Counterpoint: Someone Has to Pay

Abstract

Drs Farrell and Curran raise some provocative issues in their commentary on Dr Hillman’s [1] January 012 JACR editorial “Somebody Has to Pay.” Many of their suggestions are reasoned and timely, including measures to reduce alcohol and drug abuse, tort reform, price transparency, the recognition of charitable activity, and the reduction of bureaucracy. And some of their recommendations touch on some of America’s most polarizing and knottiest social issues, for instance, immigration reform. The debate about such matters, though informed by medical professionals, will require a Herculean consensus-building effort at the national and international levels, far beyond the reach of the health care community. Unfortunately, many of their other, more medically focused ideas are unpopular, not well grounded, or both. To explore just a few of these, start with the delinking of employment and health insurance. This is the so-called Dutch plan, named after a dramatic reshaping of health care initiated in the Netherlands in 2006 whereby employers converted from the actual provision of health insurance coverage to the financial subsidization of independently obtained employee coverage. Private health plans have to sell community-rated policies to all, and every citizen must purchase insurance, aided by government assistance as needed. In the United States, the Dutch plan gained early bipartisan backing from Sens Ron Wyden of Oregon and Robert Bennett of Utah. Introduced as the Healthy Americans Act, the legislation garnered little support. Senator Wyden (D, Ore) has since shifted his interest to a voucher approach in collaboration with Rep Paul Ryan (R, Wis). Senator Bennett lost his reelection bid in 2008. In addition to a scarcity of legislative interest, the Healthy Americans Act bumped into another reality: for those fortunate enough to have it, most employees and companies like employer-based insurance. Workers prize the volumebased purchasing leverage, not to mention the tax savings, and corporations treasure the ability to provide a valued benefit, especially in a competitive labor market. Health savings accounts can be a source of substantial savings, but unfortunately usually not to those who need it most: the sick. Why such a limited benefit? Consider that 70% of the population consume less than 10% of health care resources (20% spend nothing annually). But 5% are responsible for more than 50% of spending, and that group can exhaust a health savings account very quickly, even one accumulated over a lifetime. Thus, such savings accounts are helpful to the healthy and well-to-do, but few others. Vouchers for health care insurance invariably peg their growth to general metrics such as the Consumer Price Index, not actual health care costs. For decades, medical expenses have annually far outstripped the overall cost of living, so vouchers become increasingly inadequate over time. A reduction of state coverage mandates shows up on a lot of these lists and in political speeches always