Like many people I know, I support the concept of a increasing gasoline tax. The reason for this is straightforward; we want to discourage the wasteful use of this finite resource. As was amply demonstrated when we had a market spike in the price of gas to $4/gallon in the summer of 2008, the consumption of gasoline is in-fact “elastic.” This is fancy economics-speak, that basically translates to “as the price of gasoline goes up, people will use less of it.” Simple concept, everyone gets that. A steadily increasing national gasoline tax, say increasing it $0.25 a year for the next 20 years, nicely and transparently encourages the right kind of consumer and environmental behavior. Use gas wisely.
Now let’s examine the issue of auto-insurance. In the United States we have a fairly vibrant market for auto insurance, with interesting pricing options along at least two dimensions:
(1) Consumers can choose the level of deductable they want to incur. Choose a high deductable, say $1500, and your monthly auto-insurance goes down. This makes rational sense because the auto-insurance companies know that you will now apply rational economic thinking to the day to day costs that you incur. Imagine the reverse, if you had a $0 deductable; why not insist that every small ding, dent or scratch gets immediately fixed?
(2) Auto-insurance is risk-based. If you have a history of speeding, drunk-diving, or auto-accidents, you are a risky driver. Auto-insurance should cost more for you because you are making decisions that are riskier. If you can prove that your driving has become safer, your rates will come down. Again, very rational.
Most states mandate that drivers carry no-fault auto-insurance. This is important because driving is a shared-risk activity. Simply by being on the streets and highways, you incur the risk of being at-fault in an accident or the victim of another drivers irresponsibility. (Conversely, if you never drive, you cannot cause an automobile accident…simple logic dictates that the act of getting behind the wheel raises the risks above zero).
Now because everyone driving poses a risk to other drivers, and uninsured driving is costly to others on the road, a case could be made that we should simply include the cost of auto-insurance in the cost of gasoline. The more you drive, the more gas you use, the more automatic auto-insurance you get. Simple, eh? Yet almost everyone sees the moral-hazard here; we’ve removed the issue of personal responsibility, because both risky and safe drivers get taxed the same way. Speed all you want, run red-lights and take chances, you will pay no more for gasoline than the “55 keeps you safe & alive” person behind you filling their tank. Obvious moral hazards here. So almost everyone agrees that auto-insurance should be priced relative to individually controllable risks.
So that’s auto insurance – what about the right to drive? Driving is economically important. Further, a gasoline tax can be seen as a “regressive tax”, one that effects the poor disproportionally. There is some truth here. A poor person, who drives an old 18mpg clunker 45 miles a day to go to work, will pay a disproportionately higher part of their income toward gasoline vs. a wealthy person who drives a brand new 18mpg sport-utility-truck 45 miles a day to work. Perhaps we should subsidize the cost of gasoline for the poor? Hear we run up against a stark economic fact – if we subsidize gasoline use by the poor, we will encourage the overuse of gasoline. This is the heart of the law of elastic demand. As you raise the price of gasoline the first people to change their behavior will be those most economically affected – this is why you see more poor people on the bus. So if you want less wasteful gasoline usage the people who will lead that charge will be those that are most economically affected -- fair or not, that's the way it is kids. The fair strategy is to invest in subsidizing alternate (less wasteful) means of transportation, e.g. take some of that new gas-tax and pump it into more frequent bus service, trains, etc, to give the poor (and everyone else) more non-gas guzzling options.
The implications for health-care should be obvious.
(1) Healthcare is important, but is a finite resource. Removing price transparency will not encourage its careful usage. This is the fallacy of single-payer argument. Just as “free gasoline” will encourage its wasteful usage, “free healthcare” will encourage the wasteful usage of unnecessary tests and medical procedures. The only alternative to this is a rationing system, where the government decides what care will be supplied to its citizens. This is not necessarily an unacceptable option (Canada does this), but let’s not pretend we can have all the healthcare we want, when we want it, and it will magically get paid for. That system does not, and cannot, exist economically.
(2) Catastrophic health insurance is important for everyone. Simply by living, you pose a potentially large burden on the health system that we all pay for. People get hit by busses. Through no fault of their own, they also fall victim to diseases that are life threatening and expensive to treat. This is a serious, real, and potentially devastating lottery we are all participants in. For this reason alone (shared, faultless risk) a common-scheme for catastrophic risk insurance is necessary if are not to arbitrarily bankrupt members of society. There simply must be a maximum cap in out-of-pocket expenses. This is known as the "high deductible" option.
(3) Personal lifestyle and behavior should play an important role in pricing healthcare. Let’s be crystal clear here: all else being equal, obesity and smoking will result in higher healthcare costs, so will a myriad of other personal choices. To remove these from the day-to-day cost of health-insurance is even less wise than to remove driving behavior from auto-insurance. We should not mandate "safe lifestyle" behavior (that's very anti-freedom), but we should apply clear statistical costs metrics to it.
A baseline
We should have a system where everyone is offered reasonable catastrophic healthcare coverage – this is the price of entry into our society. But this catastrophic health care coverage should kick-in only after a high deductable. Health care decisions below this threshold should be highly price transparent (i.e. out of pocket), so that people make intelligent decisions on the use of a scarce resource. The care provided past this deductable needs to be “rationed care” (meaning that yes, the government will decide what amount of care can be provided based on the need to provide care to the maximum number of people -- there is no other solution to a government funded option).
This is no different that our view on public education. We provide a free K-12 education, because it is clearly in our common interest as a society to do so. The same is true for basic catastrophic coverage. We should offer it to everyone, and it should be very hard (but not impossible) to “opt out”.
Personal responsibility
Just as you are allowed to buy lower deductable auto-insurance, you should be able to buy lower deductable health-insurance. Private insurance can provide both lower deductibles, and higher levels of (non government rationed) service. Importantly, this health-insurance must be adjusted to “personally controllable risk factors” (yes… you can control your weight and smoking habits).
Charity
Should people decide that “the baseline” of high deductable insurance is unfair to the poor (and people will clearly decide this is so), this is a wonderful domain for charity to supplement the baseline. Minimum deductibles can be partly or fully subsidized by charities. Supplemental health services above the “baseline” can be provided or funded by charities. Since we cannot all collectively agree on these supplemental services (e.g. which AIDS drugs should be free? Or shall we concentrate our funds on treating Type II Diabetes? – both worthy causes for sure. What about the right to an abortion for a 15 year old girl? – Clearly we will not all agree!), let’s let individuals decide how they will make society better though their own charity.
ps: An excellent op-ed piece on the subject
And a very interesting NYTimes article on the Swiss heath-care system
Oct 19, 2009, NYT Op-Ed along the same lines
...But there’s another path, equally radical, that’s more in keeping with the traditional American approach to government, taxation and free enterprise. This approach would give up on the costly goal of insuring everyone for everything, forever. Instead, it would seek to insure Americans only against costs that exceed a certain percentage of their income, while expecting them to pay for everyday medical expenditures out of their own pockets.
Such a system would provide universal catastrophic health insurance, in other words, while creating a free market for non-catastrophic care. In the process, it would marry a central conservative insight — that we’ll never control spending so long as Americans are insulated from the true price of their medical care — to the admirable liberal premise that nobody should go bankrupt paying for life-saving treatment...