Want healthcare reform? Change your terminology

We all know that words matter. Why don't we pay attention to the words we use in health policy?

Executive summary

• We use the wrong words to describe the US healthcare system. In doing so, we mislead people into thinking that it reflects conservative values. This makes conservative voters resistant to healthcare reforms that they would otherwise support.

• We all describe US healthcare as “private insurance” in a “for-profit, market-based” economic structure. Those terms are misleading. It’s way broader than mere insurance; the for-profit nature is irrelevant; and it definitely isn’t market-based.

• US healthcare is more accurately described as “privatized entitlement programs” funded by “privatized taxes” in a “socialized” economic structure. Money is taken from paychecks (a tax) and used to pay for other people’s care (socialism).

• “Privatized entitlement programs” funded by “privatized taxes” in a “socialized” economic structure sounds weird, irrational, and awkward. But that’s because US healthcare’s economic structure IS weird, irrational, and awkward. We shouldn’t sugar-coat it.

• This change in terminology (using words that clarify that the current US healthcare system does not reflect conservative values) can produce political consensus to implement a lower-cost, less-bureaucratic healthcare system.

Introduction

What words do you use to describe someone taking money from your paychecks and using that money to pay for stuff for other people? 

I don’t know - perhaps you would say that you’re being “taxed.” Maybe you’d say that your taxes are being used to run an “entitlement program.” Maybe you’d call the people taking your money “bureaucrats” or “tax collectors,” and maybe you’d call the whole thing a kind of “socialism.”

In describing US healthcare, we don’t use any of those words. However, that’s exactly how US healthcare works: someone takes money from your paychecks and uses that money to pay for stuff for other people.

Instead of calling it a “tax,” we call it a “premium.”

Instead of calling them “tax collectors” or “bureaucrats,” we call them “insurance companies.”

Instead of calling it “socialism,” we call it “for-profit” or “market-based.”

You might think I’m just being pedantic, but I’d argue this terminology is supremely important. The misleading euphemisms we currently use are essential in maintaining public opposition to healthcare reform. They (falsely) portray our existing healthcare system as being palatable to conservative voters. 

A more truthful - but awkward - description of US healthcare is this: a system that taxes people (through the IRS, but also through private tax collectors), socializes their tax money, and uses that money to run thousands of duplicative healthcare entitlement programs.

This description is more honest and accurate. Also, it makes it clear that the system shouldn’t be palatable at all to conservative voters.

This is important - our terminology should not only be technically accurate, but also enlightening. We should use terminology that gets rid of misconceptions about the nature of the US healthcare system.

So without further ado, let’s look at each inaccurate/misleading term we currently use when referring to the US healthcare system and replace each of them with a more accurate, more enlightening term.

“Health insurance” isn’t really insurance

Inaccurate, misleading term: “health insurance”

Accurate, enlightening term: “private health entitlement program”

Insurance is something that covers large, unexpected expenses. US healthcare plans, on the other hand, covers all expenses, expected and unexpected. We shouldn’t call the plans offered UnitedHealth, BCBS, and Cigna “health insurance.”

Does Geico determine which gas stations are “in network” for you or how much you’ll pay for a Honda vs a Ford? Do you have to get prior authorization from Geico before booking a flight?  Does your homeowner’s insurance determine how many bedrooms you can have or what neighborhood you can live in?

American “health insurance,” unlike actual insurance, inserts itself into the middle of every transaction, not just those for expensive, unpredictable events. It covers everything from wart removal to ankle surgery to psychotherapy to physical therapy to blood pressure medication. If car insurance or homeowner’s insurance worked this way, we’d think it was ridiculous.

This is not a unique observation on my part - other commentators have noted that the term “insurance” is a poor descriptor for US healthcare plans.

Since US “health insurance” plans are so weird, there isn’t a perfect word to describe them. In my opinion, though, the best option would be the term “private entitlement program.” A US healthcare plan entitles you (the beneficiary) to certain rates for an expansive set of goods and services within an entire sector. 

Avoiding the term “insurance” clarifies that US healthcare plans are far broader than actual insurance. Using the term “entitlement program” is helpful in enabling laypeople to understand that US healthcare isn’t associated with greater financial freedom/liberty/independence than “socialized medicine” (which I’ll discuss later).

If it isn’t insurance, we shouldn’t call the payments “premiums”

Inaccurate, misleading term: “health premiums”

Accurate, enlightening term: “health taxes”

I think this is fairly straightforward. If health insurance isn’t insurance, we shouldn’t call the money taken from people’s paychecks “premiums.” But if we don’t call it a “premium,” what should we call it?

Well, since what we call “premiums” are really just money taken out of your paychecks and sent to a bureaucrat, I think it makes the most sense to call them “health taxes” or “privatized health taxes.” 

A “privatized health tax” sounds bizarre, but again, that’s because it is bizarre. Nothing about the way US healthcare works is sensible.

