Today in Poor Arguments (Health Care Edition)
From a column in the NYT, What the Republican Health Plan Gets Right
I learn from my patients every day about the benefits, limitations and contradictions of their health insurance. One charming 60-year-old with severe seasonal allergies insists on seeing me every few weeks this time of year, even though I tell her she doesn’t need to — her antihistamines and nasal spray treatment rarely changes. But she worries that her allergies could be hiding an infection, so I investigate her sinuses, throat, lungs and ears. I reassure her, and her insurance (which she buys through New York’s Obamacare exchange) covers the bill.
If she was responsible for more than a small co-payment for these visits, I’m sure I would see her less often.
[…]
Why shouldn’t a patient who is risk-averse pay more for coverage she might never need, while that construction worker be allowed to choose a cheaper insurance plan that might cover only the essentials?
Ok, these are not invalid points, but the reason I noticed them, and why I am commenting on them, is because the basic dynamic being described is a pre-existing condition (if I can use the term) of our health insurance system. While the AHCA does provide for more high risk pools it does not, as best as I can tell, really address the problem of the allergy lady in the anecdote.
One of the aspects of the health care debate that drives me a bit crazy is that every aspect of our system that is problematic is blamed on the ACA. Now, on the one, fair enough in the sense that the ACA deepened the pre-ACA system. But, on the other, it is not intellectually honest to pretend like a pricing system in which patients pay a co-pay and insurance pays the rest is the result of the ACA (or to act like the AHCA fixes the price distortions in the system).
Of course, the example in question underscore that a) we do not have a pure market for health care, and b) health care decisions are not always perfectly rational.
“One of the aspects of the health care debate that drives me a bit crazy is that every aspect of our system that is problematic is blamed on the ACA.”
I don’t know what you are reading, but I’ve not seen any meaningful number of such claims. Sounds like another straw man that so permeates this blog these days.
“But, on the other, it is not intellectually honest to pretend like a pricing system in which patients pay a co-pay and insurance pays the rest is the result of the ACA…”
Again, I don’t know who is making such claims. It is, however, a problem that the young and healthy be forced to pay premiums and deductibles for coverage packages they do not need or want, and are simply designed to subsidize the old an relatively unhealthy, as ACA does.
@Guarneri:
Insurance pools need healthy people who are not (or do not) utilize costly medical care and health services in order to offset the costs of those insured who utilize a lot of medical care services. That’s part of the risk assessment calculus that every insurance company goes through to set premium prices for their plan coverages. Far too many people do not understand insurance pooling and plan pricing.
Companies do not generally offer plans that are tailored specifically to young workers, they offer plans that have a wide array of procedures covered, co-payments required, deductible levels, some perhaps HSA oriented. The coverage I carry through my employer covers maternity (something I will never avail myself of) I do not see that as an unfair burden on me (a male.)
Healthcare is now a 17% share of our GDP, over 3 decades in the past it was around 5%. In most OECD countries the ratio to GDP is about 10%. No other health care system in any advanced country is as costly and inefficient as ours is, and we have many measures of health and medical outcomes that are far less than those in many other advanced countries.
Republicans want to return to a much more market-based pay-to-play system that has led us to the cost and inefficiency that characterizes our health care system today.
If our system is so special, why have no other advanced countries decided to abandon their single-payer health insurance system and move to one that is based on the American model?
A very similar argument could be made against Social Security and Medicare…such a pity that they are such popular programs…
Um… I think physicians are quite familiar with how to deal with hypochondriacs. So, why isn’t this doctor: confirming that the patient really needs to come in or triaging the patient through a nurse and or physician’s assistant instead?
The physician in this case needs to step up and confront the patient. That is his job and part of his professional responsibility.
@Guarneri:
The column as I was referring to was using this as an example of how the AHCA is an improvement over the ACA.
I will admit I overstated my case, so fair enough–I should not have used such absolute language. However, it is not hyperbole, nor a straw man, to note that a lot of criticisms leveled at the health care/insurance system are blamed on the ACA (much like a lot of people blame Common Core for things they don’t like about public education).
