Health Insurance, the Incentive Not to Care

I have chosen this evening to talk about health care in this country.  It is a shame indeed that an endeavor so deeply rooted in the most fundamentally decent human instinct, the effort to alleviate suffering, should have deteriorated into a mechanism for the creation of wealth. That the wealth created accrues to only the very few could be excused if at the same time the citizens of this country could count on the most efficient and best medical care available. Sadly, very few commentators make such a claim.  As good as the treatment is for many Americans, it is surely not available to all on an equal basis, and its costs are close to twice what Canada spends on a per capita basis.  That such good treatment, where it exists, comes attached to an impenetrable bureaucracy of private health insurance companies simply underscores the critical nature of our situation.

I have come to the realization, reluctantly I concede, that capitalism, the engine of growth and wealth responsible for the highest standard of living in the world, brings with it forces which are fundamentally inconsistent with the goals of a just and efficient health care system.  I think we would all agree that medical treatment should be available to all Americans regardless of race, religion, national origin, disability, sexual orientation, political affiliation, or medical condition.  Rather than promoting such equality of access, when it comes to health care, market forces in fact create rewards for the denial of care.

Let me talk about this idea in some greater depth as it is the pillar upon which my policy choice rests.  The health insurance industry contracts to pay for the medical treatment of its enrollees.  It is able to accumulate capital to the extent the premiums that it collects exceed the actual health care costs.  Those citizens in poor health, with chronic diseases or catastrophic illnesses, requiring expensive medical tests and procedures cost the insurance companies enormous amounts of money.  As a result, the effort to create wealth on the part of the corporation leads to a disincentive to provide care and a disincentive to enroll the unhealthy among us in the first place.  In the last twenty years, with the emergence of the HMO, the insurance industry has learned a variety of techniques that allow these companies to maintain their economic viability.  First among them, the industry has learned how to identify the unhealthy that are most likely to require extensive medical attention.  Where there is leeway, or a loophole, the industry does what it can to resist the enrollment of the unwell.  Second, HMO’s have put into place elaborate systems designed to interpose a medical judgment between doctor and patient.  These systems include requirements that the industry give authorization for treatments or medications prescribed by the physician.  While the aim may well be to insure that wasteful or unneeded therapies are not used, the process itself creates the ability on the part of the corporation to increase profit by denying authorization.  Third, the health insurance industry has fallen prey to the tendency to find ways to deny payment when it is sought, and the tendency to create obstacles to the swift resolution of claims, so that whatever funds must eventually be transferred for the payment of services spend a longer period of time in the bank accounts of the insurance industry where interest accrues to their benefit.  Most of us, forced to receive medical treatment, can recount an instance where an HMO made an effort to deny authorization or payment or refused to pay what the patient understood to be the insurance industry’s obligation in the situation.  We each must understand that these frustrating encounters with the insurance industry, interminable periods of time on hold, inevitable proclamations that the treatment was unauthorized or not allowed are the inevitable result of the impulses and incentives which capitalism uses on a daily basis in almost every other economic enterprise for good.  It remains an incontestable truth that those capitalist forces, when applied to health care, do not produce better cars, they produce less treatment..

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