Wednesday, June 22, 2005

Mandating Universal Coverage

One of the things I learned very early as a follower of politics was that how one defines a problem very often implies a particular solution. For instance, Governor Romney sees our health care problem as such: there are too many (roughly half a million) people in Massachusetts who do not have health insurance. So what is his proposed solution? Make it illegal for them to not have it. It's almost too obvious!

Now, I'm being a little unfair to Romney because his plan does not just propose mandating health insurance and then hoping everything works out. That would be completely ridiculous and even someone as out-of-touch as Mitt has admitted as much. The reason that these people don't have health insurance is not because they don't need or want it -- after all, everyone needs health care eventually -- but because they can't afford it. So, Romney's plan includes three tiers of low-cost care: Medicaid, Safety Net Care and Commonwealth Care. Why he can't introduce these without also making it a crime to not be covered by them is beyond me. As always, though, the devil is in the details and Governor Romney is chronically allergic to details. As a CEO he could get away with leading by interoffice memo and Powerpoint presentation, but in a Democracy, people usually want to know what they're getting into before it's thrust upon them. If his two new health care products include things like sky-high deductibles, unaffordable copays or a lack of coverage for preventative care or prescription drugs, then they're almost worse for the individual than no insurance at all. What's the point of having insurance if you can't afford to use it?

I do, however, agree with the Governor that this measure will probably not lead to large numbers of companies dropping health benefits all together. While encouraging the idea that health insurance is an individual's obligation is a little worrisome to me ("No health insurance? Well, that's your problem"), I doubt that companies that currently offer health plans will push those back on to the individual worker. After all, these firms still need to hire people and with workers facing penalties for not being insured, they'll place a premium on working for companies that do provide health benefits.

What does bother me, though, is that emphasis on health care as an "individual mandate" will open the door to widespread adoption of so-called "health savings accounts" as a substitute for insurance. When Romney says he wants everyone to "maintain adequate savings to cover their medical expenses" -- that's the first thing I think of. After all, what is "adequate" anyway? I could save 10% of every paycheck but still get into some catastrophic accident or come down with some horrible disease that would cost me more than I'd see in a year. Health care costs are not predictable in the way that housing costs are. You can be responsible and save money in your pre-tax health savings account and still wind up broke and in need of further care.

Don't get me wrong, I'm glad that the Governor wants everyone in Massachusetts to have health coverage. I'm just skeptical of a plan that could end up punishing people because they couldn't afford health care and if underfunded could be even worse than doing nothing.

Read more at Blue Mass group here and here. Cape Cod Works has his take here and Health Care for All also has some good information.