Health Care as an Individual Responsibility

Over the past two months, the debate over health care reform has been engaged. It's fairly certain that legislation of some kind will be forthcoming. Statistics, estimates and theories abound as to how to improve a system that is unquestionably the best in the world, and that has advanced medical knowledge, practice and technology at a geometric pace during the last century. Unfortunately, in the rush to get "something" passed, and to make it "free" for all of us, what is missing is an examination of our individual responsibilities.

In the past, there was no question as to who should pay for your health care - it was a simple agreement between you and the doctor - a service was provided and payment was expected. If there was financial hardship, doctors were often accommodating, accepting goods or services in barter, or payment over time. However, this simple arrangement was initially broken by the concept of insurance, eroded more when employers started providing health insurance as a benefit, and destroyed completely when government became an "insurer". Over time, the patient has become further and further removed from the responsibility of actually paying for the service. It's no wonder that the step to "let the government do it all" appears so small that many people can't tell the difference. However, this is something our Founding Fathers would see clearly - the difference between freedom (making a personal choice and accepting responsibility for that choice) and tyranny (being forced, either directly or through coercion, into making that choice).

One basic problem with the current health care system is that the insurance concept really only works when used to cover chance events, such as a house fire or serious injury - a "pool" of small premiums is collected, invested, and then used to pay out an occasional large claim. When almost everyone in the pool is making claims, the premiums must naturally increase to cover all the payouts. This is what has happened in health care - more usage (claims) resulting in ever-higher premiums. To reduce premiums, it would be necessary to reduce, not expand, coverage. This is why the concept behind health savings accounts (HSAs) is a sound solution - because the insurance component is only intended to cover major medical costs (chance events), the premiums are lower, and the individual uses the savings to pay directly for routine and preventive care services. If more widely utilized, HSAs would lower the control of the insurance companies, and increase the effect of market forces (through individual choices and responsibility) on the entire health care system.

Liberals like to cite the fact that, in the United States, our health care expenditures are vastly higher than other industrialized nations. While that may be true, it is almost entirely due to the fact that we consume vastly more health care services - precisely because we do not have rationing. Patients and doctors are generally free to utilize the system as they feel necessary. In a perfect world, the patient's decisions, under doctor's advice, would simply be followed - unencumbered by bureaucrats, whether working for an insurance company or the government. Again, the HSA concept puts direct control in the hands of the patient - the individual has a built-in incentive to prevent overuse of the system - the ability to retain the unspent funds in his or her account.

Another factor repeatedly used as a need for reform is 46 million Americans that are uninsured (or underinsured - an ambiguous term that helps inflate the number) and "lack access" to health care. It should be noted that this cited number has remained essentially unchanged since the last attempt at a government take-over under President Clinton. This long-paraded group consists of people who choose not to buy coverage (often young, single, healthy), those who changed jobs (may simply have had coverage lapse), the "working poor" (employers do not provide insurance), illegal aliens (an entirely separate debate), and those who are considered uninsurable due to a pre-existing or severe medical condition. Existing government plans could easily be tweaked to provide an acceptable safety net for the truly uninsurable or as assistance to the working poor. A mandate to purchase health insurance likely could be passed - in a form acceptable even to conservatives - perhaps in exchange for a removal of the emergency room "free" care mandate on hospitals that is currently in place.

Basically, the crux of the problem is that Americans are free to, and do, choose to consume a lot of health care services. Reductions in cost can be achieved in only two ways - commoditizing services or rationing. In the current system, when the government "cuts" costs by limiting Medicare and Medicaid reimbursements, the true cost to the system is not reduced, but simply shifted to private payers. When the consumer is re-engaged in the process, through direct purchasing of services, ownership/portability of records and standardization/simplification of orders, health care services become commodities and costs naturally fall. We have already seen this happen with Lasik surgery, with some imaging (such as MRI) services, with generic prescription drugs and with the opening of basic-care clinics in retail stores. If we go the other direction - that of more and more government control, whether directly or through increased mandates on the insurance companies - the result will inevitably be a single-payer system, which eventually will lead to rationing of services.

Reform of existing insurance regulations could also provide increased competition among companies; for instance, allowing sales across state lines and allowing individuals to purchase through groups and associations. Encouragement of HSA plans and de-coupling insurance from employment would help re-engage individuals, and thereby the free market, in the cost of health care services. Innovations in services and delivery methods are never developed under bureaucratic control, but through legitimate competition. True competition among insurers and health care providers, along with a sense of responsibility for our own personal health care, is what has been missing from this equation for over a half century.