caring about the system, about wanting to get their money's worth, and about wanting to control costs. Too many people like Cindy sit outside the system, with no incentive to get in. And this costs us all in the end.