Editorial:  Health Care: Can We Care for Everybody? Should We? Will We?

 

As the 2004 presidential election approaches, we are hearing a lot about health insurance—the lack of it for millions, and the inadequacy of it for a lot of the working middle class and seniors. Most of the discussion concerns schemes to reform managed care, malpractice insurance, medical savings accounts, and create pools for the uninsured. To his credit, John Kerry has put publicly funded universal catastrophic health coverage on the table, perhaps as an interim step to broader universal coverage. Kerry has also proposed adding the uninsured to the Federal Employee Health Benefits Program (which is premium-covered at 72% by the federal government) with guaranteed issue. Kerry and Edwards have also suggested a somewhat large tax credit for health care premiums (perhaps $1000 per year, especially for the self-employed), but either of these proposals would be too little for many people. Kerry also proposes extending coverage (somehow) to 95% of Americans, including children. In another interview, Kerry proposes allowing association members to buy into the Congressional Health Plan, although this arrangement might encourage freelancers to let associations speak for them politically.  President Bush’s proposals emphasize tort reform and various private initiatives.  Quasi-libertarian writer Ronald Bailey suggests mandatory private insurance (similar to auto insurance), probably voucher-driven for low-income people, although the actuarial and anti-selection issues for the aged (at least up to Medicare age) and those with pre-existing conditions would become politicized quickly. Bailey seems to consider the national systems in Germany and France as quasi-privatized mandatory health insurance (with payroll deductions). Matt Miller backs up this notion when he observes that community ratings without mandatory insurance can backfire, and Miller wants to use a similar but separate system even for Medicare. Princeton professor Uwe E. Reinhardt has also supported mandatory health insurance, claiming that the current system encourages a “freedom to mooch” (like the name of a weak Ayn Rand character in Atlas Shrugged!), although it also encouraged inequitable charges for services (Barbara Ehrenreich, below). In April 2006 the Massachusetts legislature actually passed a bill requiring every resident to purchase health insurance by July 1, 2007, and based its concept on mandatory auto insurance (although there are many components to support low-income people).[1]

 

The economics of health insurance is extremely complicated, and it is difficult to boil the policy discussion down to a single thread of argument. Actually, this is true of a lot of policy issues. There have been numerous comments that health care does not behave in a free market like other services. There seems to be more competition among carriers in arranging bargaining power from providers than in actual delivery of critical diagnostic or treatment services, and there are genuine complications in recovering the cost of research and development for new drugs and devices, given the amount of government regulation. Partly because of the malpractice crisis and because of the contingent availability of so much lifesaving care, employer-sponsored group premiums have risen by 11/2% in 2004, for which the average single person contributes $558 a year and average family $2661, with only 61% of workers now obtaining health insurance this way now. It is significant that employers began offering health care after WWII, and that this technique has been encouraged by treating health care premiums as pre-tax dollars. Today, the expectation that employers provide health insurance could well hurt the job market in many industries.

 

But what strikes me first is the basic ideological question? Is access to health care supposed to be a fundamental right? Right now, it is at best a social right, because it can be guaranteed only by requiring some kind of shared sacrifice from everyone. When I was in the Army we would mock the Marxist mantra: “From each according to his ability, to each according to his needs!”  It offended our notion of freedom. But in health care there is a need to face this idea for purely pragmatic reasons, perhaps.

 

Consider our private model right now. It is largely predicated on individuals obtaining group coverage from their employers.  In theory, working people are supposed to be more stable and successful people have “earned” the right to preferential treatment by the health care system (it hardly works that way any more). Originally, economics drove employers to offer health insurance as a fringe benefit when they needed stable workers (from World War II on through the relatively, compared to today, stable 50s and 60s), and soon it became a pretax benefit. Conservatives usually propose the idea that everyone should manage his own health care needs from young adulthood with medical savings accounts and flexible spending accounts. Already individuals are being told that they should also consider starting purchasing long term care insurance (for custodial nursing home care) when they are young, but it appears that these premiums would come with after-tax dollars unless you itemize deductions. This is a somewhat unclear situation that is likely to change and may require the help of tax advisors. Under the proposed Long Term Care Act of 2005, pre-tax retirement contributions could be used to pay LTC premiums; one will need to keep up with policy legislation on this.[2] 

 

