[ Pobierz całość w formacie PDF ]
.And suppose the United Statesenacted a new income-security program that assumed that we face, or preferto face, income unpredictability not in equal but in unequal degrees in accor-dance, say, with George W.Bush s ill-fated proposal to set up personalinvestment accounts in Social Security.Neither McGovern/Ackerman-Alstott nor a partially privatized Social Secu-rity system has gained much political traction in America.And that may be 0333-4-09 ch09:Layout 1 10/29/09 3:38 PM Page 130130 HEALTH CAREbecause, at the deepest level, programs like these are unable to tap into eitherthe self-interest or altruism required to mobilize support from those who arebetter off.A McGovern/Ackerman-Alstott scheme would not appeal on altru-istic grounds because the better-off would be getting back just as much as theworse-off would; nor would it be attractive on self-interested grounds, becausethe better-off would be getting back less than they gave in the progressive taxesneeded to fund the program.As for privatizing part of Social Security, theensuing inequality of portfolio sizes would vitiate any self-interested need, orreason, for better-off individuals to continue participating in the larger pro-gram.At the same time, the inevitable uncertainty besetting their ownportfolios would dampen any altruistic motivation that they might otherwisehave harnessed for contributing to the savings of others.These tensions within U.S.public income-security programs are apparentin that other major area of the welfare state: private health insurance.It mayseem odd to call private health insurance a component of the welfare state, butcertainly its proponents believe it to be an adequate substitute for any publichealth insurance plan that might otherwise cover that part of the populationthat does not receive Medicaid or Medicare.6 Of course, unlike income-security programs, whose linchpin is redistribution from rich to poor, with pri-vate health insurance, redistribution is from healthy to sick.But privateinsurance has always resembled public income security in that it, too, relies onlinking equality with unpredictability and inequality with predictability.More specifically, private health insurance has always relied on the ideathat, to the extent that our health care needs are unpredictable, we face themequally: a spinal injury from a car accident, for example, or the onset of Park-inson s in an individual with no previous warning signs.Such risks areunpredictable because they have not yet manifested themselves in a symptomor a family history at the time the insurance contract takes effect.And they areequally faced precisely because since their faintest glimmerings lie entirely inthe future no one member of the community can be said to bear such risksmore than any other.We all (as far as one can calculate ex ante) face themequally.Conversely, to the extent that we know what our health care needs areor are likely to be, then, private insurance traditionally assumes, we face themunequally.If A has Type 1 diabetes and B does not, A will need insulin and Bwill not.Such expenses are predictable and are faced unequally because onlythose diagnosed with certain symptoms will predictably need insulin.Of course, there are innumerable gradations between the equally facedunpredictability with which accidents may strike and the completely pre-dictable inequality that arises because A has diabetes and B does not.Insurers, 0333-4-09 ch09:Layout 1 10/29/09 3:38 PM Page 131FOR RICHER AND FOR POORER, BUT NOT IN SICKNESS AND IN HEALTH 131for example, will charge the cohort of seventy-year-old men a higher premiumthan that of fifty-year-old men.As a group, the former s predictable risk ofprostate cancer is greater than in the male community as a whole, even if,within the group, it is not possible to tell which individuals will or will notdevelop it.Within the group, in other words, there is equal unpredictability, butbetween the group and the community, there is a predictable inequality.Thegroup collectively has a comparatively predictable and unequally greater like-lihood of developing cancer cases.The existence, for the purposes of setting premiums, of such groups asseventy-year-old-men testifies to the larger point: the less predictable the onsetof any given condition is for any given person the less we can tell who willexperience it the more equally the risk of it confronts members of the com-munity.And the more predictable a need is for any given person the morewe can tell who will experience it and who not the more we face it withinterpersonal inequality.Because of this, private health insurance has, at leastup until now, always been able to call upon both self-interest and altruism tomotivate redistribution from healthy to sick not perfectly, of course, butenough to make for a functioning (if often perilously unstable) system.To the extent that private health insurance covers risks that we face withequal unpredictability, the motivation for those who turn out to be healthy tohelp those who turn out to be sick is self-interest: it just as easily could havebeen the other way round.As for needs that are more predictable for any givenindividual and hence faced with greater inequality across individuals, privatehealth insurance relies on altruism.A nondiabetic worker in a given workplacewill pay the same health insurance premium as a diabetic worker, therebyhelping to defray the latter s predictable, unequal, higher expense.Only animplicit altruism could explain this.Or, as the Princeton health-policy analystsTsung-mei Cheng and Uwe E.Reinhardt put it, A positive externality in theconsumption of health care occurs when individual A derives happiness fromknowing that individual B receives health care of a given type. 7Even critics of private health insurance buy into these conceptual premises.Ron Pollack of Families USA, for example, speaks of health insurance partic-ipation as being partly an issue of altruism for a discrete and disadvantagedpopulation, and partly one of self-interest for a very substantial part of thepopulation. 8 Indeed, one recent innovation in private health insurance, thecombination of catastrophic coverage with individual Health SavingsAccounts, simply highlights this distinction.The catastrophic plan is meant tocover relatively large, unpredictable needs we face with equality, while theHealth Savings Account is available for smaller, mostly predictable needs we 0333-4-09 ch09:Layout 1 10/29/09 3:38 PM Page 132132 HEALTH CAREeach face to our own unequal degrees and, on some such proposals, theywould be subsidized for those whose medical needs are greater
[ Pobierz całość w formacie PDF ]