@al-Ameda:
Indeed.
How much does this little old lady’s extra visits cost?
Sure, they are wasteful, and a burden on the system, but ultimately, what percentage of health care spending goes to little old ladies coming in because they think their allergies are an infection? (Also, is this woman at higher risk of complications for respiratory infections?)
Before attempting to solve a problem in health care — or any complex process — you need to be able to measure how much of a problem it is, and then how expensive it is going to be to solve it, and what new problems the solution will create. (For instance, if she is of higher risk of complications from respiratory infections, it may actually be cheaper to have her come in when she doesn’t need to, just to catch the one time in 20 when she does before it gets expensive)
Most costs of health care are from end of life care, and major events — childbirth, cancer, bypass surgeries, etc. The routine doctor’s visits are chump change.
Just a bit off Steven’s topic: Some 60% of Americans obtain their health insurance through their employers plan (whether insurance underwritten or self-insured).
In all my years of being covered by an employer sponsored plan ( by several different employers) I don’t think that I ever was given a choice of the insurance carrier (or in the case of self-insured – who managed the plan). I was never given the election to opt-out of (for example) maternity care, or mental health coverage.
I’m not complaining, simply pointing out that 60% of Americans have no choice about their healthcare insurer or the coverage. However, for the some 10% of Americans who obtain their healthcare insurance via the insurance exchange – the republicans would have us believe that it is unconscionable that their might be only one insurer available in an area.
just saying
And, of course, this bill is really about cutting the cost of the ACA so that a tax cut can be given. It really isn’t about much of anything else.
@Guarneri: Young people may not want expensive health insurance, but they also don’t want cancer, skiing accidents or STDs. Or to give birth at home. Or to remove their own appendix.
Also, most young people I know are far more likely to be in favor of single payer health care than old people. Old people scream “that’s socialism!” and “death panels” and “keep the government out of my Medicare”. Young people love Bernie Sanders — and want to keep him healthy.
It is a problem that the young and the healthy subsidize the old and infirm, but it’s the only current alternative to letting the old and infirm die. I would prefer to put more of the costs of society on the upper classes — go back to the tax levels under St. Reagan, perhaps — and then the upper middle class and upper class can subsidize the costs of the old and infirm rather than leaving it to the young and healthy.
So my question to you would be this: who do you want to pay for health care for the old and infirm?
@Gustopher:
As a person with 64-some years of experience in suffering from sinusitis,asthma, and allergies (which have been listed as a preexisting condition in every health insurance policy that I have ever had, BTW), I find myself agreeing with your view on this question. One of the things that my doctors started needing to tell me while I was in Korea (and have continued since my return to the States) was that I needed to be more proactive in seeing the doctor when I think I may have an infection in that my age is starting to interfere with my ability to “tough it out” as I have done in the past.
I have little doubt that the lady of the story is probably a little hypochondriacal. On the other hand the fact that one is paranoid is not proof that no one is out to get them.
@Gustopher: I suspect the answer is “anyone who isn’t named Drew.”
@Steven L. Taylor: As I’ve said: we have average health care in this country, we just pay twice as much for it as any other.
I can’t think of any other thing in life people are willing to pay double for to get the same, but then the level of right-wing bullshit isn’t nearly as high for cars or whatever.
From TFA:
Construction workers actually have pretty tough jobs where they are doing a lot of physical labor in moderately dangerous conditions. I’m a little impressed by the subtle classism show in the editorial — “real men don’t need no stinking health care” — masquerading as standard right wing talking points.
If the construction worker had a good paying union job, he might not have to “choose” a cheaper health insurance that covers only the “basics”
And, aren’t the “basics” just a lowbrow way of saying “essential benefits”?
@Gustopher:
Or rather: but it’s the only current alternative to forcing the old and infirm to move in with their relatives and drain them of all emotional, physical and monetary resources before dying.
Speaking as a life long construction worker….BWAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHA……
Hey idiot? There are no inessentials in health care and we don’t get to pick which maladies we are inflicted with. I have a broke down arthritic body that will attest to that.
