Do We Have a Shared Future, or Not?
Do We Have a Shared Future, or Not?
The current economic crisis in the United States, together with the growing federal budget deficit, places serious debate about Medicaid and Medicare in the spotlight. Or at least, it should -- the international military showdown keeps domestic issues off the front pages and diverts our attention. This could be a deliberate move, or it could be accidental; in either case, it is unfortunate. Changes in both programs have been proposed that would alter our long-standing commitment to support one another.
The heart of insurance is an understanding of shared risk: not being sure who among us might need assistance, we pool our resources in advance to be certain that the funds are there to be drawn on when required by anyone needing care. The shift away from community rating of employer-based or privately purchased insurance was accomplished long ago. We no longer see an entire state or region as having a mutual interest such that the burden of financing care should be equally shared. Part of this is our greater understanding of the role individual behavior plays in health risks. If your behavior causes you more illness, shouldn't you pay the cost? But it also seems to be extremely selfish and self-centered: I can pick out the other person's risky behavior much more quickly than I can acknowledge that I, too, make some poor choices. (Note the differing treatment of those who smoke compared with those who are overweight.)
Also, we are reluctant to face the fact that we live in a society in which our collective decisions (or lack thereof) lead to poorer health for all of us. So we see employers shopping for experience-rated plans that can control their own costs without attention to the impact that might have on the costs to others in the same community. The latest trend is for employers to offer not a plan of insurance but a fixed dollar amount, leaving the individual employee to shop for a plan. While this can lead the apparently healthy person (and family) to save money in the short run by buying a minimal plan suited for those whose use of health care resources is minimal, it leaves those with identified problems facing huge price increases and unaffordable benefits because of the smaller risk pool. Are we a community, or not? Those with HIV infection are painfully aware of the likelihood of exclusion from community because of the association of the infection with behavior seen as negative, controllable, and thus deliberately self-destructive. Associations that detract from our common engagement to pay for care make exclusion of those with HIV infection from insurance or other shared financing more likely also.
The current economic crisis in the United States, together with the growing federal budget deficit, places serious debate about Medicaid and Medicare in the spotlight. Or at least, it should -- the international military showdown keeps domestic issues off the front pages and diverts our attention. This could be a deliberate move, or it could be accidental; in either case, it is unfortunate. Changes in both programs have been proposed that would alter our long-standing commitment to support one another.
The heart of insurance is an understanding of shared risk: not being sure who among us might need assistance, we pool our resources in advance to be certain that the funds are there to be drawn on when required by anyone needing care. The shift away from community rating of employer-based or privately purchased insurance was accomplished long ago. We no longer see an entire state or region as having a mutual interest such that the burden of financing care should be equally shared. Part of this is our greater understanding of the role individual behavior plays in health risks. If your behavior causes you more illness, shouldn't you pay the cost? But it also seems to be extremely selfish and self-centered: I can pick out the other person's risky behavior much more quickly than I can acknowledge that I, too, make some poor choices. (Note the differing treatment of those who smoke compared with those who are overweight.)
Also, we are reluctant to face the fact that we live in a society in which our collective decisions (or lack thereof) lead to poorer health for all of us. So we see employers shopping for experience-rated plans that can control their own costs without attention to the impact that might have on the costs to others in the same community. The latest trend is for employers to offer not a plan of insurance but a fixed dollar amount, leaving the individual employee to shop for a plan. While this can lead the apparently healthy person (and family) to save money in the short run by buying a minimal plan suited for those whose use of health care resources is minimal, it leaves those with identified problems facing huge price increases and unaffordable benefits because of the smaller risk pool. Are we a community, or not? Those with HIV infection are painfully aware of the likelihood of exclusion from community because of the association of the infection with behavior seen as negative, controllable, and thus deliberately self-destructive. Associations that detract from our common engagement to pay for care make exclusion of those with HIV infection from insurance or other shared financing more likely also.