Ezra continues on his health care beat with an examination of "skin in the game":
This "skin in the game" phraseology has emerged the leading trope of the HSA-movement, so much so that it was a running joke throughout a recent health policy conference I attended. But its weirdness transcends its linguistically resemblance to George Allen's politics-as-football-metaphors language. In health care, all your skin is in the game. If you don't seek out the right care from competent professionals in sanitary environments, you...die. And if the threat of death, or illness, or amputation (as seen in the negligent self-care of many diabetes-sufferers) doesn't put your "skin in the game," Huckabee thinks moderate financial exposure will?
Something else I've been pondering is the flawed way HSAs are being introduced into the market. If they're supposed to introduce more risk then the employee should feel like it's their money they will have to spend in order to get care. But if their employer is putting in money up to the deductible (in the case of several companies), doesn't that erase the incentive to be "cost-conscious"? Isn't their skin not really in the game?
Speculation aside, how much skin should people have in the game? Many compare the cost of insuring your car, or your house, to insuring your health. But let's play a game. Let's say you take away the insurance --- how much is your car or your house? A house is really a one-time expense, something that you pay for over decades. With health care you continue to rack up costs. I, for example, am only 22, but I've racked up well over $200,000 worth of health care costs at this point in my life. The ability for me to pay for that expense, versus my ability to pay for a house over the course of my lifetime are quite different. You simply can't have the same amount of skin in the game as you would with houses or cars.
So what is the right level? What is the moral level? Right now there are positions in the great health care debate that advocate for extreme personal responsibility. Under these kinds of Utopian spending arrangements, I would have a fraction of the care I've received.
Underlying all these arguments needs to be the recognition that, for the most part, individuals don't choose their health status. They get a terrible illness, have a costly genetic defect, are hit by drunk drivers. Conversely, we choose how fancy a car, how big a house we will buy. When it comes to health decisions, the amount we're able to choose, regardless of whether that's in a libertarian Utopian way (between prices for procedures) or whether we get procedures at all, is quite limited. Theoretically we could choose not to have cancer treatment, or not to have pacemakers, but no one should have to make that choice.
So I ask again, as Americans, how much skin do we think people should have in the game?