Obamacare and HDHP's -- Reality Bites

In my never-ending quest to produce an oped type article that could get published, I have come up with the following.  When will lightning strike?

On the other hand, I have to admit I don't put much effort into getting my works published -- I send them out to one or two papers and then go back to writing something else. 

Reminds me of the guy who prayed to God to win the lottery.  Amazingly, God appeared.  He said, "Manny, this is your lucky day.  I am God, and I will grant your wish.  I understand you have been a careful man, and you haven't taken many chances in life.  I have heard your wish, and Manny, because you have been respectful and careful, I will grant your wish."  And with that, he disappears.

Overjoyed, Manny then waits for the call from the lottery people day after day.  But nothing appears, no call, no letter.  So Manny prays again, and says, "God, why have you abandoned me?  I have been a careful man, a respectful man.  I believed in what you promised me.  Why, God, why?"

Once again, God appears to him, and Manny renews his plea.

God looks sternly at Manny, and says, "Manny, it is true I am a jealous God and a vengeful God.  But Manny, I am also a just God, and I keep my promises.  Manny, will you work with me here?  Buy a ticket!"

Well, enough of merriment.  Here is my new oped.  One of these days I'll get it right.

 

Now that the ACA is here, many people are being faced with the stark reality of the health insurance plans on offer.  That reality in many instances is called the High Deductible Health Plan (HDHP).  The most reasonable reaction is: is that all they could come up with?

We are told that HDHPs are necessary to make the insurance policies “affordable,” which they barely are.  HDHPs mean that the subscriber pays the premium, a co-pay for each medical visit, and then pays fully out of pocket for everything except preventive visits and tests up to the deductible, which is typically $5,000 or more.  One may ask, by what definition is this “affordable?”

Defenders say that these policies are so expensive because of the high cost of health care.  No kidding.  That’s the definition of a circular argument, it is expensive because it is expensive.

In fact, HDHPs are themselves evidence of the failure of cost control.  The high cost centers of medical care are generally in the hospitals, in specialist procedures, in extensive testing, in medications, and in end of life care.  It used to be thought that utilization was the problem, that too much was done to and for patients.  Increasingly, however, we realize that the real problem lies in the prices.  The United States far outstrips other countries in the price of procedures, drugs, and hospitalizations.

But as we know, one person’s cost is another person’s or institution’s income.  Those with high incomes are called vested interests, and every vested interest will defend itself.  When the ACA was being negotiated, the health care reformers hoped to extend insurance coverage and contain costs.  In the end they had to settle for only extending coverage as health insurance companies, hospitals, pharma, and high-income specialists defended themselves very well.

Who won’t do well under the ACA?  While many more patients will be “covered,” it is clear that ordinary outpatient health care still will be hard to afford for many.  Likewise, while the large institutions will probably prosper, your local primary care practitioner will feel the bite as insurance companies strive to reduce those payments, and patients try to economize even more on visits to the doctor.

In fact, HDHPs are terrible medicine for the health care system to take.  These policies restrict primary care, when the country needs more primary care, not less.  Even fewer graduating doctors will choose primary care as careers when that is the main target for economizing.  Quality of care will be reduced as many diagnoses of serious disease will be made later rather than sooner, because patients will be thinking twice or three times before visiting the doctor.  The burden of disease will not be dispersed among all the insured under HDHPs – if you or your child have a chronic illness, you will be paying up to the deductible every year.  In other words, instead of relief, the sick get another burden placed upon them.

Moreover, HDHPs violate exactly the group that President Obama has vowed to protect.  If you have a sick child and you are on Medicaid, you will visit the doctor at no cost to yourself.  If you are financially well off, the deductible and co-payment will not be an obstacle, you will visit the doctor.  But if you are in the just-making-it class, if you have a job but not much left over to save, and if you have a sick child, then you will have to think, “Is my child $100 sick, plus tests?”

HDHPs are terrible health policy.  There are plenty of alternative solutions that actually do save money on the expensive areas of care, and maybe the pressure of the ACA will deliver us to those solutions in time, despite the objections of vested interests.  One can only hope.  In the meanwhile, pardon us if we look at the HDHPs on offer and say, “Is this the best that they could do?”

Budd N. Shenkin, MD, MAPA