Protect the Sick: Health Insurance Reform in One Easy Lesson

In German, “Krankenversicherung”; in French, “l'assurance maladie”; in Spanish, “seguro de enfermedad”; in Italian “assicurazione contro la malattie.” Interestingly, in Denmark, the long-standing public insurance program goes by the name sickness insurance (“sygeforsikring”) while new private insurance plans that have come into being in the last several years call themselves “health insurance” (“sundhedsforsikringer”) (author communication via e-mail from Marie 0stergaard Moller, Dept. of Political Science, University of Aarhus, Denmark, May 12, 2008).

See Mechanic D. Tanner J. , “Vulnerable People, Groups, and Populations: Societal View,” Health Affairs 26, no. 5 (2007): 1220–1230.

For this history, see Hacker J. S. , The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security (Princeton: Princeton University Press, 1997); Quadagno J. , One Nation, Uninsured: Why the U.S. Has No National Health Insurance (New York: Oxford University Press, 2005); and Richmond J. Fein R. , The Health Insurance Mess: How We Got Into It and What It Will Take to Get Out (Cambridge: Harvard University Pres, 2005).

See Friedman M. , Capitalism and Freedom (Chicago: University of Chicago Press, 1962); Nozick R. , Anarchy, State and Utopia (Oxford: Blackwell, 1974).

The strongest statement of this view is in a book by Norman Daniels; see Daniels N. , Just Health Care (New York: Cambridge University Press, 1985).

Goldstone R. , “Substandard, Not Inferior,” Best's Review 92 (1992): 24–28 at 26. Goldstone was vice president and medical director of Pacific Mutual Life Company at the time.

For this argument from the insurance industry perspective, see Clifford K. Iuculano R. , “AIDS and Insurance: The Rationale for AIDS-Related Testing,” Harvard Law Review 100 (1987): 1806–1824, at 1811; and Hoffman J. N. Kincaid E. Z. , “AIDS: The Challenge to Life and Health Insurers' Freedom of Choice,” Drake Law Review 35 (1986–87): 709–771, at 717.

The story of competition between commercial insurers and the Blues plans is detailed in Fein R. , Medical Costs, Medical Choices (Cambridge: Harvard University Press, 1986): At 10–32; and in Starr P. , The Social Transformation of American Medicine (New York: Basic Books, 1982): at 295–310.

Census Bureau, Income, Poverty, and Health Insurance Coverage in the U.S., 2005, Washington, D.C., 2006, at Table c-1 (three million fewer people had coverage through employers in 2005 than in 2000).

Stone D. , “The Insurance Industry and Health Reform,” unpublished manuscript prepared for Seminar on Future Directions for American Politics and Public Policy, Kennedy School of Government, Harvard University, September 30, 1993 (on file with author); Hamburger T. Marmor T. , “Dead on Arrival: Why Washington's Power Elites Won't Consider Single Payer Health Reform,” Washington Monthly 25, no. 9 (September 1993): 27–32 (the insurance industry has been able to stop proposals that would eliminate actuarial rating and competition among insurers); Stone D. , “Ad Missions: How Insurance Companies Sell Ideology,” American Prospect 16 (Winter 1994): 19–25 (explaining insurance industry's rhetoric of fairness as its strategy to defend actuarial rating).

Stone D. , “The Rhetoric of Insurance Law: The Debate over AIDS Testing,” Law and Social Inquiry 15, no. 2 (1990): 385–407 (insurance industry fought restrictions on its right to use HIV test information to screen applicants for life and health insurance).

Stone D. , “The Implications of the Human Genome Initiative for Access to Health Insurance,” in Murray T. H. , eds., The Human Genome Project and the Future of Health Care (Bloomington: Indiana University Press, 1996): At 133–157.

Associated Press, “Senate Passes Genetic Discrimination Ban,” April 24, 2008, available at <http://www.msnbc.msn.com/id/24293216/from/ET/> (last visited September 29, 2008.); Genetic Information Nondiscrimination Act, 42 U.S.C.A. § 2000ff (2008).

Marino W. , “A Health Insurance Priority; Changing the Individual Market Would Allow More People to Buy Coverage,” The Philadelphia Inquirer, July 21, 2005, at B02; Stark K. , “Companies Could See Blue Cross Rates Soar; To Avoid a 50% Premium Increase for Small Firms, the Insurer Wants Pa. to Make Competitors Use the Same Rate-Setting Method It Does,” The Philadelphia Inquirer, August 11, 2003, at C01.

Pauly M. , “The Economics of Moral Hazard: Comment,” American Economics Review 58, no. 3 (1968): 531–537; Newhouse J. , Economics of Medical Care (Reading, MA: Addison-Wesley Longman, 1978); Herzlinger R. , Market-Driven Health Care (Reading, MA: Addison-Wesley, 1997); and Herzlinger R. , Who Killed Health Care? (New York: McGraw-Hill, 2007).