Ideological (if impractical) arguments favoring a private system emphasize the concept of “moral hazard,” the idea that if someone pays for something out of his own pocket he or she won’t abuse it (see the New Yorker reference below). One of the biggest problems in the current system is misutilization, partly by doctors over prescribing tests out of fear of malpractice suits. A bigger problem seems to be malpractice premiums themselves, driven by huge punitive jury awards. Everyone is paying for “pain and suffering”—most of all patients with weaker policies and high deductibles but still expected to undergo extensive tests just to maintain prescriptions. Another problem is that the uninsured are often charged several times more than patients with group politices, whose PPO’s or HMO’s have negotiated discounts. The uninsured in the United States, in effect, are subsidizing reduced prices for the insured and even for publicly funded health care in other countries.[3] The uninsured are in turn chased by collection agencies, find their bank accounts frozen or wages garnished, and have even been jailed. The “liberals” and unions are right in maintaining that the malpractice crisis is exaggerated partly by low interest rates and stock market valuations, which force insurance companies (used to investment income) to be pickier about anti-selection and charge higher premiums to make their profits quickly. There is controversy as to whether the large jury awards are the biggest source of trouble, or whether it lies with inadequate administrative and judicial oversight against frivolous lawsuits.

 

The single-payer system, then, is beginning to look pretty tempting, at least in publications, even if the major political candidates shy away from it. The best system paradigm might be Canada’s, which would retain a great deal of private choice in doctor-patient relationship.

 

Reputable sources report that such a system could probably be funded in the United States by a 3-1/2% payroll tax (in addition to social security), a small stock or securities transfer tax, and a rollback of the Bush tax cuts. Presumably such a system replaces Medicare, Medicaid MMIS in every state, and most general coverage for individuals and workers. This would require enormous systems programming and implementation and conversion, although probably BCBS  plans and health insurance companies could act as intermediaries. There are variations, such as universal health insurance with everyone paying modest premiums for one large group, with some copayments and deductibles and some exclusions (which would be politically volatile).

 

How would this (single payer system) affect typical workers or salaried employees? If I were still working at my last salaried job, I believe that I would be paying about $70 per month out of my own pocket, and my employer about $200 per month. In the new system, it sounds like I would be paying about $200 per month, but I would recover the employer’s contribution in additional compensation since the employer no longer has to pay it.  It sounds too good to be true. Families with children would come out much better, as they would pay a fraction (in payroll taxes) compared to their premiums now, until they reached high compensation levels.

 

In any case, one benefit of such a system would be to “force” healthy people without dependents to pay their share rather than cherry pick their way out (by avoiding insurance or by sticking with very high deductibles). Presumably a wage-earner with many kids would not pay any more tax for this whole family than a childless person (a dicey idea, but Europeans prefer to fold health care into their progressive income tax, although some European systems seem to be quasi-private).  Another idea is that routine preventative care and cancer screenings could be covered, encouraging health maintenance (as compared to episodic or crisis-oriented care) and prolonging working lives, especially into the senior years. (Along these lines, Health Savings Accounts, often promoted by conservatives and libertarians, may well encourage preventative care in young adulthood and middle age. They must be linked to high deductible insurance policies.)[4] [5]If most health care were removed from the employment world, employers might be able to create more or better jobs or pay better, or reconsider offshoring. Of course, that point is reflected with the proposal, suggested above, to have mandatory but voucher-driven private health insurance. Getting employers out of the game, even with a public single-payer system, does sound like a big win-win  A surprising claim is that administrative costs for a single payer system (including HIPAA compliance now) are likely to be less than for our current system emphasizing managed care. (Utilization review, especially postpayment, is still important in Medicare and Medicaid MMIS (MARS and SURS) programs today.) In the essay “Debunking Centrism” by David Sirota (The Nation, Jan. 3, 2005, p. 18), there is mention of a Washington Post 2003 survey that suggests that two-thirds of the general public favors a single payer, government backed system instead of a profit system for health care (maybe even for prescription drugs). But other problems surface. What about the waiting lists for elective procedures? Would life-extending surgeries (like coronary-bypass) be denied patients over certain ages or delayed? There are mixed results on this. Canada uses the private system in the United States as a backup, and Britain has turned to private resources. But these countries seem to be doing better now with the waiting list or availability issue. Furthermore, particularly in middle and upper classes, the British (according to reports in 2006) seem to be in better health than are Americans, and that may reflect well on the concept of Britain’s system.  But I worry about the outliers. When I fell and sustained an acetabular hip fracture in 1998, I easily obtained state-of-the art new surgery at the University of Minnesota from my private employer’s plan, and was back to work in three weeks and walking normally in about ten weeks. I doubt this would have happened in a single payer system. An late 2004 article in the AARP (American Association of Retired Persons) points out that in the Netherlands, a typical wait for elective hip surgery is eight weeks, and for heart surgery is 14 weeks.[1F] However, right away we should note that the United States effective has a limited single payer system for those over 65 – Medicare, of course—and since the late 1990s it has been common in the United States (it apparently seems harder in Canada and European countries) for the extreme elderly to get expensive treatments, like coronary bypass surgery, if they are capable of getting better.

