How the argument for universal coverage changed

Suppose it were the case that health insurance did not lead to any health benefit. Then whatever financial protection function it provided would also be indicted, as would medicine itself. After all, it's well known that insurance facilitates use of medical care. If such utilization is of literally zero value, the right policy move would not be to continue to encourage insurance coverage. The right move would be an education campaign to help people appreciate how useless health care is. Of course, the actual debate isn't whether health insurance and health care, or some of it, are of any value. Though their value is of some debate, it is generally accepted as positive. Most of the debate is over whether the value they offer is worth the price (or cost). So, one broad research agenda has been to estimate that value and another has been to document that price. This research takes myriad forms, and hardly a day goes by when some aspect of it isn't discussed on TIE and elsewhere. Yet another strand of literature addresses the financial protection functions of health insurance. But of the three strands I have just mentioned -- value, price, and financial protection -- it is this latter one that is the oldest justification for coverage expansion. Over time, the emphasis of value/price vs. financial protection as justification for health insurance has shifted. In his inaugural editorial in Inquiry (2007), Alan Moneheit documented this shift. It's ungated and worth reading in full. In the early part of the 20th century, the notion that health insurance would enhance health was largely taken for granted. Proponents of coverage expansion, therefore, stressed the financial protection it would offer. For a variety of reasons Monheit explores, from the 1960s through relatively recently, the extent to which health insurance offers health benefits has been the subject of academic scrutiny. Though not mentioned in his piece, the RAND Health Insurance Experiment played a role in this debate. By contrast, during this period, the extent to which health insurance offers financial protection received relatively less attention, almost as if that matter had been settled. Then the argument shifted again.

Most recently, evidence has emerged suggesting that the perspectives of improved health outcomes and financial risk reduction may not be independent with regard to the performance of health insurance. For example, cost-sharing has been found to deter patients with chronic illnesses from complying with treatment, leading to unfavorable clinical outcomes and possible future health care costs. Moreover, the financial protection afforded by health insurance can make resources available to purchase other inputs to the production of health (such as nutritious food, education, and better housing). Although findings are not conclusive, a recent strand of literature has examined whether financial insecurity may have a causal impact on health status through its impact on psychological stress and anxiety.