It is amazing how quickly a benefit becomes an expectation becomes a right. Our immersion in the present blinds us to the recent past from which we have just emerged. The phenomena to which I am referring are employer-based health care–and contraceptive–benefits.
The idea of social insurance originated in the late 19th C in Europe, but took root more slowly in the US. Here the most popular form of social insurance in the early 20th C was “industrial” life insurance, providing funds to cover the expenses of the final illness and burial. “Sickness” insurance, where it existed, arose primarily for purposes of financial stabilization during illness, and were initially offered as a benefit by employers to enhance worker loyalty. Actual “health” insurance was a later addition.
But even with the advent of health insurance, “health” and “health benefits” were narrowly defined. It is only within the last decade that insurers have begun to include contraceptives in their benefit package. Prior to that the only form of contraceptive covered was sterilization. But that benefit has morphed quite quickly in the social rhetoric to an expectation and a right.
An editorial in the NEJM, January 2014, entitled “Contraception at Risk,” cites the two cases currently before the US Supreme Court arising from the ACA mandate: Sibelius v Hobby Lobby Stores, Inc. and Conestoga Wood Specialties Corp. v Sibelius. While the editorial avoids explicit use of the term “right” in reference to the provision of contraceptive benefits, the idea is implicit in the it’s reference to contraception as a “compelling public health need” and as an essential ingredient in “high-quality medical care” (others, like R. Alta Charo, J.D. are not so nuanced). Furthermore, the authors make the lofty and vaporous claim that “the welfare of the patient must trump the religious convictions of her employer…for after all, it is the woman, not her employer, whose health is at risk.” Such claims fail to acknowledge that while some contraceptive agents are an option for treating some medical conditions, the primary indication for their use is not medical care but life-style management.
But this raises a provocative question: why do businesses remain in the health care benefit business? Why should businesses, many of whom are struggling to maintain financial solvency during these times of economic uncertainty, continue to subsidize health care for their employees? Why should health insurance remain yoked to employment and employers? In reality, that is one of the factors contributing to the high percentage of un- and under-insured in this country—the fact that those who are unemployed or part-time employees are denied benefits. Perhaps it is time in this country to sever health insurance from employment and make it true “social insurance” putting it in the hands of the government or government-subsidized insurance plans. That would end part of the controversy over contraceptive coverage, allowing businesses to focus on their business, not health care coverage, and allowing persons to purchase subsidized plans that met their needs, eliminating questions of conscience. Such a move would lay to rest an area of considerable political strife that divides us all.
What would be required? A voluntary and consensual agreement on the part of all businesses (or alternatively, a governmental mandate–the former is preferable) to cease provision of such benefits to their employees, returning those savings to them in the form of higher wages which employees could then use to purchase their own plan. For those businesses that refused to do so in an attempt to maintain a competitive edge, there could be governmentally-imposed financial penalties.
Employer-based health care benefits has been just that–a beneficent benefit, not a right. But now, as an expectation, it is no longer a gift. It was a good idea in its time, but one whose time in the sun has come to an end. So it is time to shift the responsibility for this expectation elsewhere, and the only other logical entity is the government. “But,” some would argue, “that would allow too much governmental intrusion into the health care—into the profession of medicine!” To that I would say, “Wake up, Goldilocks. There is not only an intruder in your house; he’s already sleeping (and snoring loudly) in your bed.”