I'm
back! I apologize for my absence; a combination of personal business,
actual work, and my old motherboard's treacherous decision to stop working
have been keeping me away from this blog for much too long.
One of
the things I've been following in the news is the controversy over
requiring employer-provided health insurance policies to cover birth
control pills in the face of objections from employers who are
morally opposed to birth control, most notably the Catholic Church
and other Catholic institutions. I
am opposed to laws that make an insurance policy illegal because it
doesn't cover everything the government thinks it ought to, so I'm on
the anti-mandate's side as far as the substantive policy question of
whether or not employer-provided insurance should be required to
include contraception is concerned.
My reasons for that
belief are already well-expressed in Sheldon Richman's articles on the
subject at The Freeman here and here, so I'll not reinvent that wheel. There
something else about this controversy worth commenting on, however.
One of the most
conspicuous elements of the whole controversy is the conflation of
government- mandated provision of birth control by insurance
companies with access to birth control, and the lack of such a mandate with actively preventing- or allowing employers to actively prevent- women from acquiring it. (This article at Salon is nicely representative.) This is not surprising, since
many people have an extremely state-focused conception of human life
and society that elides the difference between not having something
provided by the government and forcibly depriving people of it. In this case,
however, I think there's an additional factor at work fueling the
conflation. Namely, what do Americans typically mean when they talk
about health “insurance?”
The purpose of
insurance is, or at least was, to reduce risk- you pay a relatively
small, predictable cost on a regular basis to protect yourself from
the financial consequences of large, unpredictable losses.
In purely dollar
terms, this is a losing proposition, since over a lifetime you're
much more likely to pay more money than you receive. However,
certainty and predictability have value in themselves. Eliminating
or at least reducing the risk of sudden, unpredictable losses make it
easier to form and execute long-range plans, and of course there are
also psychological benefits. Additionally, the declining marginal
utility of money means that the difference in lost well-being between
a small financial loss and a large one can be many times greater than
the difference in dollars.
Now, what's
conspicuous when considering birth control pills in light of the
above is that it just doesn't make much sense for them to be covered
by insurance, especially if they're actually being used for birth
control. They are a regular, predictable, and (compared to treatment
of many serious illnesses or injuries) relatively minor cost, and the
condition they are most commonly used for is highly predictable-
being a sexually active female of childbearing age isn't an exotic
disease.
That's not unique to birth control, by any means
; many medical goods and services
covered by insurance share these qualities. There's no risk of
financial loss being managed- bringing insurance into the picture
just adds an extra pair of hands that the consumer's money passes
through before she gets the product. (Or, if the cost is not ultimately borne by the consumer, simply gives a pseudomarket veneer to what is essentially a government welfare benefit.)
This
outcome is not the product of a free market, and would almost
certainly not occur in one. There are tax benefits to paying
employees part of their compensation and health insurance instead of
money, so many employers do precisely that. Wages that travel from
the employer to the employee to the healthcare provider are taxed,
while wages that travel from the employer to the employee to the
employer's health insurance company to the healthcare provider
aren't, so it makes makes sense to pay for things that aren't really
insurable through insurance companies despite the cost of adding a
middleman. Some jurisdictions push this further by actually punishing
employers above a certain size that don't compensate their employees
in this fashion. Once
the recent health "reform" legislation goes into full
effect, that will become the case nationwide.
Further,
every state has a list of things of things that an insurance policy
must cover, many of them quite extensive, and policies without them
are illegal, so even if you are buying insurance yourself an
insurance policy that is limited to actual insurance rather than
serving as a middleman for regular healthcare expenses isn't an
option. Since insurance coverage is not the magical money fountain
many people seem to think it is, this tends to make it more
expensive.
And meanwhile, the
huge amount of healthcare consumption filtered through third parties
combined with huge amount of medical spending paid for by government
benefits drives up consumption and reduces sensitivity to cost- and
thus incentives to control those costs- by weakening the link between
how much a person consumes and how much it cost them. Which makes
health care in general more expensive and the cost of treatment for
serious illnesses or injuries even more potentially ruinous for the
uninsured.
Those are some of
the economic effects government intervention has had on healthcare in
the United States, which many people have previously pointed out.
What doesn't get mentioned much are the cultural effects, which I
think are being demonstrated in the birth control mandate
controversy. (And in many debates over health care in this country in
general.)
In short, health
insurance is now seen not as a way of managing the risk of unexpected
medical expenses, or even as a way of paying for medical
expenses in general, but as the thing all medical care comes
from. Insurance is so pervasive in the healthcare system that the two
are commonly seen as inseparable, or not even seen as distinct
concepts at all. This pervades political arguments for the subject,
with having “insurance” routinely treated as interchangeable with
having access to medical care.
(Now, if you were to
ask someone who thinks this way, point-blank, if it's possible to buy
medical care directly, they'll no doubt agree that it is. But being
aware of a fact when your attention is specifically called to it is
not the same thing as having that fact in mind whenever it's
relevant. Similarly, treatment and insurance are implicitly
acknowledged as not being equivalent in arguments over the recently
passed requirement that everyone buy health insurance, where the tens
of of millions of poor souls who don't have proper health care
because they can't afford insurance suddenly are able to
afford it, and must be compelled to buy it so that they can't
continue to leech off of the rest of the country by selfishly dumping
the cost of their medical care- which they apparently have
been getting, after all- onto the healthcare system. However, the
inconsistency is almost never pointed out by anyone in the
mainstream, and that bit of doublethink is largely allowed to remain
safely sealed away in its own little bubble.)
In
this light, the often bizarrely overwrought response to the idea of
letting employers who provide insurance choose whether or not that
insurance includes contraception- claims that this would interfere
with or violate a woman's right to birth control, or that it would
mean giving employers control of the medical and reproductive
decisions of their female employees, or is somehow analogous to laws
outlawing (as opposed
to merely not requiring) insurance
provision of drugs like Viagra- start to make a good deal more sense.
After all, most Americans receive health insurance through their
employer, something the government actively encourages and something
the typical liberal/progressive supporter of the contraceptive
mandate for insurance policies thinks the government should
encourage, at least as a
next-best solution if single-payer isn't on the table. (If I
had a dime for every progressive complaint about how awful it is that
this or that employer pays its employees with money rather than a
combination of money and insurance benefits, I'd probably have enough
money to make this whole issue moot by building my own pharmaceutical
plant and just giving birth control pills away.)
In
that context, if health insurance
and access to healthcare are indeed one and the same, allowing
employers to refuse to provide coverage for birth control actually is
more or less equivalent to letting employers decide whether female
employees are allowed to use contraception or not, and the claim that
opposing mandatory birth control coverage is an attack on women's
sexual and reproductive autonomy becomes much more defensible. Thus,
while I still think much of the rhetoric to that effect is a matter
of specifically political assumptions- that something not being done
by government equals it not being done, period- a lot of it is
probably cultural, and is the product of assumptions that are common
among the public in general. Decade after decade, more and more
people have been conditioned to think of health care as something
that always comes through some sort of bureaucracy, either government
or corporate, that stands between the consumers and producers of it,
which the consumers of it are often utterly dependent on- and it
gets harder and harder for people to imagine getting it any other
way.