Trading Coverage for Freedom

I personally have a stake in the outcome of the healthcare debate. Having been unemployed for three years, I have been through the current system of COBRA and then the coverage of last resort which is HIPAA. The latter is the 1996 requirement that health insurers offer continuing coverage from two of their most popular plans without requiring a waiting period for pre-existing conditions.

The ability to obtain coverage is one of the important issues in this debate. The administration has proposed limiting pre-existing condition limitations, which is an appropriate role for the government. However, the expansion of health care access to the majority of uninsured comes at a price, depending on the implementation. The administration has proposed that an alternative plan be available to act as a safety net for those that cannot obtain coverage, offered through regional health insurance exchanges, which would also act as a downward influence on pricing because of subsidies. In other words, our federal budget dollars would be spent to buy down the cost of premiums either directly or indirectly, instead of having the federal government as the payer.

The goal of expanded coverage is provide access to health care for more of the population and eliminate "emergency room medicine". There are alternatives to expand access to services other than expanded insurance coverage. San Francisco has a model program on the local level to provide health care access to residents of the city. It utilizes existing organizations for health care delivery such local clinics, San Francisco General Hospital, and now Kaiser to provide the services. It handles the problem of emergency room medicine on the local level with some state and federal contributions.

Advocates of a single payer health care system have an alternative solution to this issue. Make the federal government the insurer and provide access to everyone. Then all care gets reimbursed by a federal agency. The simplicity of this solution makes it seem attractive, especially to the physicians that only need to deal with one organization to get paid. But this simplicity ignores the fact that this still has to be paid for by federal taxation with a limited budget. Right now the health care system is largely funded by contributions from employers, which operate on the state and local level, through insurance intermediaries. These insurance companies are accustomed to dealing with corporations and are not very responsive to individual consumers, since they operate more on a risk pool basis.

Uninsured individuals fall into several categories. First, are those with catastrophic illness which are considered uninsurable. Second, are those that are unemployed or self employed. Third, would be new immigrants or illegal immigrants that are not able to establish long term employment. Fourth, are those young people that opt out of the system because of robust health or due to a perceived unnecessary expenditure. In which cases do we want our federal tax dollars to be used to purchase insurance coverage? The problems that we are trying to solve are mainly a question of access to health care in an appropriate way, not waiting until it becomes an emergency room situation.

Insurance coverage by the federal government is a two edged sword. As with other federal programs like Social Security, Food Stamps, or Medicare that directly impact individual citizens, there is a loss of privacy as a quid pro quo to receive those dollars. I have personally experienced the process of signing up for Food Stamps as an example of how the federal government collects copious amounts of information and biometric data on individuals in order to prevent fraud. This information is by federal regulation not to be used for other purposes, but it seems there is much information collected by federal agencies that is used by other agencies such as Homeland Security when national security directives are issued. A prime example is the wiretapping by NSA to infiltrate terrorist organizations.

Concentration of power in the federal government was a concern of the founding fathers and authors of the Constitution. Technology has progressed in a way that makes it too easy for the government to overstep the limits of power authorized by Congress. So in some sense, by making the federal government the insurer in order to provide proactive access to health care, we have created two other problems, which are privacy of individual citizens and the prospect of health care rationing when federal budget constraints dictate.

So the question is, do we really need universal insurance coverage or do we need universal health care access? The latter can be achieved through state and local initiatives, without involving the federal government directly in our health care. I, for one, as a voter and citizen am opposed to federalized health care in any form. And I say this with something at stake, because I too am about to lose my coverage, but fortunately not my access since I live in San Francisco. But I would rather have no access to health care than lose my freedom. Those that cannot afford insurance coverage may be tempted to trade freedom for coverage, but I have made my choice. The simplest solution can have unintended consequences beyond health care and I urge people to consider this.