In the United States, universal health care is frequently derided as anti-American and liberty-infringing. In The Freedom Premium, Professor Valarie Blake turns this argument on its head by systematically exploring the ways in which our fragmented system of health care coverage influences the fundamental life choices of Americans – where and how much they work, when or if they marry or divorce, and where and with whom they live. Our current approach to health care coverage, she argues, unduly constrains these personal choices and, if freedom is a primary consideration, universal coverage is the answer.
To make this provocative argument, Professor Blake begins by establishing what she terms the “freedom premium” imposed by our system of health care finance, for both means-tested public programs and employer-sponsored insurance (ESI). The freedom premium refers to the incentives embedded in the eligibility provisions and coverage terms of a particular source of health care coverage that influence core social choices. Rather than relying solely on statutory terms to establish the relevant freedom premia, Blake interviews nearly two dozen individuals who have directly grappled with these and other trade-offs inherent in obtaining health coverage. Professor Blake finds, perhaps not surprisingly, that public programs tend to impose the most significant freedom premia on participants, primarily in the areas of work and marriage.
For example, an individual with a disability might decline employment opportunities because, even if their job came with ESI, that coverage would be unlikely to provide coverage for the types of services an individual with a disability requires. To maintain eligibility for Medicaid, the only type of coverage specifically designed to meet the needs of individuals with disabilities, the individual must limit their income and asset levels—for example, by self-employing and paying themselves below-market compensation, or by forgoing work altogether. For those considered categorically needy under Medicaid, income and asset thresholds are lower per person for a married couple than a single individual, creating a disincentive to marry for those who must rely on Medicaid to access health care. Unlike in many other areas of the law, Medicaid (by piggybacking on SSI provisions) actually allows the government to go a step further and treat individuals as married if they hold themselves out as married, creating an incentive not only to forgo legal marriage, but to forgo a committed relationship altogether.
While public programs most obviously impose freedom premia, so too does ESI. Professor Blake catalogs the well-known phenomenon of job lock (where individuals either pick jobs or stay at jobs for purposes of obtaining or retaining specific health insurance benefits), but also highlights less appreciated aspects of ESI’s impact on life choices. For example, as Americans increasingly delay childbearing into their thirties and forties, many workers have children who rely on them for health coverage well past normal retirement age. It is not uncommon, then, for workers otherwise eligible for Medicare to continue working in order to provide coverage for young adult children who can remain on the worker’s ESI through age twenty-five. While this incentive might not strike many as particularly problematic, it not only impacts a worker’s fundamental economic choice, but it also impacts the broader economy and labor market as individuals continue working past expected retirement age.
The solution, Professor Blake argues, is to uncouple eligibility for health benefits from “socially salient categories of work, poverty, and dependency and instead tie benefits to universal criteria like residency or citizenship.” (P. 9.) She works through some of the basic components of a universal system of coverage without getting too far into the weeds of system design. But the power of her argument does not depend on the particulars of a system of universal coverage. Rather, her argument’s power is in plainly stating the truth that the way we finance health care has a significant impact on how people structure their lives.
“Freedom” and “choice” are common buzzwords in debates about health care reform, but they are nearly always used in reference to the freedom to choose one’s own health plan or freedom to see the doctor of one’s choice. What Professor Blake argues is that we need to consider more fundamental personal freedoms—the freedom to marry or not and the freedom to structure one’s working life according to one’s personal and economic preferences—when we contemplate how health coverage should be arranged and financed. Not everyone will be swayed by the position put forward in The Freedom Premium, but the article caused me to think about our fragmented system of health finance in a new way, and I look forward to seeing where Professor Blake takes this line of inquiry in future work.
