Changing the Rules of the Game

Obamacare has been passed into law and signed. Despite fulminations from conservatives, it is unlikely to be repealed or found unconstitutional. All we can do now is wait for the unintended consequences to show up. Yet, like a moth to the flame, I am still drawn to write about the intertwined issues of health care and health insurance.

At the root of Obamacare is a profound shift in the understanding of what health insurance (or any insurance) is designed to do. The core concept driving any insurance plan is risk management. Basically, the lucky are subsidizing the unlucky.

If a tornado blows away your house, your neighbors who were missed are paying for your rebuilding through their policy payments. “Wow,” they think, as they write out the check, “that tornado just missed my street.” Or let’s say you beat the actuarial odds and die young. Your beneficiaries are taking advantage of all the other policy holders who didn’t die that year. “Gosh,” they think, sitting at the funeral, “that could have been me that got hit by that freak meteorite strike.”

The thing about the lucky subsidizing the unlucky is that you can never know in advance in what category you’re going to end up. So you pay your premiums, and you’re grateful if you never have to use the insurance.

At the heart of Obamacare is a radical conceptual shift. Instead of the lucky subsidizing the unlucky, the basic principle is now going to be the healthy subsidizing the unhealthy. Hence the push to require younger, healthier people to buy insurance, at the same time lifetime limits on care and exclusions for preexisting conditions are dropped. If you are sick, you are going to get all of the medical care your doctors want to give you, and the people who are well are going to have to pay for it.

The thing is, lucky or unlucky is pretty much a random event. For healthy versus unhealthy, there is not so much randomness involved. If you see someone who smokes, it is predictable that heart disease and breathing problems are in their future. Looking at someone who is grossly obese, you know they can plan on developing type II diabetes, followed by back pain, followed by joint replacement surgery. These tend to be chronic conditions. They can be managed, but somebody’s going to have to pay for them. The healthy are being asked (well, actually told) to foot the bill.

The thing about most insurance is that it is inherently fair. That’s why I willingly pay the premiums. But as someone who likes to eat, but has the self discipline to push away from the table, as someone who sweats it out at the gym several times a week, as someone who has never taken up smoking, I look at many of the unhealthy and question how fair it is that I’m being asked (well, actually told), that I am responsible for paying for the consequences of other people’s behavior.

Those of us who work hard at managing our risks should not have to subsidize the reckless. Frankly, I’ve got better ways to spend my money.