At a November 14 panel discussion, Health Affairs released its November-December 2006 issue, titled “Will Employer Coverage Endure?” One of the panel members at the event was the always thought-provoking Mark Smith, president of the California HealthCare Foundation. Mark offered some fascinating comments taking apart the meaning of the term “insurance.” Below are excerpts from Mark’s presentation:
What is it that people mean when they say everyone should have insurance? We toss that word around as if we all agree on what that is, and then it turns out we don’t. . . . When you hear the things that people desire in their health insurance, you’re struck by the fact that they are in some ways inconsistent. . . .
When you ask people why they want health insurance, they will give you one of four answers. . . . (1) “What if I’m hit by a bus?”; (2) “I need to be covered for my preventive services”; (3) “I can’t afford to go to the doctor, or to get my medicine”; and (4) “I’ve got a chronic disease, for which I can’t afford to pay over time.” . . .
Those are the reasons why people want health insurance. Please note: Only the first of those is insurance, in the sense in which anyone would understand that term — that is to say, protection of financial assets against the rare, unpredictable, catastrophic event. That’s what homeowner’s insurance is; that’s what renter’s insurance is. . . .
So that’s our starting point when you’re talking about insurance: I pay money against a circumstance which will probably not happen. Some component of what we call health insurance is that “what if I’m hit by a bus” concept. But the difficulty, we think, in trying to find a method of coverage which is acceptable to the various constituencies who are involved in health insurance — not only those who are covered by it, but also those who are paid by it — is that this thing we call health insurance is actually four different market items put together in one financial instrument which is increasingly unaffordable. . . .
. . . In the end, insurance is mainly a mechanism, other than its financial insurance function, to buy people into an underlying system of care which they can not afford. And no matter how much we tinker around with the insurance product, if in the end the care into which it buys you is unaffordable, it’s like getting increasingly creative with your mortgage for a house you cannot afford. A lot of Americans over the next few years are going to be very sorry they did that . . . because they were trying to buy a financial instrument that would get them title to an underlying asset they could not afford. . . .
And so, in our view, while many of these things in the insurance world are important, while we need to align people’s incentives and give them “skin in the game” and all those buzzwords . . . if in the end, reforms of the delivery system don’t make the underlying asset more affordable, all of our dickering around with the niceties of the insurance product which basically gets you in there will be unsatisfactory for this pressure which is documented in this issue of Health Affairs.
It does occur to us that if you’re trying to reform the delivery system, it puts you in a somewhat different attitude towards various reform proposals. . . . To the extent that insurers and providers both see the problem of the uninsured as a revenue problem — which is to say, there are all these people out there who aren’t part of our system, and we need to find a way to buy them into our system at more or less our system’s price, at more or less our system’s configuration, and more or less maintain the incomes of everybody in our system — that is a very different question from how can we make the underlying asset more affordable. . . .
It seems to us that part of where we’re stuck in this question of how to expand insurance is to unpack at least conceptually the jobs that insurance does for people and try to figure out: “Are ways to do those jobs differently?” For instance, many of the proposals that one sees at the federal and state levels about buying drugs or getting discounts on drugs, one can argue about how effective they will be, but they don’t necessarily depend on having an individual insurance product — coverage — in order to access one of the things that insurance does for you, which is get you discounts on drugs.
Similarly, there are various proposals, one from the New America Foundation, and others, which say that the way we ought to pay for prevention is to not necessarily assume that it’s covered under your individual policy and that your primary care provider does all those things; perhaps we have a special fund that buys preventive services for people where you can actually stimulate some innovation and get them done on a mass basis much more cheaply than they are done now.
My point, therefore, is not they shouldn’t continue with the quest for expanded insurance coverage but that in so doing, we try to understand what it is we mean by insurance in the first place, and the extent to which combining these functions in one financial package creates a package which is simultaneously attractive for some people and unattractive for others. And in a voluntary market you create this mismatch, because for instance, how many people would pay money to protect their assets if they don’t have assets to protect? Most of the uninsured are low income; most low-income people don’t have huge amounts of assets to protect. They know that the hospital won’t come after them in quite the same way as the department store will, even for the same bill, and so asking them to pay money every week or every month, to protect assets that they don’t have, in case of an experience which will probably not occur to them, strikes us as not a very likely way to expand coverage among that population.