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How to make the health care system fairer for young people

April 13, 2021, 3:00 PM UTC
"The current model of insurance is shipwrecking young people’s financial future," write the authors. "We can turn things around by breaking away and demanding better."
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Following a new executive order, the Affordable Care Act (or “Obamacare”) marketplace enrollment recently reopened to help people regain health insurance lost during the pandemic. While not a bad idea, it will not be life-changing for very many Americans. A surprising number have managed to hold onto coverage, evidenced by stable enrollment numbers.

Instead of the usual obsession over insurance, we should pay more attention to overall access to care, where our money flows, and how the system penalizes younger generations. With the right reforms and a better awareness of the tools and flexibility already at our disposal, young Americans just might be able to change the script.

Health insurance is not the same thing as health care, especially when it requires the average family of four to pay over $28,600 in yearly premiums with a high deductible. Today, the rule is simple: The elderly reap more in benefits than they paid into the system. The current young generation stands to pay more than they’ll one day receive. And if the economic crisis we’ve been facing is truly unprecedented, we won’t be able to cure funding problems with old solutions—especially when they haven’t worked in the past.

Indeed, modern American history is replete with instances of radical change to the system. World War II gave us the tax exemption on health insurance, the Great Society created Medicare and Medicaid, and the Affordable Care Act promised affordable coverage for all through subsidized plans and Medicaid expansion.

Somehow, health care still topped the list of Americans’ policy priorities in the 2018 midterms, and was second only to the economy in an eventful 2020 election. If insanity is doing the same thing repeatedly and expecting different results, we have every reason to doubt that another top-down reform will be a silver bullet.

Since the tax exemption for employer-sponsored coverage was implemented decades ago, private health insurance has become inextricably tied to employment. This model is ill-suited to today’s economy, where contracting to freelancers, flexible hours, performance-based pay, and (in some cases) the absence of traditional benefits abound. Ballooning costs have helped family health care premiums reach a full third of the median U.S. household income. No wonder some independent workers think twice before signing onto individual health plans.

These high costs should worry everyone, not just independent workers. They provide a potent explanation for the stagnating buying power of our generations’ wages. 

A swath of the American population has—thankfully—no need for the luxurious services their insurance covers. Adults ages 19 to 34 use on average $2,500 a year worth of health care services, yet their employers spend multiple times that on insurance for them every year. Workers have little-to-no ability to choose higher wages or spend this money on benefits better-tailored to their needs.

Absurdly generous insurance isn’t the only problem. Without significant changes, there is virtually no chance young people will benefit from Medicare coverage—for which they pay a 2.9% tax—in the same manner current beneficiaries do. On its current trajectory, the program will become insolvent this decade.

Not all hope is lost, though. Recent reforms have started to expand our options, and young people need to take advantage of them.

First, we can save pre-tax money today by maxing out health savings accounts (HSAs), which work like retirement accounts for health care, offering accountholders the option to invest and earn returns. At this time, they are only available for people enrolled in high-deductible health plans, and the range of services on which the funds can be spent is relatively narrow. But the CARES Act added welcome flexibilities, extending HSA funds to pay for the purchase of menstrual products and over-the-counter medicines.

Obamacare allows children to remain on their parents’ insurance until age 26. With millions of  people that age working, that means millions of covered individuals have jobs and yet consume little healthcare. The hypothetical person who starts work around age 18 has an eight-year opportunity to save, take advantage of existing arrangements to build an HSA, and invest unspent HSA funds to earn returns. 

But to encourage more young people to do this, Congress should consider revising some of the limits of participating in HSAs, especially the prerequisite of enrollment in a high-deductible plan. Anyone, regardless of their plan, should be allowed to set up an HSA.

Another category of benefits, health reimbursement arrangements (HRAs), give employers the ability to offer benefits without bending the knee before large insurance companies. It lets them put the cash they would have spent on insurance into accounts that employees can use to purchase the plans of their choice in the individual marketplace.

HRAs are a boon to companies that are looking to attract talent but cannot afford today’s sky-high premiums. The more people have HRAs, the more people will be flowing to the individual market, which will become increasingly affordable with more participants.

The current model of insurance is breaking the bank, shipwrecking young people’s financial future and ultimately jeopardizing our health. We can turn things around by breaking away and demanding better.

Kofi Ampaabeng is a senior research fellow and data scientist and Elise Amez-Droz is a program manager at the Mercatus Center at George Mason University.