Another problem, with finite resources, is balancing the needs of different groups. There may be moral arguments to devote more care to children than to seniors, who have already lived their lives. Who has the most political clout? Young parents, or seniors? Or there may be a temptation to tie some medical procedures for seniors to the availability of adult children to help care for them (often sacrificially, and this could be especially nettlesome with custodial). This is getting to be a bigger issue in the era of smaller families and many adults who never have children, and can even track back to the gay marriage debate. I was almost caught by a situation like this in 1999.  We can judge our civilization by how it cares for people in the dawn (children), twilight (elderly) and shadows (ill and sometimes disabled) of life—but how much of that is public responsibility through government, and how much of it is up to the accountabilities of individual citizens? Given the consequences of low birth rate demographics, I can imagine, at some point, a “modest proposal” to withhold publicly funded health care for persons over a certain age who have not had, adopted, or raised children themselves or at least carried out at least one caretaking responsibility of their own; at least, such an idea would render a very sharp edge to the cultural wars over family values and even gay marriage and adoptions. Whatever the rosy promises of both presidential candidates to improve access to health care, truly universal and optimal care for everybody (especially the elderly) might require a degree of jawboned or coerced lifestyle socialization that many Americans would not accept in today’s individualistic society.

A tough moral question comes out of the observation that an enormous percentage of our medical expenditures go to benefit the sickest patients. 50% of our health care costs are accounted for by 4% of people. This is particularly true of the elderly, as some studies indicate that the average person will spend a third of his medical expenses in the last six months of life. There is a temptation to use technology to prolong biological life as long as possible, out of reverence for human life and deference to family emotions, but this comes at everyone’s expense. Does this mean that standards will have to be developed regarding availability of treatment given age or previous behaviors? This can occur any time public funds are used, single payer or not.  On the other hand, the health insurance industry could develop models to predict when free or low-cost preventive care is cost-effective. This could include scheduled cholesterol screenings, colonoscopies, breast and prostate exams for seniors, since we (compared to countries with single payer) have very high expectations of cure when malignancies or circulatory diseases occur.

And, finally, public underwriting of health care (even if just catastrophic) gives “the state” more reason to meddle in private behaviors—overeating, sex, drug use, cigarette smoking. It might even provide a “rational basis” to justify sodomy laws again (as many male homosexual practices are particularly efficient in transmitting HIV).  Then you have the debate about genetics, environment, and private choice.  In Europe and Canada politicians have not gone in this direction, but the United States, with more conservative religious influences from the Christian right, would face having to deal with loss of personal freedom as a cost for providing health care for everyone. Of course, you can argue here that the public is already bearing a lot of the bill for “behavior” in Medicaid and unpaid uninsured bills.

 

The behavior-and-values paradigm has given rise to voluntary health cooperatives, particularly among evangelical Christians who have set up some “church plans” that tend to cost less than conventional health insurance but that may not be binding contractually and that may fall outside of state regulation. These plans will often refuse claims for illnesses brought on by “behavior” (especially HIV claims related to male homosexual acts). A libertarian argument favoring these arrangements is that they give private groups (especially religious groups) the power to express and implement their own moral value systems outside of government.[6]

 

The importance of our culture of individualism and the weakening of family values can add startling flavors to the health care debate. In the past, families—especially older unmarried adults—were expected to take care of the elderly. Today, of course, “family values” cannot pay for quadruple bypasses for 85-year-olds, or, perhaps more aptly, provide ten years of custodial care for Alzheimer’s Disease as former president Ronald Reagan received. But, in the United States, any plan to provide more public support for health care for older citizens (especially before they are eligible for Medicare, which itself is far from able to handle everything) might depend on expanded notions of filial responsibility and geographical availability. One grim “conservative” possibility is to tie the availability of funds or treatments over a certain age to the availability of family members to provide care or share costs. Today this debate is mediated by the fact that Medicare already pays for much of therapeutic care over 65, although the principled debate remains. (Medicare does not pay for long term custodial care as in nursing homes, but state and co-federal funded indigent Medicaid programs do.) Even with all the attention to technology, the very sickest patients sometimes cannot get coverage for or even obtain orphan drugs, or unusual medications that do not generate enough demand to be profitable to make.  The new Medicare drug benefit is only a beginning in the attempt to address this kind of problem

