Consider the following health insurance plan.
It refuses to pay for certain medical care and then doesn't offer a clear explanation. It does pay for unhelpful care that ends up raising premiums. Its customer service can be hard to reach or unhelpful. And the people who are covered by this insurer have no choice but to remain with it — or, at best, to choose from one or two other insurers that are about as bad.
In all likelihood, I have just described your insurance plan.
Health insurers often act like monopolies — like a cable company or the Department of Motor Vehicles — because they resemble monopolies. Consumers, instead of being able to choose freely among insurers, are restricted to the plans their employer offers. So insurers are spared the rigors of true competition, and they end up with high costs and spotty service.
Americans give lower marks to their health insurer than they do to their life insurer, their auto insurer or their bank, according to the American Customer Satisfaction Index. Even the Postal Service gets better marks. (Cable companies, however, get worse ones.) No wonder President Obama's favorite villain is health insurers.
You might think, then, that a central goal of health reform would be to offer people more choice. But it isn't.
Real choice is not part of the bills moving through the Democratic-led Congress; even if the much-debated government-run insurance plan was created, it would not be available to most people who already have coverage. Republicans, meanwhile, have shown no interest in making insurance choice part of a compromise they could accept. Both parties are protecting the insurers.
That's a reflection of the thorny politics of health care. On one hand, big interest groups are lobbying hard to keep some form of the status quo. Insurers don't want people to have more choice. Neither do employers and labor unions, which now control huge piles of money spent on health care. Nor do hospitals and drug makers, which benefit from all the waste now in the system.
On the other hand, the people who stand to benefit most from having more choice — all of us — are not agitating for change, because the costs of the system are hidden from us. A typical household spends $15,000 each year on health care. But most of it comes in the form of taxes or employer deductions from paychecks, which means insurance can seem practically free.
As a result, people may not like their insurer, but they don't hate it, either. If anything, they are more anxious about losing their insurance than they are eager to be given more choice. And that anxiety has driven the White House's decision to pursue a fairly conservative form of health reform.
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