In the debate over national health care, people do not seem to differentiate between health insurance and health care. They are not the same thing.

There are certain things that all humans, indeed all living creatures, need. Food, shelter, clean drinking water, and health care are all necessary to live a happy and long life. This has always been true. Health insurance, on the other hand, did not exist until some time in the last century. As with most things, it’s original form was different from what we know as health insurance today. At what point it changed from one to another is as debatable as the point at which dough turns into bread, and as irrelevant.

The current debate is virtually always framed as a debate on health care when, in fact it is primarily a debate on health insurance. Having insurance does NOT guarantee medical care. If you have health insurance, think about the process you have to go through to get testing or an appointment with a specialist. It’s not easy, and it is definitely NOT guaranteed. Even if your doctor is adamant that you need the test or appointment and goes to bat for you with the insurance company, the insurance company may still deny coverage. Even if they allow it, you’ll still have to pay some portion of it out of pocket.

You can receive health care without health insurance. Our grandparents and great-grandparents and all those who came before them went to their doctor directly for care. They generally paid him, or her, directly. In some cases, the doctor worked pro bono, or without payment, because they knew the person couldn’t afford to pay. The payment might have been cash. It could also have been barter – goods or services the doctor could use, such as fresh eggs or piano lessons for their child. The patient or their family could have done work for them, such as rebuilding a fence. Whatever form it took, they paid directly to the doctor. Since they didn’t have to wait for payment or go back and forth with insurance companies about it, the doctor didn’t need as much office staff, which kept costs lower. Doctors still happily accept cash payments, which is why rich people may opt to not buy health insurance – they can simply pay cash for their care, if they need it.

Clearly, times have changed. It is rare to pay cash for health care. Today, one common benefit of having a job is getting health insurance that your company pays for. One website I read said that health insurance became popular when wages were frozen during World War II. It was a way to increase compensation without increasing base pay.  Think about the time of year when you have to decide on your health insurance plans for the next year. Once you choose, you’re committed to that plan for the entire year, unless you change jobs.

How much time does choosing a plan take? How certain are you that you made the right choice? Do you ever wish you could change before the year is up? If companies did not pay for health insurance, what other ways could that $400 (this is a random number) or more per month of company contributions be used to pay for health care? Could it go into a healthcare reimbursement account? If it did, do you think you would spend all that money in one year? Would the healthcare accounts need changed so money could stay in them long, maybe even indefinitely? If so, do you think you would spend it eventually? What do you think employers would think of putting a set amount of money into an account instead of having to choose plans to offer their employees, provide advice and information to help their employees enroll, collect information from their employees, actually enroll their employees, etc.? (The process isn’t short or easy for either employers or employees.)

The question we need to be asking is not how do we get health insurance for everyone, but rather how do we get health care for everyone. Health insurance may be the means to that end, but it may not be. At this point, continuing to ask the same question – how do we get everyone covered by health insurance, whether they want it or not – is not helping us reach a solution. If we want a solution, and I think everyone really does, then we need to change the conversation, and the first step is by changing the question we start the conversation with.

The next time someone brings up health care reform, what question will you bring to the conversation?