Sunday, January 09, 2005

Employers' vs Employee's Control of Health Care

In the US, most employers provide employees health insurance benefits. The reasons for this have to do with history and tax law. In World War II, because of wage controls, employers could not bid for scarce employees by offering higher salaries, so they offered other benefits, such as health insurance, instead. Furthermore, employers can deduct employees' health care insurance from their income for tax purposes, while individuals cannot generally deduct what they pay for their own health insurance. This arrangement gives employers, rather than individuals, control over what health insurance options they can choose. It also can even further tilt the balance of power and control over health care to large organizations (large employers) and away from the individuals who actually need the care. Such large organizations may not always make decisions about health care that are best for their individual employees.
One example is an argument that was distributed over two other health care blogs. Medical Rants included a post from Managed Care Matters which argued that "the real issue employers have with health care costs is they have NO sense for their return on the investment. " Thus "what employers SHOULD be thinking about is the demonstrated ability of a health care provider to 'deliver' healthy, fully functional employees and families." Of course, it really is the patient who should be concerned about his or her health care provider's abilities. How a corporate benefits manager could figure out the performance of all employees' health care providers, and then sensibly figure out how to improve them, is unclear. A few comments made this point more eloquently.
A more fundamental confusion appears in a story out of Detroit. A local medical benefits administration company, Weyco, Inc. has apparently decided not to hire any new cigarette smokers, and to fire any current employees who refuse to quit. The rationale by the company president, "increasing health care costs were choking his business." I am a strong advocate of quitting smoking, but as the Detroit News editorialist wrote, punishing smoking employees by firing them has surely "gone too far."

1 comment:

Pogo said...

The ability to fire an employee for continuing to smoke, despite the discomfort it immediately evokes, makes complete sense from the employers viewpoint.

In order to reduce health care spending, both employers and the government are engaging in increasing controls over what were formerly personal health choices. In the past, “public health” referred primarily to communicable diseases. However, when the individual no longer controls their own healthcare spending, private behaviors such as smoking, overeating and using alcohol become quite arguably everybody’s business.

If someone else pays your healthcare bills, what would limit your employer's or the state’s interest in personal choices of food and drink? Indeed virtually any activity could be viewed through the health care lens, and the state might deign to forbid, favor or penalize anything that might reasonably seen as a matter of “public” health.

For example, in 2003, Arkansas legislators mandated that public schools record the body mass index of each student, and send the results home with a warning and nutritional advice to parents. Senator Hillary Clinton expanded on this theme in a NYTimes Magazine piece by introducing the concept of “our collective health”. Citing productivity losses, health expenses and national security, she endorses legislation and national policy governing social and environmental factors to design neighborhoods and schools, “control dangerous behaviors”, and implement “required responsibility” for individual health concerns.

The declaration by the director of the NIH that obesity is a “public health emergency” has initiated an educational campaign, with a call to use tax credits as incentives. In the UK, there is a proposal for a “national nutrition strategy”, including an independent agency with regulatory powers. Quite beyond simple nutrition education, such a national approach would also consider a “fat tax” or imposing legislation on the food industry to achieve the desired product development, marketing and pricing goals.

This might include “using government purchasing power to expand the market for fresh healthy foods while counteracting the current subsidies supporting the ingredients in high fat/sugar/salt products,” and placing restrictions on “the marketing of junk food to children.” Television shows and Internet sites should be altered “to ensure the support of active, healthy lifestyles”. Further, expansion of government control over “transport and rural development policies” was also recommended in order to increase the level of physical activity.

If it is the duty of the government or your employer to prevent people from harming the body by what is ingested (e.g. tobacco, alcohol, high fat content), surely there can be no objection to the state or corporation or HMO limiting those activities that might also result in harm and public expense. Riding a motorcycle, skiing and rock climbing and other high-risk activities become fair game. Mandatory exercise programs are certainly a forseeable result, something China had experience with during the Cultural Revolution..

Further, if these entities demand the right to determine what the human body can or cannot consume, there is no good reason to limit its interest in the effects of media on behavior and the human mind. In order to reduce health costs and prevent harm to society, preventing people from reading bad books or advertisements, listening to bad music or speeches and watching bad TV shows or movies should quite reasonably fall under their purview.

With economic control comes control of the person.