Rather than using the example of a 60 year old with several seasonal allergies, how about the mother with the toddler who gets fevers regularly. Most infections are viral but only bacterial can be treated with antibiotics. Should that mother just tough it out in the hopes that the infection is temporary and will go away in a couple of days? I get more will take the child to the local urgent care clinic, especially if she has insurance. I think the option of dunking the fevered child into a bathtub of ice is less than optimal.
Here’s the thing: young healthy people age into older people with declining health and medical problems. See how that works? You pay in more than you get when you’re young and get it back when you’re old. Because, see, you stayed alive long enough to GET old.
Republicans think everyone is as stupid as Republicans.
@al-Ameda:
1. Do you know how much your employer provider health insurance costs you (it ultimately comes out of your total compensation?)
2. How would you feel if you were paying for that from after tax dollars instead of before tax?
@Guarneri: For someone who claims to be a business genius you really don’t understand how insurance works, do you?
@al-Ameda:
It also crosses my mind that men have something to do with the need for maternity coverage.
The problem with the column you take as your point of departure is that the 60 year old lady who goes to her PCP every week to make sure her allergies aren’t pneumonia is irrelevant to the problems with our health care system. Our problem isn’t that a handful of well people are over-utilizing the system. That is simply unsupported by the facts. Our problem is that costs are high and rising faster than incomes or prices in the general economy.
That means either that some people will go without necessary care or some people’s health care must be subsidized or both.
@Dave Schuler: Indeed
@Dan Hill:
Dan, what I’d really like to know (what the pro-choice* advocates think they “know”) is exactly how much does that maternity care insurance inflates the cost of the employee’s premium.
* this “pro-choice” refers to the folks that would like to have policies have many options on their policy.
@Guarneri:
Are you unaware of the concept of employer provided insurance, which does exactly that?
…and weren’t you also saying you’d never seen general complaints about health insurance directed at the ACA?
@David M:
YES, this. I really wonder what the heck people are thinking about when they trot out the “why should the young and healthy pay for…” stuff, when this is EXACTLY what happens in employer-provided health care. The question right back should be, “Okay, how do you think insurers would feel if all of the young employees at XYZ company were permitted to opt-out of the company insurance?”
It’s bizarre to somehow suggest that young people are being persecuted for health care costs when that’s the exact situation that exists in the health care markets that work.
@Dan Hill:
Yes, as a matter of fact, I do.
In most of my previous positions in senior financial management I was responsible for ongoing analysis and review of our health insurance contracts. It was my responsibility to know all financial information concerning the organization commitment to fund employee health and medical insurances.
@Dan Hill:
Interesting that you should raise that question. As I understand it, if Trump gets his tax plan, medical deductions would be eliminated (including the deduct ability of medical insurance premiums) ….. the consequence of course is that your portion of medical premiums for your employer sponsored health insurance would have to be paid out of after tax dollars.
@Guarneri:
Ever since ACA passed, my company has blamed the insurance rate increase each year on it. Which is bullshit since ACA had no impact on the company insurance plan, but as a person I know in HR told me, blaming it on ACA keeps the employees from getting mad at the company and most of them are too uninformed to know better.
@Jen: Yup. I haven’t had an auto accident in decades, or a house fire ever. But I keep paying for people who do. Funny how insurance works that way.
I’m going to buy a car insurance policy from Guarneri Insurance.
It’s great because you don’t need to buy the policy until after you’ve already wrecked the car and know what it will cost to fix everything. After all, what’s the point of buying something if you may never need it?
@Gustopher:
I think the general idea is that “the old and infirm” should drop dead in their fifties or sixties, just as they did back in the mid 20th century. This is the way things were in my childhood, and it’s what people were accustomed to, so it’s clearly what God intended. Also, as a side benefit, not only did the country not need socialized medicine back then, but financing Social Security was cheap and easy.
For some reason, conservatives aren’t willing to make this argument, but I think it underlies their thoughts.