Having at least started the argument on behalf of universal coverage, why should we abandon our current system that relies on employment-based coverage and a grab-bag of governmental programs? Let's start with employment-based coverage.
Failing to find the next big thing to control their healthcare costs, employers are steadily and often stealthily reducing their role in providing health coverage. This trend will accelerate. Good!
Rather than trying to patch it up, much less use it as a foundation for universal coverage, let employment-based coverage die:
- The result of a historical accident, it's terribly inefficient. It requires every employer offering coverage to not only pay for the coverage but to pay for the administrative overhead of selecting coverage and enrolling and dis-enrolling employees.
- It creates rigidity and economic friction in the labor market.
- It constantly creates discontinuities in coverage and they often create discontinuities in care.
- Employment-based coverage disadvantages American employers in increasingly important international economic competition.
- It masks the true costs of employee compensation.
- It's a barrier to universal coverage.
It's going anyway. Instead of resisting that trend, we should embrace it.
From the Washington Post, A Health Care Cost Shift.
For cost control, first, there was regulation. Then, there was managed care. Since Helen Hunt's devastating 1998 moment disparaging managed care in "As Good as it Gets," there's been no "next big thing" to control employer health care costs. Things have been downhill since.
So the only outlet for the building financial pressure has been and will be for employers to (mostly) quietly walk away. They do this by increasing deductibles, co-payments, employee shares of premiums, dropping coverage and shifting from defined benefit to defined contribution plans. Even without current efforts to push health savings accounts, the end of employment-based coverage is coming and that's fine.
Many (most?) of those who support universal coverage (mostly Democrats) hide their heads and fantasize about "single-payer," the ultimate non-employer based system. But, when employers reduce their contributions to coverage, these folks are often the first to complain. And they are often the ones who are first to try to force employer contributions (witness, California's Prop 72 employer mandate. Some advocates, of course, are more nuanced). It's an easy trap to fall into. Twenty-five years ago, when I first started examining these issues, we learned for the first time that the uninsured are primarily workers or the members of families in which at least one adult works. So it was a simple, even magical, step to then think that mandated employment based coverage would mostly solve the problem of the uninsured. But it doesn't completely solve the problem (not even close) and it creates many other administrative complexities and economic disadvantages that just aren't worth the trouble.
Thus, those who seek universal coverage should embrace, rather than fight, diminished employment-based coverage and figure out how to use it.
Among coverage proponents, this strategy will create confusion and anxiety because many of those on the other side of the debate are those who don't support universal coverage (mostly Republicans) are also those who are concerned about the employer costs of the current system and welcome diminished employer roles and contributions.
But my opponent's unconcern should not be the cause of mine. Employment as today's foundation for coverage is awkward, antiquated, and expensive. It's barely adequate for today, much for the future.