Calling premiums “health taxes” helps the layperson better understand how the healthcare industry works. For instance, calling premiums “health taxes” would enable the layperson to understand that the concept of "I pay government workers' salaries via the money taken from my paychecks" applies to the salaries of healthcare industry workers as well. It also helps the layperson understand the fundamentally “socialist” nature of the existing economic structure, too.

“Health insurance companies” are just tax collectors for healthcare

Inaccurate, misleading term: “insurance company”

Accurate, enlightening terms: “health tax collector,” “private tax collector,” “private IRS,” “health entitlement program administrator,” or “private health bureaucrats”

Since “health insurance” isn’t really an insurance product, and the payments aren’t really “premiums,” what should we call the companies collecting the taxes and administering the entitlement programs?

The most straightforward term for an organization collecting a tax is simply a “tax collector.” Since the tax collector also does the administration of the entitlement program (that is, BCBS, UnitedHealth, and Cigna both take money from people’s paychecks and spend that money on other people’s care), it’s also fair to call a “health insurance company” an “entitlement program administrator” or a “bureaucrat” in addition to a “tax collector.”

The term “bureaucrat” aligns with laypeople’s personal experience with “health insurance” companies - the customer experience when dealing with BCBS or UnitedHealth is much similar to the experience of dealing with other bureaucracies (like the DMV) than dealing with a business operating in a market-based industry. Which leads me to my next term…

US healthcare is not “market-based competition”

Inaccurate, misleading term: “market-based competition”

Accurate, enlightening term: “private socialized medicine”

Under no circumstance should the US healthcare system be confused with “market-based competition.” It is a system based on socializing financial power away from the individual and using those socialized financial resources to pay for members of the group.

As a reminder of what an actual market-based industry looks like, consider the food industry. Consumers choose restaurants and grocery stores based on price and quality. There are no bureaucratic middlemen. 

Is money taken out of your paycheck, sent to a collective pool managed by a distant bureaucrat at a food insurance company, and used to provide you access to grocery stores and restaurants? Are there in-network restaurants where you get meals for free? Of course not.

When money is taken out of your paycheck and combined in a big pool of money with other people’s money, purchases made using that money are not “market” purchases. “Market” purchases are ones in which consumers evaluate the goods and services offered by producers based on price, quality, and convenience and pay the producers directly.

Calling US healthcare a form of “private socialized medicine” enables the layperson to grasp how fundamentally bizarre US healthcare is as an economic system.

The “for-profit” status of much of the industry is irrelevant

Accurate but often misleading term: “for-profit”

While terms like “insurance” and “market-based competition” are inaccurate descriptors for US healthcare, the term “for-profit” is an accurate but misleading descriptor. 

It’s true that the bulk of providers in the US are for-profit, and it’s true that many payers are for-profit. However, it isn’t a particularly important characteristic of the US healthcare system. It isn’t why US healthcare doesn’t work.

When the term “for-profit” is used in discussions of the US healthcare system, it’s often used as a criticism. The implication is typically that our healthcare system would improve if the profit motive were removed. 

The simplest way to understand that the profit motive isn’t the problem with the US healthcare system is to look at the behavior of non-profit providers - virtually indistinguishable from the for-profit providers. If all hospitals, doctors, drug companies, and payers in the US healthcare system were converted to non-profit entities, nothing would meaningfully change in the US healthcare system.

If “for-profit” is an accurate descriptor, how can it be misleading? It’s misleading because economic systems that involve for-profit elements typically also involve market-based competition. 

When laypeople hear the term “for-profit” used in reference to US healthcare, they assume that US healthcare must involve more market-based competition than other healthcare systems, which - as we discussed above - is not the case. That’s why it’s important that we use the term carefully, even if it’s technically correct in many cases. 

Conclusion

The goal of writing/speaking is to transfer a concept from the author/speaker's mind to the reader/listener's mind. For those of us involved in healthcare policy, our goal when writing/speaking should be to communicate concepts to the public in a way that enables the public to understand the dynamics of the healthcare system as fully and accurately as possible.

We’ve failed to achieve this goal. If you ask any member of the general public - Republican or Democrat - they’ll say the US healthcare system is an alternative to socialized medicine. They’ll say single payer is a move towards socialized medicine. They’ll say that our healthcare system is unique because it’s a for-profit system. And they’ll be dead wrong.

But they’ll be justified in being mistaken. They’ll be justified because the terminology used by those of us in health policy has actively nurtured the public’s misconceptions about US healthcare. The language we use has implied to the layperson that US healthcare is a market-based alternative to single payer.

It’s time we improved our communication. “A socialized medicine system based on redundant entitlement programs run by thousands of private tax collectors in addition to the primary tax collector” sounds absurd. But again, that’s because it is absurd. Let’s stop using euphemisms that hide how absurd the concept is.