 

How this would all play out is far from clear yet. I think this is a good time for a definitive analytical report, complete with statistics and tables and commentaries, on the various health care solutions, especially single payer (with special reference to reform of Medicare and Medicaid), with clear narratives written to be understandable by the public, from a commission with the public credibility of the 9/11 Commission. A number of universities, think tank foundations, and consulting companies would make contributions. Would a single payer plan be fair among generations if implemented suddenly? I have my own ideas as to how such a study should be undertaken (in the “do ask do tell” spirit) but it is indeed a monumental challenge. The same kind of study needs also to be down with social security, pensions (defined benefits, which are getting into solvency trouble) and various defined contribution tax-deferred retirement vehicles.  Many credible sources (ranging from ABC’s medical editor Dr. Tim Johnson even to Donald Trump) have called the question as to getting down to the business or providing universal health care. It’s time for us to ask if we shooting ourselves in the foot over ideology and whether, in our larger and more socially complicated country, a Canadian-style system really could work without undermining personal freedom and private choice. At the same time, we have to wonder if we can afford the sum of our individual behaviors:  low birth rates and small, dispersed families; extensive use of life-extending technologies; poor diets and dental habits; abuse of the environment; hyper-individualism and misplaced market incentives in delivering health care. These all create a much less than a perfect world. 

 

[1F] Mike Edwards. “As Good as it Gets: What country takes the best care of its older citizens? The Netherlands rates tops in our exclusive survey of 16 nations, but no place is perfect,” AARP, Dec. 2004, p 45.

 

Kenneth Rogoff, in “A Prescription for Marxism: The next great battle between socialism and capitalism will be waged over human health,” Foreign Policy, Jan/Feb 2005, p. 74, writes: “For example, Americans are several times more likely to receive heart bypass surgery than Canadians, where the procedure is reserved for extreme cases. Yet several studies suggest that patients are nor worse off in Canada than in the United States.”

 

Go to Health Care Tables page

 

©Copyright Bill Boushka, 2004, subject to fair use.

 

 

References supporting Single Payer:

Q: Would single-payer health insurance be good for America?

Yes: Single-payer insurance would provide better and more affordable care for everyone.

By Don R. MaCanne

 

http://www.insightmag.com/news/2000/03/27/Symposium/Q.Would.SinglePayer.Health.Insurance.Be.Good.For.America-213133.shtml

 

Physicians for a National Health program:

 

http://www.pages.drexel.edu/~dar36/facts.html

 

 

Reference against Single Payer:

 

John C. Goodman and Devin M. Herrick  “Twenty Myths About Single Payer Health Insurance: International Evidence on National Health Insurance in Countries around the World,” National Center for Policy Analysis, Dallas, TX

 

http://www.debate-central.org/topics/2002/book2.pdf

 Here are some good references from The Lewin Group (I used to work for this company’s “predecessor” as a computer programmer from 1988-1990).

One in Three: Non-Elderly Americans Without Health Insurance

Advances in Alzheimer’s: Impact on People and Related Medicare and Medicaid Spending

Lewin Insight (topic varies)

Another good resource on the uninsured is http://www.covertheuninsured.org

Barbara Ehrenreich as written about problem of overcharging the uninsured in The Progressive, Feb. 2004, in the article “Flip Side: Gouging the Poor.  Hospitals sometimes charge as much as six times as much for a procedure outside of insurance. In my case, an oral cat scan was reduced from $1770 to $360 when the insurance company agreed to cover it, and in another case a week-long rehab stay (after a hip fracture) was reduced from $4400 to $950 once a proper referral was established.

Julie Appleby of USA Today provides “Fewer getting insurance through jobs” (8/3/2004) at http://news.yahoo.com/news?tmpl=story&u=/usatoday/20040803/bs_usatoday/fewergettinginsurancethroughjobs

William J. Holstein provides an important commentary in The New York Times, Aug. 15, 2004 “Armchair MBA” column, “The Missing Reality of Health Care,” in which he discusses the competition issue.

