When it comes to health care, Americans want it all, so long as they don't have to pay for it. The so-called Patients' Bill of Rights, which passed the Democrat-controlled Senate last week, is a case in point. Enormously popular with the public, the bill would allow patients increased access to hospital emergency-room care, require insurers to pay for doctor-recommended hospital stays following mastectomies, and give patients the right to sue their insurance company in either federal or state court if insurers refused to pay for some treatments.
But the legislation is likely to fuel big increases in health-care costs, something supporters of the Senate bill, including nine Republicans and all 50 Democrats, don't want to talk about. And no one seems sure about who will have to pay for it.
Part of the problem stems from the way we Americans pay for our health care in the first place. Most Americans don't pay directly for health care, unlike food or shelter (which are every bit as necessary to survival). Most of us get our health-care coverage through our employers, who provide health insurance as a non-taxable employee benefit, paying part or all of the premiums. The effect is to lull people into believing that the benefit is free.
Nothing could be further from the truth. Employers don't really "pay" for health insurance, even if they write the entire check for the employee's premiums. Money that goes to pay for insurance comes out of whatever the employer would otherwise provide in salary or other benefits. The only difference is, employees often have little say in what kind of insurance their employers will purchase on their behalf, what benefits it will provide or how much it will cost.
Health insurance, like every other form of insurance, is a way to spread costs and risks evenly among a large group of people. You pay a few thousand dollars a year to insure your car, home or other property against the relatively small risk that it will be stolen or harmed in an accident. The company can afford to pay for repairing your wrecked vehicle or replacing your burned-down house, even though your yearly premiums amount to only a fraction of the cost, because most of its customers haven't had a similar accident. If you happen to be particularly reckless -- or unlucky -- and your insured property keeps getting damaged or stolen, your premiums will go up, often dramatically, and you may find it difficult to buy insurance at any price.
Americans don't seem to want the same rules to apply to health care, however. We want coverage, with no increased premiums, no matter how often we get sick or how costly our treatment. With most employer-provided health insurance plans, you get no direct benefit from leading a prudent, healthy lifestyle or avoiding expensive, unnecessary procedures. And not only do we expect insurance to pay for catastrophes, such as hospital stays as a result of accidents or serious illness, but we want it to cover routine health care as well. It's a little like expecting your home insurer to pay for a new roof or a paint job, or your automobile insurer to pay for new brakes or tires.
Until health insurance companies started imposing cost controls -- by restricting automatic patient access to specialists, denying doctors the right to prescribe any treatment they deemed fit and limiting hospital stays, among other things -- the price of health care was spiraling out of control. "Managed care" helped curb health-care costs in the early '90s, but it also fueled the current backlash.
If the Senate version of the Patients' Bill of Rights becomes law -- by no means a sure thing with the House yet to act and President Bush threatening a veto of the bill in its current form -- we'll all pay for it one way or another. It would be better if we were forced to do so directly rather than through our employers. Then we could make rational decisions about what services we wanted and how much we were willing to pay for them.