Last month, Sen. Jon Kyl (R-Ariz.) introduced a health-reform-bill amendment that would have prevented the federal government from requiring insurers to offer any particular medical benefits. "I don’t need maternity care," he said. "And so requiring that to be in my insurance policy is something that I don’t need and will make the policy more expensive."
Michigan Democrat Debbie Stabenow zinged back: "I think your Mom probably did."
Politicians are probably best advised to stick to a rigorous pro-motherhood line. But Kyl's point was really just an extension of a view about health insurance that a lot of Americans hold. Ask yourself how many of these statements you agree with:
- Sue smokes a pack a day. It's only fair that her health care costs (insurance premiums and out-of-pocket expenses) should be higher than a non-smoker's.
- Juan works out and weighs 160 lbs. He should be allowed to pay lower premiums than Dave, who is clinically obese at 230 lbs.
- Anna's daughter has Type 1 diabetes, a condition which isn't caused by any known behavioral causes. Anna's family should have to bear steep premiums and out-of-pocket costs.
- Susan is 60. She should pay many times more for insurance than Janelle, who's 30.
- Nick has cancer and just lost his job, so he needs to buy a new policy. Insurers should be able to turn him down for coverage, or offer coverage that doesn't include treatment for his pre-existing condition.
- Ray is 26, single and very fit, so he doesn't have to see the doctor very often. Since he can carry routine expenses himself, he should be able to buy insurance with a very high deductible that covers only catastrophic costs. Or even no insurance at all.
The more of these you say "yes" to, the more you think of health insurance as simply another consumer product, like houses, cars, clothes, or food; people have different needs, wants and risks, so it makes sense they'll pay different prices for different kinds of coverage. The nongroup insurance market works like this, although not completely. As The New Yorker's Malcolm Gladwell discussed in a 2005 article, this "actuarial" model of insurance is pretty much how car insurance is priced; go ask a 19-year-old male what it costs to insure a Mustang. People with a free-market vision of health-care argue that this model would work just fine for the vast majority of people if the government wasn't already so involved in shaping the market for insurance.
But the more strongly you disagree with any of those statements, the more you tend to see health insurance as a tool for sharing risk. That means healthy people pay for benefits they aren't using, to lessen the financial burden on people with the bad luck to get sick. The health systems in Europe and Canada are all about risk sharing, Gladwell notes, but so is Medicare. And so are the big corporate health plans people say they like so much.
This split between consumerism and risk-sharing goes way back, and it explains many of the big policy difference between Republicans and Democrats, says Jonathan Oberlander, a health-care policy expert at UNC-Chapel Hill. But the lines aren't always so bright.
The Democratic health reform bills in Congress right now mostly push toward greater risk sharing. They force insurers to offer individual coverage without regard to health status, and they require individuals to buy insurance with at least a set amount of benefits. (Otherwise, healthier people might opt out or go for bare-bones plans, driving up premiums for the sicker, more expensive people left in the more-comprehensive plans.) But the bills don't go all the way. The insurance coverage they mandate leaves families with deductibles as high as $3,000, which hurts sick people more than healthy ones. One version lets insurers charge older people four times as much as younger ones, while others keep the ratio at 2-to-1. And another provision gives employers more leeway to charge higher premiums to people who smoke or weigh too much.
Even if a bill passes this year, we'll keep arguing about exactly where to draw the line between consumerism and risk-sharing. That's partly because risk-sharing places a burden on the lower-earning young, unless you are willing to subsidize their costs. (And then the question is: how much?) But it's also because most of us have mixed feeling about this -- feelings that I suspect have a lot do with how much we think we control our own health. And that's pretty subjective: My body-mass index is still an overweight 27, even though I ran a marathon this year, so I have a sharp sense of the limits that genes impose on weight loss. Then again, I can't understand why anyone would smoke, so the idea of smokers paying higher premiums doesn't upset me on a gut level.
But the American Cancer Society's Cancer Action Network, interestingly, does get upset about that. The organization supports financial incentives to quit, such as higher taxes on cigarettes. But the people there don't think more expensive insurance is an effective way to change behavior. And when smokers (or others) get cancer, they also want them to get adequate care. So they're against anything that might make it harder for some to get insurance.
Which really gets at the fundamental question behind the consumerism/risk-sharing divide: Is affordable health insurance one of those things that's so important that everybody ought to have access to it, no matter what? In short, should we make it a right?