Summary: Those who go without health insurance burden more than just themselves. Persuading individuals to purchase insurance removes this burden on others. Massachusetts and Switzerland demonstrate that universal access to high-quality medical care is possible without turning to single-payer or a purely public sector approach.

Background

The patchwork quilt of plans and programs that is the current U.S. health care system, where access is secured primarily through employer-sponsored insurance supplemented by myriad government programs targeting vulnerable population groups (primarily indigent and elderly), has produced unique problems of affordability and choice. With family premiums at or above $10,000 per year, many Americans go without insurance, instead burdening taxpayers and those with private coverage to fund their care via cost shifting. Many uninsured are doubtless unable to absorb the cost of a standard health insurance policy in their monthly budget. But many, upward of 30 percent of the total number of uninsured at any given time, have annual household incomes that exceed $50,000 (approximately 300 percent of the federal poverty level for a family of four). For individuals who can afford coverage, unwillingness to accept personal responsibility to purchase insurance must explain going without coverage. The “free rider” option is possible because no one is refused necessary care.

The challenge for U.S. health care reform is to improve access to care significantly without jeopardizing quality and patient choice.