Skin in the game?

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?

Comments

[Ellen1910]

I'm afraid, Kate, you're as wrong about "skin" in the health care "game" as is Ezra.

For so long as employees do not realize the costs of health care because their employers are paying for it (even if the employees' incomes are lessened thereby) there will be little call for significant change and none for UHC.

Employers should be required to compete for employees with salary offers, and employees should pay for their own health care insurance. As soon as they are, the presented muted calls for UHC will become loud and forceful -- but not until then.

[Grant]

Ellen1910 thinks your general opinions are 'wrong', but that is merely Ellen1910's opinion.

HOWEVER, you are absolutely, objectively wrong here...

"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?"

If employers contribute to employees' HSAs, the contributed amount then belongs to the employee. It rolls over from year to year and it is transportable from job to job. It certainly counts as "skin-in-the-game" as Ezra defines it. Your objection looks silly.

[Grant]

Outside of the random and wrong anti-HSA memes, your posts raises some excellent questions.

Regarding the libertarian Utopia and the risk of disease we face before we are even born, you need to look up John Rawls's "Theory of Justice".

http://en.wikipedia.org/wiki/A_Theory_of_Justice

I think someone should apply it to health insurance. That would be way cool.

[SteveE]

Kate, Grant,
The question of how much skin Americans ought to have in the game has been comprehensively addressed through our elected representatives. You say you missed that debate? Well, not really. It was in the bankruptcy law overhaul that was passed last year (and truth to tell in our bankruptcy laws generally).

The bottom line is this: you and I are each obligated to pay everything we have in this world, plus everything we may ever earn. We already know that about 50% of bankruptcies are caused by medical costs -- that was before the laws were tightened.

Grant mentions the "ownership" of the HSA as if this was in any way responsive to the issue, the issue being the insurmountable cost of serious health care to all but the wealthiest individuals. In a world of negative-savings rates those HSAs aren't going to be funded by individuals -- and employers are under no obligation to fund them either. Quite simply, people will be flying bare until they hit their deductibles, so warm-up that VISA card!

I jokingly said to a friend that we can look for the emegence of pawnshop windows coming soon to a hospital lobby near you. Rolled-up stel slats, bullet-proof glass, the works.

Rawls and his theory of justice be damned. Thanks to moral idiots like Trapier we will soon have the privilage of signing-away the title to our car before the ER will work on our kids.

[Martha Grant]

Medical care is such a neccesity I can't imagine it being only provided to those families that can afford it. It seems by Ellen's standards only people that work decent paying jobs should be off Medicaid.

(Note: in NY state the Working Families Party is working on getting corporations with over 100 employees to provide healthcare, for details/a petition go here)

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