2013 Offensive Cliche Winner Is `Skin in the Game'
It's time for pundit New Year resolutions, and I've got one I'd like everyone to consider: Stop using the phrase "skin in the game." The term sometimes fits, although it's still a cliché. But if the context is social policy, it isn't just hackneyed; it's incorrect and offensive.
"Skin in the game" is a useful concept for what economists call the principal-agent problem, in which one party bears the consequences of another party acting on its behalf -- for example, making part of an executive's pay contingent on the performance of the company she's running, aligning her interests with those of company's shareholders.
That logic starts to fall apart when you get to public policy. The clearest example is health care, where the discussion around two tenets of Obamacare -- state exchanges and the Medicaid expansion -- have been infected by a noxious mix of thoughtlessness and rhetorical laziness.
For the exchanges, defenders of high co-payments and deductibles make the same argument they've always made about high-deductible plans: They give patients an incentive to be more careful about the services they use, saving money for everyone.
It isn't clear whether that's true. Sure, a RAND Corp. study on cost-sharing from the 1970s found that people respond to out-of-pocket costs by using fewer services. But as Aaron Carroll wrote in these pages a few weeks ago, people just as often skimp on needed care as unneeded care, which can lead to higher costs down the road.
And even if cost-induced skimping did save money for the health-care system over the long term, praising that approach overlooks the gruesome choices it imposes on beneficiaries. If somebody decided to forgo a procedure they think they need but can't afford, that isn't something any policy maker should be proud of. At best, it's an economic necessity, not something to brag about.
The same goes for governors who have deigned to accept new federal money for Medicaid only on the condition that they can charge premiums to new beneficiaries. Iowa Governor Terry Branstad calls that "skin in the game." Punitive is another word. Remember that we're talking about people who earn no more than 138 percent of the federal poverty level, which was about $21,400 in 2013 for a family of two. What some policy makers call "personal responsibility" others call grocery money.
After all, what is charging premiums to poor people supposed to accomplish, aside from saving face for Republican officials looking for a way to back down from their hysterical opposition to anything associated with Obamacare? It can't be about saving money; if that were the goal, Republican-led states would channel their new Medicaid beneficiaries through the traditional program rather than the exchanges, which cost more.
The "skin in the game" meme has metastasized beyond health care. As the New York Times reported last week, the state of Georgia wants to change a 30-year-old federal program that provides free phone service for the poor. The nominal reason is to prevent fraud, in this case by imposing a monthly fee for the first time.
"There should be some skin in the game," the Times quoted Linda Oviatt, outreach director for the Christian Aid Mission Partnership, as saying. Here again, the original meaning of the phrase has been forgotten: Imposing a fee on poor people won't bring their incentives in line with the people paying the bills. It just gives them an incentive to stop using the program even if they qualify, defeating the program's purpose.
The solution isn't for more people to take Econ 101, though that couldn't hurt. It's to acknowledge that levying fees on the vulnerable is about imposing a cost on people conservatives think are coddled. So let's drop the euphemism and call that it what it is: Callous.
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To contact the author on this story:
Christopher Flavelle at firstname.lastname@example.org