Health Care Access: Affordable isn’t the Same as Universal
Posted on May 7, 2012
Politicians should stop confusing “affordable” health care with “universal” health care. Like most other Americans, a majority of Kansans agree that access to necessary health care should be available to everyone. By that standard “affordable” is good but “universal” is better.
Sadly, neither the Kansas legislature nor the Kansas Health Policy Authority has yet supported either goal. However some Kansas politicians are calling for health care that is “affordable” while others say it should be “universal.” And some call for both. It is logically impossible to have both. Voters should hold politicians’s feet to the fire until they tell what they really support. Here’s why.
“Universal health care” is a straight-forward goal. “Universal” means that all necessary health care should be available to everyone on demand. There is one important hidden assumption:
1. There has to be a government system for determining what health care is truly “necessary.”
In practice there are many other complexities and hard questions. To what extent should we make health care available to non-citizens? How will our medical delivery systems need to be reformed? How will we pay for it?
Nevertheless nearly every industrialized country has made a creditable effort to answer those questions, and they have provided working approximations to universal health care–with the sole exception of the USA, and that includes the state of Kansas.
“Affordable health care” is a reasonable goal, but not nearly as straight-forward as “universal health care.” Affordability means that all necessary health care is available at low enough prices that most people will choose to purchase it. Providing “affordable health care” raises all the same problems raised by providing “universal health care.” In addition “affordability” depends on several hidden assumptions:
2. There has to be a health insurance system (whether public or private or mixed), so that most people make regular payments to cover the catastrophic medical costs that sick people can’t afford to cover on their own.
3. Not just health insurance, but also out-of-pocket medical expenses have to be affordable.
4. There has to be a government standard for defining and measuring ability to pay for health care.
5. Both insurance prices and out-of-pocket expenses have to be either minimal or on sliding scales keyed to ability to pay.
6. The government must determine how much people at each level of ability to pay are expected to pay.
One state, Massachusetts, has actually provided a system of affordable health care. However access is not universal. About 5.4% of Massachusetts residents still fall through the cracks and lack insurance coverage.
More generally, it is logically not possible for an “affordability” system to be “universal.” By definition any affordability system treats patients as medical consumers who are making free choices about the purchase of medical insurance and medical services. In practice many consumers won’t purchase the medical insurance or medical care that they need. This happens for many reasons. For example:
a. Any government standard of affordability leaves out factors that are hard to measure, such as extended family obligations. It also leaves out factors viewed as unfair to recognize, such as commuting costs. Consequently some patients who the government thinks can afford a given level of payment, really can’t.
b. Out of fear of stigma, some patients refuse to reveal their ability to pay.
c. Patients often don’t know whether a given medical service is really needed or not, and tests to determine that are expensive. If there are significant out-of-pocket costs some patients avoid having the tests.
d. Some patients have different views about what choices are “rational” than the government does.
e. Some patients are financially dependent on a breadwinner who could afford to pay for their medical care, but chooses not to.
f. Many patients who are young and healthy quite rationally decide not to buy any health insurance. When some of them get sick they can’t afford necessary health care.
Some politicians claim these problems can be overcome by means of “mandates” that require everyone to have or purchase insurance. Massachusetts has mandates, but they don’t work very well. To the extent that mandates are fully enforced, they amount to taxes rather than consumer choices, and the concept of “affordability” is being misapplied.
Some politicians prefer affordability over universality for philosophic reasons related to individual responsibility. While that might be a defensible position, what is not defensible is confusing two very different approaches to health care access.
31.4% of Kansans under age 65 went without any health insurance at some point during 2007-2008. Politicians, if you want to do something about it, please stop muddying the waters and take a stand. Do you support health care that is truly universal, or do you support health care that is only “affordable”?