Neither Health Care Killer Nor Health Care System Is a Hero
It is unfortunate that Pennsylvania Gov. Josh Shapiro had to state the obvious about Luigi Mangione, who apparently gunned down UnitedHealthcare’s Brian Thompson: “In some dark corners, this killer is being hailed as a hero. Hear me on this: He is no hero.” Mangione’s fans are even crowdfunding to raise money for his defense.
Imagine a world in which the response to every imagined slight and injustice was murder. It seems sadly appropriate that it was a privileged scion of a wealthy and influential family who channeled anti-tech assassin Ted Kaczynski and similarly acted as jury, judge, and executioner. Mangione, if guilty, committed a horrid crime. Those lauding him will share in the guilt if his act inspires others to take up his murderous enterprise.
However, Thompson’s murder highlights genuine and widespread dissatisfaction with America’s health care system. UnitedHealthcare has the industry’s highest claim rejection rate, about a third. As Obamacare fades into what passes for ancient history in Washington, the system’s serious infirmities go undiscussed and unresolved. It would be unfortunate to lose the tragic opportunity for policy reform created by Mangione’s presumed criminal response to his own health problems.
Health care in America is a mess. Not because it is private. Rather, because it is a bizarre hybrid, malformed by inefficient and maladroit government intervention at almost every turn. The problem with Obamacare was not that it attempted to radically restructure the system, but that it sought to do so by intensifying and expanding federal control of medicine.
We all have a basic human right to make our own health care decisions. However, saying that everyone has a “right to care” is meaningless. Who has an obligation to provide that care? And what is included in that right — every procedure, treatment, and medicine ever created or imagined throughout human history? A good society seeks to ensure that everyone has access to a basic level of care, irrespective of person, income, or status. However, that requires assessing alternatives, making tradeoffs, judging effectiveness, and considering cost. “Rights” talk is of no help in addressing any particular individual’s problem, such as Mangione’s reported back pain.
Health care should be ultimately controlled by patients, delivered to reflect their interest. They should make the final decision on what kind of treatment they desire and how much they want to spend on their own care. They should be advised by professionals along the way, of course. But they should have the final authority.
Unfortunately, the existing system is very different. Other than those with substantial wealth, Americans today suffer in a system designed and controlled by others. The federal and state governments decide on largely one-size-fits-all care for tens of millions of Americans through Medicare, Medicaid, and other programs. Moreover, the tax system encourages employer rather than patient provision of health insurance, and advantages fringe benefits over salary.
As a result, those deciding on coverage and doing the paying are not the same as those being treated. “Health insurance” is more typically prepayment of expected medical expenses than reimbursement for unexpected catastrophic costs — akin to an auto insurance policy that paid for gasoline fill-ups, oil changes, and engine tune-ups. The result is a third-party payment system far more extreme than even in most European nations, in which roughly 90 percent of health care expenses are initially paid by someone else. Several perverse consequences result.
• The vast majority of Americans — recipients of government programs and holders of business-provided insurance — have little control over the benefits that they receive. Plans are developed by and for governments and businesses, with little input from or choice by those covered. In contrast, most people select their own auto, homeowner, and life insurance policies.
• The ability to receive health insurance tax-free has encouraged policies to expand beyond traditional insurance to cover even common treatments by choice. Employees rationally favor employers providing more “insurance” than salary for them to purchase insurance. Moreover, providers have taken advantage of state insurance regulation to mandate coverage of their services, further moving health “insurance” from catastrophic to comprehensive care.
• Patients who enjoy greater coverage for more services and face minimal direct cost for treatment seek more and more generous care than they would otherwise. They also have little incentive to even inquire about medical prices, let alone attempt to minimize costs, by, for instance, shopping around. (The rise of health savings accounts has helped moderate this effect.)
• Patients largely unconcerned about costs and with little choice in coverage naturally expect expansive coverage whatever the formal policy limits. Insurers respond by restricting care, often through arbitrary rules and irritating “utilization review.” Imagine a supermarket or restaurant that offered “food insurance.” After everyone raced to fill their carts with steaks and lobster, “utilization review” restricting high-value meals would inevitably follow. Although some companies abuse the process to increase earnings, no health care policy covers everything, making claim denials inevitable. The more “insurance” covers, the tighter the restrictions will be.
Overall, these factors have greatly inflated health care spending. Hence America’s seeming outsize expenditures. Imagine if Americans could purchase autos while writing a check for only 10 percent of the cost, with the rest covered by auto “insurance.” However, America’s problem is not that the country spends “too much” on health care. There is no right amount, especially for a wealthy nation with an aging population. Having had two knee replacements, I’m glad “America” spends a lot on medicine. Rather, today the U.S. devotes more than it should for the care that is provided. We should spend our money more effectively, whether we end up devoting more or less in total to health care.
As a result, reform — serious, systematic, difficult — is necessary. President Obama moved the U.S. toward greater government control. The alternative beckons, with empowerment of patients. Overall, move the system away from third-party payment, both by government and private insurance.
The possibilities are many. End the tax preference for fringe benefits. Encourage a vibrant marketplace for individuals with diverse policies, including guaranteed renewability. Expand buying pools beyond employers, with insurance available through professional associations, fraternal organizations, schools, retiree groups, and more. Reduce state mandates and relax medical licensing restrictions to cut costs and expand competition. Create risk and income-adjusted vouchers for Medicare and Medicaid recipients, as well as others of modest means. Also provide the equivalent of HSAs to beneficiaries, to share the benefits from careful shopping.
Most important, shift fundamental decisions to patients. Ultimately, everyone should be able to choose their medical future. Obviously, treatment often reflects complex issues that require the judgment of specialists. In many cases, there is no right answer given our differences. However, people know themselves. Let them choose the broad parameters of their coverage and minimize the much-maligned role of insurers. Do you want expansive coverage with every available medical treatment? You’ll pay more. Do you want basic emergency coverage and no extraordinary care? You’ll pay less. Want to spend more on something else? Skimp on discretionary medical treatment. Want to avoid the risk of a vegetative end and leave more to your family? Exclude dramatic end of life coverage.
Nothing about the health insurance industry justified Thompson’s cold-blooded execution. But dissatisfaction with UnitedHealthcare and the industry is real. The problems are systematic, for which neither Thompson nor anyone else in the industry is to blame. With a new administration coming to Washington and a new Congress about to take over, policymakers should turn back to health care, only this time to empower patients rather than bureaucrats. Doing so would help reduce the chance that there will be more Brian Thompsons, victims of bad policies that today permeate the health care system.
Doug Bandow is a Senior Fellow at the Cato Institute. He is a former Special Assistant to President Ronald Reagan and the author of several books, including Foreign Follies: America’s New Global Empire.
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