In the recent presidential debates, Obama mentioned that, according to the Chamber of Commerce, McCain's plan will lead to the unraveling of the current employer provided health insurance system. While searching for the source of this information, I came across an
interesting view point on health insurance published in the Boston Globe. First, for those searching for the origin of Obama's comments, it seems to be
this New York Times article which quotes R. Bruce Josten, executive vice president for government affairs at the Chamber of Commerce. Both articles are interesting, and I'd encourage any one interested in the issue to read both.
However, the Boston Globe one, being an op-ed, provides much more opinion and is therefore more interesting to discuss. The author argues that health insurance ought not be tied to employment. His primary reasons are to improve health insurance portability (something I think is an important issue) and to reduce over consumption of medical services. Its this latter point that I find both intriguing, but ultimately unconvincing.
First a bit of history from the article. The origins of employer based health care according to the article stem back to WWII, when certain laws prevented worker salaries from increasing. The law however did not ban perks, such as medical insurance. It turned out, that not only was this a way to sneak in additional pay, but employees and employers alike did not have to pay taxes on this form of compensation. While initially contentious, this was ultimately codified by Congress.
This creates a bit of a problem in the health care system. If I don't get health insurance from my employer and go purchase it on my own, its paid for with post-tax, not pre-tax dollars. I'm not an expert on the tax code, but even if health insurance is deductible, its not the same as the employer version since it competes with other pieces of the tax code (e.g., the standard deduction) and ultimately may not cause my taxes to be any lower. In my mind, this dichotomy gives unfair advantage to those people fortunate enough to receive insurance from their employer.
McCain's approach to the problem is to tax the employer health provided health insurance and then provide a $2,500 ($5,000 for families) tax credit to allow people to shop for their own insurance. This seems silly to me when a more obvious solution (or at least a less radical one to level the playing field) would be to simply not tax health insurance purchased by individuals.
The other effect, however, of making health insurance tax free is that it encourages health insurance to pay for things not insurance-y. What do I mean by that? Well, many health insurance plans (mine for sure) pays for (or at least subsidizes) preventative care. For example, I can go get an annual checkup, semi-annual teeth cleaning, etc. No doubt the cost of this is transferred to me (or my employer) in the premiums. However, those premiums are paid
pre-tax. If only I could convince my insurance company that my rent was a medical expense...
This situation is interesting because these expenses are routine and completely predictable. So it seems silly to involve a middle man in the transaction. Why pay my insurance company to pay my dentist, when I could pay the dentist myself? Normally insurance is used to hedge against uncertainty. Taking automobile insurance as an example, my auto insurance doesn't pay for an oil change (as the Boston Globe op-ed points out), in part because this is routine predictable service. It does however pay for repairing my vehicle if I get into an accident. This is an unexpected event, and the sum total of my premiums up to the accident may not be enough to pay for the repairs. In other words, stashing the premiums in a bank account is not an acceptable replacement for the auto insurance. The insurance company does not operate at a loss (of course, only if it is well managed) because on average the premiums they collect
do cover the costs of the repairs they pay for. In summary, while one person may receive a net cash flow
from the insurance company (at least for a fleeting instant in time) on average money flows into the insurance company. As customers of the insurance company, we're willing to pay the difference between the premiums we pay and our lifetime accident repair costs for the peace of mind that if we were to require a very expensive repair (a repair that exceeds our premiums thus far and what we could presently afford), the insurance company will pay. This simply does not apply to the regular visit to the dentist for a cleaning (but does for things such as root canals or wisdom tooth extraction, etc.).
The author of the Boston Globe op-ed suggests this is responsible for an over consumption of medical services. In essence, since medical insurance distances the patients from the true cost of medical care, patients get more treatment than they need. I think this is a tenuous argument for several reasons, some pointed (albeit sarcastically) article's comments. Who in a life or death situation is going to question the doctor's advice? However, one does have to wonder if doctor's would be more sensitive to cost when making suggestions if they knew that costs were going to come from the patient and not their insurance company. This may have the effect of reducing unnecessary procedures. Its far easier to take from a faceless insurance company than the patient sitting right in front of you. It may also avoid the insane situation where the list price for medical service is outrageous on the assumption that the insurance company will negotiate it down. This leaves those without insurance in a lurch since they have to pay full price or close to it.
However, the flip side of the story is that the medical insurance companies have a vested interest in their customers receiving preventative care. Returning to the auto example, my insurance company, in addition to not paying for oil changes, doesn't pay for an engine overhaul either. This is a consistent position. If they paid for the latter (because its expensive and often unexpected), but not the former, I as a customer am given an incentive not to protect my engine with regular oil changes. After all, the price of the oil changes come out my pocket, whereas the price of the engine overhaul comes out of the insurance companies pocket. Economists call this
moral hazard. A similar moral hazard exists for medical insurance. Its often significantly cheaper to prevent a disease or treat it in its early phases than to deal with it as an emergency. Consequently, if the medical insurance companies are going to pay to deal with the emergencies, they ought to give their customers incentives not to create emergencies. This means paying for preventative care. While no one deliberately wants to get sick or have an emergency, if customers are left to their own devices, when faced with challenges in meeting the family budget, preventative medical care may be cut. That's the last thing the insurance company wants.
What this means to me is that even more things need to be tax deductible. If my routine medical care is being paid by insurance, which is tax deductible, then if I can't afford insurance, or choose not to have it, it's only fair that my routine medical costs are tax deductible. Once again, just being deductible is not enough, it should be deductible before considering things like the standard deduction, etc. If I understand correctly, this is what medical savings accounts are for, but its not at all clear to me why I have to predict at the beginning of the year what my medical expenses are going to be. Why can't I just save the receipts and deduct the costs when filling out my return.
In summary, it seems to me that our current tax code is inconsistent on dealing with medical care and medical insurance. While I'm not sure that the McCain plan is fiscally sound (i.e., does it make health care less affordable for some who are already covered and not go far enough for others who are not, all the while spending more government money with no new sources of government income?), I do think the doing something about the current inequality in the taxation of medical expenses makes sense. On the other hand, I'm also pretty skeptical of Obama's plan (once again, is it fiscally sound?) of having a government run insurance plan. Ultimately, I'm not convinced the government is good at running large programs of any form, nor does it have the incentive to be efficient. Unfortunately, on the corporate side of the world, companies have incentives to be efficient, but they don't have incentives to be sympathetic and caring. That's what makes health care such a tricky issue.