Abelson R. Freudenheim M. , “Even the Insured Feel the Strain of Health Costs,” New York Times, May 4, 2008, at A1: “Many of the 158 million people covered by employer health insurance are struggling to meet medical expenses that are much higher than they used to be — often because of some combination of higher premiums, less extensive coverage, and bigger out-of-pocket deductibles and co-payments.” Freudenheim M. , “Employees Are Shouldering More of Health Care Tab,” New York Times, December 10, 2001, at C6; Gabel J. R. Ginsburg P. B. Whitmore H. H. Pickreign J. D. , “Withering on the Vine: The Decline of Indemnity Health Insurance,” Health Affairs 19, no. 5 (September-October 2000): 152–157, at 152: “[P]ercentage of employees with indemnity insurance coverage declined from 95 percent in 1978 to 71 percent in 1988, and then to 14 percent in 1998.”17. Committee on Consequences of Uninsurance, Institute of Medicine, Care without Coverage: Too Little Too Late, Washington D.C., 2002, at 28.

Fronstin P. Collins S. R. , The 2nd Annual EBRI/Commonwealth Fund Consumerism in Health Survey 2006: Early Experience with High-Deductible and Consumer-Driven Plans, EBRI Issue Brief No. 300, December 2006, available at <http://ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=3769> (last visited September 22, 2008). Adults in high-deductible health plans “were significantly more likely in than those in more comprehensive plans to say they had not visited a physician's office in the past year…and were significantly more likely not to have had a diagnostic test in the past year or to have been treated in an emergency room” (at 22). The tendency to delay or avoid getting needed care was most pronounced among those people who reported being in poorer health and having lower incomes (at 26).

Goldman D. P. Joyc G. F. Zneng H. , “Prescription Drug Cost Sharing: Associations with Medication and Medical Utilization and Spending and Health,” JAMA 298, no. 61 (2007): 61–69. This article is based on a review of 132 articles about the impact of drug cost-sharing on drug use and other health outcomes.

Id., at 63 (a 10 percent increase in cost-sharing is associated with a 2–6 percent decline in drug use or expenditures; increased co-payments are associated with decreased use of antidiabetic, antiinflammatory, and antidepressant medications.)

Id., at 64–65.

Id., at 66 (“While it is often claimed that low-income groups are most sensitive to cost sharing changes, there is little reliable evidence to support this conclusion.”)

See Abelson Freudenheim , supra note 16.

Hirth R. A. Greer S. L. Albert J. M. Young E. W. Piette J. D. , “Out-of-Pocket Spending and Medication Adherence Among Dialysis Patients in Twelve Countries,” Health Affairs 27, no. 1 (January-February 2008): 89–102, at 94, Exhibit 2.

Quoted in Lin R.-G. II , “McCain's Health Plan Fails Her Test,” Los Angeles Times, March 30, 2008, at A31.

The statements below distill ideas put forth during the 2008 election campaigns and bandied about in health policy circles. These are not meant to be specific proposals, but rather current concepts of how best to reform U.S. health insurance to achieve broader coverage.

Cohen J. T. Neumann P. J. Weinstein M. C. , “Does Preventive Care Save Money? Health Economics and the Presidential Candidates,” New England Journal of Medicine 358, no. 7 (February 14, 2008): 661–663.

Mariner W. K. , “Social Solidarity and Personal Responsibility in Health Reform,” Connecticut Insurance Law Journal 14, no. 2 (2008): 190–221.

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 , Public Law 108–173, §101, 117 Stat. 2006 (2003). The Act included a provision to exempt from taxes income placed in a Health Savings Account.

Enthoven A. C. , “Employment-Based Health Insurance Is Failing: Now What?” Health Affairs (May 28, 2003): W237–W249.

Stone D. , “The False Promise of Consumer Choice,” Saint Louis University Law Journal 51, no. 2 (Winter 2007): 475–487.

Mariner W. K. , “Can Consumer-Choice Plans Satisfy Patients? Problems with Theory and Practice in Health Insurance Contracts,” Brooklyn Law Review 69, no. 2 (2004): 485–540; see Abeslon Freudenheim , supra note 16; Institute of Medicine, supra note 17; and id.

See Stone D. , “The Struggle for the Soul of Health Insurance,” Journal of Health Politics, Policy and Law 18, no. 2 (Summer 1993): 287–317, at 296 (quoting underwriting manuals that specifically exclude racial and ethnic groups and pregnant and menopausal women) and 309–310 for disability discrimination in underwriting. By denying coverage to people who have or have had specific diseases or injuries, underwriting patently operates to exclude people with disabilities.

Genetic Information Nondiscrimination Act, 42 U.S.C.A. § 2000ff (2008).

Sturm R. McCulloch J. , “Mental Health and Substance Abuse Benefits in Carve-Out Plans and the Mental Health Parity Act of 1996,” Journal of Health Care Finance 24, no. 3 (1998): 82–92; see Stone , supra note 12, at 144–148.