Grace-Marie Turner

The Commonwealth Fund continues its advocacy for universal coverage and a larger role for government in our health sector with a new paper in Health Affairs: It cites the rising number of people with health coverage that does not adequately protect them from high medical expenses — the under-insured.

News coverage has headlined the study's finding of a 60% increase in the number of people who are underinsured since 2003, bringing to more than 25 million the number of adults under age 65 who "had inadequate insurance in 2007." You will hear this number repeated often in the political debate this year, but it is worth noting that the number is based solely upon subjective recollections of participants in a telephone survey taken last year.

Here's the back story: People are considered underinsured if they had out of pocket medical expenses equal to 10% of their income (5% for those earning under $40,000) or if their deductible was 5% or more of their income.

That means that if a family earning $60,000 a year purchased a health insurance policy with a $3,000 deductible, they were underinsured, even if they chose that option — as they very well might do in order to save on insurance premiums and qualify for a Health Savings Account.

Certainly there are millions of people for whom paying for health care and health insurance is a hardship. But should those who choose the sensible option of buying a more affordable, higher-deductible policy also be considered victims of the system?

Yes, the authors imply, led by Cathy Schoen, senior vice president of Commonwealth.

This gets to the fundamental definition of health insurance: Should it provide financial protection against major medical bills or protect against even moderate expenditures on health care? That is a valid policy question, but one ignored by the study.

Fast forward to a system where government domination of the health system is firmly established — in Italy. I spoke in Milan last Friday at a seminar sponsored by my good friend and colleague, Alberto Mingardi, director of the Istituto Bruno Leoni.

While academics predictably defended their system as fair and equitable, others said that it was increasingly not serving its citizens: A lack of public money leads to shortages of personnel, equipment, surgical time, diagnostics, and medicines.

"We have a promise of universal care in name only," one participant told me.

Clearly, the problems of cost and access to care are universal.

Europeans increasingly are facing a more informed patient population that is gaining access to information via the Internet and demanding greater access to care and new medicines. These nations recognize that consumerism is inevitable, and some are looking at new models of supplementary private insurance and even Health Savings Accounts to meet patient demands.

They have a hard time listening to the ideas and innovations offered in the U.S. because they have been so poisoned against our system by the constant drumbeat tearing it down. But the U.S. system is flexible and adaptive, and these ideas and innovations could be beneficial.

No one country has a lock on the right solution. But recognizing that all of us share similar problems would be a big step toward exploring solutions enabled by a more efficient and rational use of resources and a more informed, engaged patient population.

Grace-Marie Turner

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