Cecil Connolly, “15 Illnesses Drive Up Costs: Conditions Linked to 56% Increase in Health Care Bills,” The Washington Post, Aug. 25, 2004.  HIV disease is not one of these conditions, but diabetes is.

Debra Kozilowski provides an interview with John Kerry, “Up Close and Personal: John Kerry Talks About Health Care” in American Writer, Summer 2004.

Albert B. Crenshaw, “Health Insurance Costs Keep Rising: Premiums for Employer-Sponsored Plans Grew by 11.2%, Survey Finds,” The Washington Post, Sept. 10, 2004.

Ronald Bailey’s article is “Mandatory Health Insurance Now!—It will save private medicine—and spur medical innovation,” Reason, Nov. 2004, p. 38.

I have seen and reviewed the film The Barbarian Invasions (Buena Vista) about the Canadian health care system. The film depicts bribery and corruption in the system. John R. Graham provides a review in the Nov. 2004 Reason, p. 42. The review is called “Losing Patients: A film questions Canada’s nationalized health care.”

Sarah Rubenstein, “Health Insurers Often Reject ‘Near Elderly’”, The Wall Street Journal, Nov. 16, 2004, p. B1.

Daniel Altman, “How to Save Medicare? Die Sooner,” The New York Times, Feb. 27, 2005, p. B1, explores expenses of care at the end of life. 

Matt Miller’s book is The Two Percent Solution.

Arnold S. Relman, “The Health of Nations: Medicine and the free market,” The New Republic, Mar. 7, 2005, claims (as the TNR cover says) “Health care is not a business,” and advocates a tax-supported system feeding a private but non-profit system.

Malcolm Gladwell, “The Moral-Hazard Myth: the bad idea behind our failed health-care system,” The New Yorker, Aug. 29, 2005, p. 44. He compares the “social insurance” model for health care, which would support single payer and universal coverage, with the “actuarial” model, which supports medical savings accounts and, at some level, ultimately holds individuals accountable for their own health. It is a matter of ideology.

“The Great Divide: Public vs. Private Health Care. Part One: Getting the Facts,” NewsHog, Feb. 1, 2005, does indicate gradual improvement in the waiting list problem in single payer systems. http://cernigsnewshog.blogspot.com/2005/02/great-divide-part-one.html

Visit http://billonmajorissues.blogspot.com/2006/09/hr-2355-health-care-choice-act.html for a discussion of HR 2355, the proposed Health Care Choice Act, allowing purchase in states other than the state of residence. There is a viewpoint by Diana Ernst in the DC Examiner at http://www.examiner.com/a-271361~Diana_Ernst__Still_hope_for_meaningful_health_insurance_reform.html

I have a more updated (Dec 11 2004) piece on health savings accounts, as associated with high deductible policies (they must be) and US Treasury links with FAQ’s, at this link: (blogspot).

Business Roundtable on universal health care (Steven Pearlstein, The Washington Post, Jan 17, 2006): blogspot link.

Milt Freudenheim New York Times story (May 5, 2007) on small employers’s health care premiums (affected by one claim) here (blogger link).

Healthy Families Act of 2007 bill (seven days paid leave for employers with 15 or more employees), here.

Coalition to Advance Healthcare Reform, discussed here.

Blogger: discussion of proposal from Employee Benefits Research Institute (http://www.ebri.org) subcommittee called ERIC (representing employers covered ib ERISA), here.

Blogger discussion of comparison of Obama and McCain health care plans, Oct. 29, 2008 (sources: Washington Post, Lewin Group), link here.

 Candidates’ pages:

John Kerry

George W. Bush

Ralph Nader   (also, paper on Patients Bill of Rights)

Libertarian Party

A Personal Note: (12/2004)

Having retired (and not yet at Medicare-eligible age), I have some high-deductible health insurance, and no dental. There have been some recent problems. I find it difficult to control expenses: providers want to order tests of questionable necessity, probably to protect themselves, and resist giving the pragmatic care that I ask for. I cannot afford to pay for other people’s pain-and-suffering jury awards. (I would persoanlly be willing to sign a “release of all claims” medical waiver forfeiting the right to sue for malpractice, but if I were allowed to do this, what would happen to people who expect a higher level of preventative or exploratory care and have the family infrastructure to back them up?) I note that people on Medicare do not seem to have the harness on getting “in network” referrals to specialists that private insurance companies, HMOs, PPOs, or “managed care” normally requires. I probably will not get care as good as the “older old” get now. As someone who does not have children to provide sacrificial custodial care (the “loving family” paradigm), I probably would not expect certain extreme life-saving measures (various transplants, castration, etc) that could happen and that others get today, although this might turn out to be a moot point anyway.

