Is Healthcare an Individual Right or a Responsibility? The Massachusetts Universal Healthcare Plan

Jon Cohen

Is Healthcare an Individual Right or a Responsibility? The Massachusetts Universal Healthcare Plan

The recent bill passed in Massachusetts has accomplished more that just insuring the residents of that State, it has taken the electricity out of the third rail of politics: Universal Healthcare. The central problem in the healthcare crisis continues to be a lack of a set of guiding principles that would serve as the basis for policy development. We continue to substitute fiscal policy and fiscal solutions for real health policy and continue to dodge the central question of whether healthcare is a "societal good", to be priced through an open market, or a basic right afforded to all citizens. We as Americans have recognized healthcare as a right for the elderly (Medicare), for the poor (Medicaid) and specifically guaranteed for prisoners based on a 1976 Supreme Court interpretation of the 8th amendment (Estelle vs. Gamble).

Who the law requires to be insured is important in the context of The Massachusetts plan for universal coverage. In Massachusetts, they have recognized that covering everyone is critical but do not define it as a right. They are mandating that individuals obtain coverage and define it as an individual responsibility since it will be affordable and accessible. If government provides you with access, is it a right (although you have to pay for it) or an individual responsibility?

The plan implies that there is an inherent fairness to an individual mandate as it is unfair to the rest of us to cover the costs every time a young adult or wealthy individual shows up in emergency room without insurance? In addition, young healthy people use fewer resources thereby spreading the risk for the insurance pool which drives down the costs for the rest of us.

Employees of small businesses make up a large number of the uninsured. The Massachusetts plan addresses this by making insurance more affordable to the small business owners; although the plan does not mandate that the employers provide it to their employees. Is it fair that most big businesses offer healthcare and subsidize those companies that don't offer it? In this country, the majority of people get their health insurance through their employer. Should there be an employer mandate whereby all employers have to provide insurance as many states are now contemplating?

Some states are increasing the age of family dependents allowing parents to extend coverage to their older children. Arkansas is experimenting with offering Medicaid to small businesses. The good news is that there is momentum gathering towards universal coverage. The bad news is that we still haven't figured out what we really want in this country as a real healthcare policy.

We have agreed to the principle that every child should have a 12th grade education, we said it, we made it the law and we paid for it. Should we agree to the principle that everyone should have basic healthcare, should we say it, should we make it the law, and who should pay for it?
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Jon Cohen, M.D. Chief Medical Officer, North Shore Long Island Jewish Health System

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Posted at 9:20 AM, Apr 17, 2006 in Health Care
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Comments

The devil, if there is one in the Mass. health plan, may be the details. Three that trouble me are:

1) Private, profit making plans may end up offering light-weight insurance to be affordable.

2) fining individuals who may not be able to afford to buy coverage may not be effective. and

3) risky behavior will cost people money -- smokers get higher rates. Below the url to a Boston Globe article. I've been led to believe that -- as a group -- people who smoke are poorer than people who dont. Charging them higher premiums may drive them out of the system.

http://www.boston.com/news/local/articles/2006/04/16/bay_states_nonsmokers_could_save/

It seems to me that for advocates of universal coverage to start jumping on the individual mandate bandwagon is pretty dangerous.

Insurance companies are already clamoring for government to get rid of mandates as a way to make coverage more "affordable." But that's not really the appropriate answer, as Amy Traub wrote in one of her posts (http://www.dmiblog.net/archives/2006/04/manhattan_institute_junk_insur.html).

We need to address the spiraling cost of health coverage. And we need to figure out ways to make sure that costs are equitably borne throughout society

Medicare for all solves both problems pretty well. It's funded through broad taxes, which can be made progressive. And it cuts down on profits and paperwork, both of which are huge costs in our current system. And as soon as everyone were in one pool, it would be very easy to negotiate prices down for segments of healthcare that are spiraling out of control - like pharmaceuticals.

Unfortunately, this solution is not politically possible in the foreseeable future. So, while we need to keep calling for it, and building support for it, I would argue we need to be pushing for more practical, progressive solutions like the Fair Share bill being proposed by Assembly Member Gottfried, Senator Spano and the Working Families Party. And we certainly shouldn't be seduced by an individual mandate.

I appreciate the comments;
-However Mass. or any state gets to universal, whether it is an employer or individual mandate or any other mechanism, may not be as important as the bigger picture of getting everyone covered. I believe that once everyone has some sort of coverage, the next step will be to address the single payor issue. I just don't believe it is going to be possible to get to a single payor without getting to universal first in the current political environment.

I think we need to differentiate between universal access and universal coverage. The former is more likely to be attainable. However, If we as a society are not willing to deal with the harsh reality of limited resources, neither universal access nor universal coverage can succeed. It is clear to me, that having a single government run health care system is where we are heading. One standard set of rules, eliminating the profits
of the insurance agencies and reinvesting those dollars back into the system and the ability to cover all citizens are all drivers that seem to be taking us down a single path.
The Mass Health plan is a noble experiment and will certainly provide lessons learned to those who go next

Let the free market loose. Let all the rich folks pay for boutique care, private rooms, house calls, delivered prescriptions, no-wait test results, immediate appointments...anything they want to pay extra for. Get their money flowing into the system. Stop discouraging it. Law firms charge fortunes to their clients...then do pro bono work. 70% of college freshmen are on some form of aid, but 30% pay the full cost. Airline tickets prices are based on demand and convenience. Get the money into the system, then implement Kerry's super-insurance underwriting for the top catastrophic tier, and make the lowest level of employee premium tax deductible to the employer.