Conservative Health Care Rationing Made Simple

Let's talk about conservatives' broad rhetorical approach to the health debate: "choice." It runs through virtually every "idea" about health care they offer up.

If you cut through the rhetoric, what it usually means is this: offering you a cash sweetener of some kind that encourages you to choose to go under-insured, or at least carry less insurance than you would otherwise.

This "bends the cost curve" of the system as a whole downwards without making any of the kind of structural changes in how we deliver and pay for health care that might result in cheaper goods and services in the sector -- changes that could really threaten Big Health's bottom line.

At the same time, somewhat ironically, the proposals usually extend that dreaded government-run health care to a few more of the working poor -- a nod to the reality of nearly 50 million uninsured Americans. There's nothing wrong with that, of course, but once more, without systemic changes that could bring the per-unit costs of care down, the primary effect will be maintaining some coverage for those people -- or customers -- priced out of the market altogether as premiums keep rising.

It's certainly not hard to understand that if you can rejigger the incentives of those who have employer-based insurance in such a way that moves them into cheaper policies -- plans that cover less and require them to shell out more from their own pockets -- the cost of insuring them decreases.

With more "choice", but less actual coverage, they will choose to seek out less care. This is health care "rationing" by other means -- by using economic incentives to give people a "personal choice" to forgo care that they would otherwise seek out. That's a legitimate way to ration care, and it's certainly true that we can't have unlimited health care without breaking the bank. But those who advocate it don't make that argument honestly.

It's a perfect conservative approach -- easing the burden businesses have to bear for their employees' health care, shifting more risk onto the employees themselves and at the same time protecting the profits of the insurance, pharmaceutical, medical devices and related industries.

It's also about the worst method of rationing imaginable. Rather than doing it based on any rational (or equitable) measure of need or cost effectiveness or quality-of-life improvements or what-have-you, it's rationing by the ability to pay -- by class and education and ethnicity and all that divides us.

And it's not a terribly smart approach to health care -- it doesn't make sense in the long-haul. Care deferred now often would stave off costlier measures later. Catch many cancers early, and they're treatable with minimally invasive means that lead to high survival rates. Catch the same types of cancer later, and the costs get much higher, while the outcomes are not so great.  And in addition to the obvious quality-of-life issues, deferring health care comes with a productivity cost. 

But it all costs less in the near-term. And this idea is common to all the conservative "solutions" to health care. Health Savings Accounts offer you a cash incentive from your employer to buy a policy with a huge deductible and often lifetime or annual caps. Bush's plan was to sweeten the HSA pot with tax credits. McCain was going to tax employer health benefits and then use the revenues from those taxes to give people without coverage from their jobs -- what else? -- a tax credit that was enough to cover a cheapo plan but not a comprehensive one. The House GOP's solution in the current Congress is to give you a modest tax credit with which you can afford to buy crappy insurance coverage and then allow insurers in states with weak regulations (and the worst coverage) to sell across state lines to people who live in states with strong consumer protections (McCain was going to do that too).

The sweetener is the key -- it distracts folks from their longer-term interests. Get your boss to throw $1000 bucks in your Health Savings Account and you can spend it on anything health-related. It's yours. It'll roll over if you don't use it. Never mind the $3,000 deductible on the insurance policy it comes with. Get a refundable tax credit, and that's a politician putting money into your pocket! And as long as it doesn't cover the cost of a decent plan for the family in the first place, you might as well get a super-cheapo plan and take 'em to Disney World with the difference. Never mind that you're screwed if Junior should get really sick.

And let me just add that if the reports of what's coming out of the Senate Finance Committee are accurate, it fits neatly into the same general theme with a little more sweetener for progressives: subsidies for the low end of the middle class, expansion of Medicaid to more poor folk, but no public insurance option and no mandate on employers to cover their workers. And ... a steep tax on "Cadillac" health plans -- an incentive to get you into a less comprehensive plan if you're lucky enough to have really good coverage.


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