Health, Insurance or Care

This is not an argument for one thing or another, it is meant as a discussion of the differing aspects of proposals for medical insurance or health care. The two phrases are often used synonymously, but they are quite different.

I listened to the speeches at the Democratic Convention, particularly Sen. Kennedy and Sen. Clinton. A part of their platform is “universal health care” as a right of all citizens (and some non-citizens). Sen. Obama hasn’t yet spoken, but in his previous speeches – as well as the speeches (and legislation) by Gov. Romney – the term is insurance. I have no axe to gring on this matter, but I believe that before voting on an issue the public should be well informed of the distinctions.

Insurance is, by definition, a pooled fund contibuted into by all members that will pay out funds to those members who have unexpected expenses. Homeowner’s insurance, accident insurance, etc. Health care, as proposed by many, is a universal right for all people and paid for by the general tax revenues. Let us look at the ramifications of the difference (and do so without predjudice for one or the other).

I had health insurance from my employer (IBM) in the early sixties. My wife’s pregnancy, and our son’s birth, were not covered as these were not accidents. (It turned out to be covered, she had a difficult labor and an emergency Caesarian was performed when the baby’s heart stopped in the womg). With my previous employer, the US Navy, I had health care – all medical attention was covered. Which is better? I don’t know! IBM paid me a lot more and I could afford the routine medical procedures (not that obstetrics is routine in a philosophical sense, but it is in the sense of expectation). The Navy paid me less, but gave me the full health care.

Here is the problem, the mixing of the terms “care” and “insurance” confuses the issue. There is great pressure in NY State to cover birth control pills under medical insurance,  the excuse being that Viagra is covered for men. Personally I don’t think either should be covered by insurance, unless the Viagra is being prescribed for something other than sexual activity. No prude here, the blood flow medicine Viagra might have medical value in some real life theatening diseases which aren’t expected.

The key word is “expected”. Insurance is meant to cover the unusual and unexpected – and to do so with funds that are voluntarily contributed as a pool. The members of the pool would far prefer not to have the “disaster” that makes them draw from it – I pay for homeowner’s insurance but I’d rather not get my money back as I’d rather not have a tree fall on my house.

In contrast the implication of universal health care is that all medical care will be the responsibility of the government (even if it farms the actual administration out to insurance companies under contract).  The argument of “single payer” versus “multiple payers” is irrelevant – the relevant thing is a defined right to medical care. There is a Constitutional rationale for this, even if it is a stretch. The Declaration of Independence speaks of “life, liberty and the persuit of happiness” – so perhaps we can include health care as a right to the extent that the Constitution is a fulfillment of the goals of the Declaration.

Where we run into difficulty is when we confuse the care and the insurance. And I beg the reader to not make any value judgements from what follows – I am only presenting both sides of a case, it is up to each voter to decide for themselves which system they prefer. There are plusses and minuses to each.

One philosophical ramification of universal health care would be (or should be – in many countries with “health care” people with money can get better care by buying it) that all – rich or poor – would have the same access to the same doctors and facilities. For that to work it would seem to me that medical personnel would all have to be government employees by law, else how do you require them to not take private patients. I suggest that I’m putting up a bit of a straw man here, I doubt that legislation would go that far. But if it doesn’t then how do you ensure that all get the same health care? Does the rich man wait in the same line as the poor man? A nice goal but not likely attainable. So we have already got a problem.

Universal Health Insurance is another matter, but as soon as we call it insurance then it must only cover the major matters, the unexpected health crises like cancer or accidents. Routine care would be on the tab of the patient. If the Federal government were involved then the individual states wouldn’t be able to include their laundry list of covered items, and the contracted insurance companies could sell in competition across state lines. There are proposals for similar programs (and Romney’s Mass. program is an example of required insurance, with state subsidies for the indigent, but I understand the experience isn’t good so far).

I’ll not insult the reader by going into further detail, each of you can imagine the various constructs and possilities – and each judge according to his own philosophy. Health care, by government mandate, and health insurance (whether mandated or voluntary) are yet different. The former covers everything from hangnails to hip replacements – the latter covers only the extraordinary expense of disease or accident. To confuse them allows the fuzzy logic of insuring against pregnancy among the sexually active.

I take no stand on the issue, I only ask that it be debated with clarity rather than euphemistic terms. Access the costs both to society as a whole and to the individuals, look to your conscience and to your pragmatic side, judge as you will. Were I a Roman slaveholder, interested only in economics, I’d give health care to my gladiators and valued house slaves, but let the field slave be replaceable. I hope I’m a better man than that, and I claim to be.

Best, Jon