The problem with this analysis and these judgments is that "unaffordable" runs a range of personal definitions from "it's physically and financially impossible" to "I'd rather spend the money somewhere else because paying for health insurance will really cut our/my lifestyle."

There's no doubt that there are millions of people in poverty who simply can't afford any form of health insurance, but based on my observations and experience, there are also millions who choose to gamble with their health care costs for any number of reasons. The problem with this sort of gambling is that society is left with the choice of either (1) picking up the costs in one way or another, either through higher insurance premiums for those who pay, or through longer waits and less adequate care for everyone, or higher taxes on lots of someones or (2) denying care to those who cannot pay, and letting people suffer or die. It's politically quite clear that the second option is not feasible, at least not overtly.

Moreover, as health care costs continue to rise, and they will, given the remarkable advances in medical technology, insurance costs will also rise, and more and more individuals and families will be tempted to opt out of insurance as costs of care and insurance increase... because those costs will reduce the funds available for other goods and services.

Every day, my wife and I see this happening. I've mentioned how many students lack health insurance because their parents won't pay for it, although most plans will cover [if the parents will pay] students through ages from 21-25. The university discontinued its student plan because not enough students would opt for it. In many cases, the parents have incomes above the cut-offs mentioned in the plans now before the Congress, but choose not to pay health insurance. They take vacations, buy new cars, and many even have toys such as snowmobiles and ATVs. Their children also have cars and cell phones and don't have any trouble eating out whenever they want. They do protest that they can't afford sheet music and text books, but they do have all sorts of electronic gadgets.

But... many of these people are among those protesting the President's push for health care reform. People are now screaming that requiring insurance will squeeze people, force small business to close if they're required to come up with insurance for employees, and they're furious about the idea that those families who make more than $66,000 (or $88,000 in the other legislative proposal) will have to pay thousands in tax penalties if they don't buy health insurance.

But who is supposed to pay for their health costs if something goes wrong... as it often does?

Let's look at this in terms of a personal example. My wife and I are fairly healthy individuals, and for ten years after she took her position here at the university, we incurred relatively few major medical costs. Then some eight years ago, we took a vacation to Yellowstone. We were walking, not even hiking, along a gentle slope, and she turned to take a picture. Somehow, she set her foot down wrong and slipped, just slightly, and snapped her ankle and leg in two places. She wasn't carrying extra weight; she was in excellent physical condition; and she didn't have osteoporosis. It was just a freak accident. A year later, after two operations, months in a wheel chair, and physical therapy, she was finally able to walk close to normally... and, of course, after more than $40,000 in medical bills. We were insured, although the co-pay wasn't insignificant, but the total wasn't even close to the cost of more major medical events, such as trauma care from severe auto accidents or cancer treatments, etc. Exactly how many people have even $40,000 to spend on medical costs?

The total savings of the average 60-year old male in the United States amount to something like $50,000, yet the size of the average house has doubled in the last generation, and just compare the size of the "average" American car or SUV to a car of the 1940s or early 1950s. Credit card bills have skyrocketed... but millions of Americans are furious that government is trying to force insurance coverage so that those already covered -- or taxpayers -- don't have to pay more.

As I discussed earlier, medical cost savings are close to a red herring. The rate of cost increases may be held down, but total medical costs aren't going to decrease -- not unless we decide not to treat people or to treat them a lot less extensively.

The entire issue is about who's going to pay for what... and how, and all the arguments avoid that basic issue. Those who are covered now don't want their coverage costs to go up and their benefits to go down, and those who aren't covered seem to want someone else to pay for their care. In some cases, particularly in cases of documented poverty, it's clear that people need help, but it's also clear that there are more than a few people out there who claim that health care insurance is "unaffordable" because they want a standard of care they don't want to pay for, and they resent the possibility of being told that, one way or another, they're going to have to pay the bill one way or another.

So... the questions remain: "unaffordable" for whom, and why do so many claim it is unaffordable, given the American standard of living?

—L.E. Modesitt, Jr.:  9/22/2009 11:02:00 AM