See Cato Institute notes from “Health Care University” 2006; my notes on this.

Cato books on health care (direct blogspot link): David A. Hyman: Medicare Meets Mephistopheles (2006); Michael F. Cannon and Michael D. Tanner, with foreword by George P. Shultz: Healthy Competition: What’s Holding Back Health Care and How to Free It (2006).

 

Blogger reference on conservative commentary on Michael Moore’s film Sicko

 

Blogger reference on Newsweek coverage on Alzheimer’s disease

 

Blogger reference on filial responsibility burders and eldercare (Dec. 30, 2006)

 

Discussion of filial responsibility laws

 

Blogger on problems with Canadiam health care (families sometimes pay for care in US to bypass waiting lists)

 

Blogger discussion of SCHIP (State Children’s Health Insurance Plan), 9/4/2007.

 

Blogger discussion of problems with individual health insurance and pre-existing conditions, 7/17/2008.

 

 

Back to home page     controversies page   Note on Medicare compared to managed care     

 

Contact me:  JBoushka@aol.com  or visit my contact page.

 

 

 

 

 



[1] David A. Fahrenhold, “Mass. Bill Requires Health Coverage: State Set to Use Auto Insurance as a Model,” The Washington Post, April 5, 2005. Governor Mit Romney is expected to sign. Employers not providing health insurance would have to pay a $295 annual fee per employee. The Boston Globe provides an Associated Press link at http://www.boston.com/news/local/massachusetts/articles/2006/04/05/the_legislation/

Single adults who make less than $9500 a year would pay no premiums, and a sliding scale would be available for up to three times the poverty level; individuals who failed to purchase could be fined $1000 a year or lose state income tax exemptions. It is unclear from these writings what happens to senior adults below the level of Medicare, for example someone 62 who has started social security early. There is also a Scott Gelman article, : “lobbyists took in $7.5 m on health bill” in that April 5 2006 Boston Globe issue. Vermont and Maine have similar programs, and the District of Columbia and Maryland are considering them as of early 2007. Could there be some rationing in this system? Blogspot entry: http://billonmajorissues.blogspot.com/2007/01/states-start-experimenting-with.html

 

[2] “Want More Affordable Long Term Care Insurance? Tax Breaks May Help”  Business Wire, Oct. 22, 2005. http://www.emaxhealth.com/105/3549.html 

[3] Editorial, The Washington Post, Aug. 31, 2006, “Health Care’s Vicious Cycle: And how an enlightened policy could break it” talks about the cherry picking problem, and suggests that government reinsure group policies for certain conditions, as a way to make it affordable to employers. Republicans want to let employers and insurers add more exclusions (maybe HIV??)

[4] Jonathan Cohn. “Crash Course: The danger of consumer driven health care,” The New Republic, Nov. 7, 2005. Mr. Cohn explained his article on CNN on Nov. 5, 2005. Health savings accounts in his view would encourage cherry picking, with the young and healthy saving money and the chronically ill hit even harder. Universal health insurance spreads out the risks. Most people want some insurance for unpredictable risk (like auto insurance). A 23-year-old healthy person may accept the idea of paying for some of his or her old age premiums now without perceiving the arrangement as “socialistic.” At any given age, however, some people need many more medical services than others, whether this is due to their own behaviors or not. Should we all share the cost of the chronically ill?  The paradigm of individualism might say no, especially if you strengthen the idea of family responsibility.  The way the insurance is structured (pre-existing conditions, etc.) certainly affects the way the burdens are shared, a basic ethical question.

[5] Albert B. Crenshaw, “Debating the Impact of High-Deductible Plans,” The Washington Post, April 30, 2006, pays a lot of heed to the fact that the sickest people spend a disproportionate part of health care costs. Better specialty centers could cut costs, it is argued.

[6] Sandra G. Boodman, :Seeking Divine Protection: Some Believers Put Faith in Church Plans Instead of Standard Health Insurance,” The Washington Post, Oct. 25, 2005. Three of these plans include Medi-Share, Samaritan, and Christian Brotherhood Newsletter. Culturally, they remind one of “fraternal companies” in the life insurance market. Sometimes individual members make individual payments to help other claimants after serious illnesses.