January 14, 2010

The Haves and Don't Have Tos of Healthcare

Justin Katz

Mark Patinkin begins a brief examination of "why there's all this fuss about revamping the [healthcare] system" with a faulty premise:

I'm guessing there have been two distinct audiences for the health-care debate.

Those who have an affordable plan and those who don't.

If you don't, you doubtless paid a lot more attention.

Patinkin's essay stands as evidence that there are at least three audiences, and since the third implies an antipode, there must be four:

  1. Those who have an affordable plan and believe something like the Democrats' plan will not affect them.
  2. Those who have an affordable plan and believe something like the Democrats' plan will threaten them.
  3. Those who don't have an affordable plan and believe something like the Democrats' plan will ensure one.
  4. Those who don't have an affordable plan and don't believe something like the Democrats' plan will ensure one.

So dramatically different is my understanding of the landscape than Patinkin's that he assumes the "don't haves" to be the most interested in the debate, while I've perceived the debate mainly to be between the factions of the "haves." Note that the Tea Party phenomenon was heavily populated by working and middle class folks, and that much of the advocacy for the Democrats' policies has come from Patinkin's peers in the media, academia, and government, all likely having excellent benefits.

A telling bit of the perspective difference between the "have" groups comes when Patinkin investigates the options that "have nots" can pursue. Just after explaining to his readers how a deductible and copay would work on a $2,000 MRI, he writes:

I was told you might be able to get that $660 monthly fee down to $487 if you proved you were very healthy. But you'd still have the deductible, leaving folks to debate every procedure.

Here's my question in response, as somebody who has decent (although too expensive) coverage and fears that the Democrats are on track to price me out of it: What is wrong with folks debating every $2,000+ procedure? Simply put, there will never, ever be an effective mechanism for controlling healthcare costs unless every potential patient weighs the value of every test, drug, and procedure. Pretending otherwise is going to cause a whole lot of suffering among a whole lot of people.

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Double true, Katz. The Atlantic Monthly article on this whole issue by David Goldhill ("How American Health Care Killed My Father," September 2009) remains the single best thing I've read on it. The author makes an excellent case that the whole idea of health "insurance" needs to be rethought. Many of our expenses could be handled differently. While catastrophes happen (and call for insurance), most health care doesn't need to be handled that way. My auto insurance doesn't pay for oil changes, nor for engine repair. I can plan and pay for my own checkups, and when my wife has a baby there is plenty of warning, enabling me to save for the delivery, hospital stay, etc. Further, a system in which health care is genuinely competitive is one where prices go down. An MRI (a 20+ year-old technology) does not have to cost $2,000 anymore! High-demand technology goes down in price on the open market. Goldhill's universal solution is very high-deductible (e.g. $10-20,000) insurance for everyone, with the deductible and premiums covered for lower income Americans. Works for me.

Instead what we get is the ossification of the status quo. Way to go. God willing, these guys won't put try to "reform" anything else.

Posted by: Daniel in Pawtucket at January 15, 2010 6:34 AM

How is a patient supposed to effectively "weigh the value" of every test?

Patients are not medically trained. They cannot reasonably learn all the information necessary. And even if they could, how do they balance that against a threat to health?

Posted by: Israel Silverman at January 15, 2010 7:08 AM

I don't know that there's ever been an easier question posed here than the one by Mr. Silverman.

Question for you, do you think that everything doctors prescribe (drugs, treatment, etc) are 100% medically necessary 100% of the time? Of course not. So the job of the patient will be to try to help sort those out. A doctor says you have a viral cold, here's a prescription for an anti-biotic. Absolutely useless and a total waste of money. I have a little pain in my back. "Get an MRI". At this point, useless. Try other things first.

Another question for Mr. Silverman. Ever gotten your car looked at by a mechanic and had the mechanic list off a great many things that should be serviced and the bill for such things would be ridiculous? So then you ask how many are "necessary" and usually he'll list off the things that he would not drive the car again until fixed, the things that really, really *should* be fixed and then there are things that will help with fuel efficiency or a smoother ride or are general maintenance. Same thing with a doctor. Many doctors are in "cover your a**" mode because of malpractice and drastically overprescribe. What does the patient care? He paid his co-pay. But if people actually had to pay for those things or were directly affected by the cost of unnecessary drugs or treatments, we might have more discussions of "is that totally necessary?"

Posted by: Patrick at January 15, 2010 8:52 AM

I question the basis for using Patinkin's article for discussion on any serious issue. There are plenty of articles written by others who actually have some clue on the topic. The guy writes puff pieces without any wit or intelligence. You show his healthcare piece, but what about his piece earlier this week on "hungry man dinners" and his inability to cook with his wife away? I'm sorry Justin, it's too easy to drag up the likes of Patinkin and use his article to trash on healthcare. The guy is an eastside liberal know nothing without one ounce of understanding of the hard work and troubles of the average person. The guy writes in the lifebeat section and doesn't even do that well, you think he'd have some sort of wisdom on healthcare? Obviously he would muck it up and write a piece easy to rip apart for foolishness

Posted by: steadman at January 15, 2010 10:00 AM

What about cutting doctors out from the vast majority of medical transactions?

Have a viral cold? Imagine if the person on the phone told you to have some chicken soup and get some rest.

Sprained ankle, but you thought it was broken, so you're already at the hospital? Triage nurse determines that it's not broken, you go home with a suggestion (not a prescription) to double-up on ibuprofen for a week.

The problem is that the way hospitals and doctors get paid is based on providing care, so the less care they provide, the less money they make. That doctor is making a lot more money by writing you a prescription for antibiotics than if they didn't even see you.

The consumers listen to their doctors, when you call with a cough and they say 'come in for a visit', you're going to go, because it costs -you- nothing (in the short run), and it makes them $160.

The answer to rising health care costs is to force co-pays to be a -percentage- of the care, with no 'kick-backs' allowed. Good plans would cover 90% of care, bad ones would be... worse. Plans would scale-up their contribution for very expensive treatments, so you might get 90% coverage for an MRI, but 95% coverage for a $100K surgery. Hospitals would have finance units so you don't get a $5000 bill all at once.

Co-pays were designed to do this, but they've failed since they're 'fixed' in relation to the cost of the services they help pay for. I know I've paid $10 to get a $3000 MRI before, I needed mine badly enough that I would have paid $300, but I know plenty of people who've had them prescribed for very minor things.

Also, I heard that 40% of Medicare goes to the terminally ill. I want terminal people to think really hard about spending their childrens' money before they go ahead and get that $100,000 surgery to make it another month, the best way to do that is also the percentage system (if you had four months left, would you shell out $10K for five? I wouldn't.) It's certainly better than 'Death Panels' of the private or public type.

You want to get more than one mammogram every two years? Pay for it yourself.

You want an abortion? Pay for it yourself. (I'm pro-choice, I would actually donate to an organization that helped pay, it's abhorrent to expect pro-life people to pay for abortion in any way.)

You want a facelift, or a 'prescription' for something you can get OTC? Pay for it yourself?

Want to fix that and there are two drugs to do it? You'll have to pay for 10% of the generic before you pay for 10% of the name-brand, not a fixed 'prescription co-pay', no coupons allowed from the drug company to sneak the more expensive product in, and no kickbacks to the doctors.

Posted by: mangeek at January 15, 2010 9:04 PM


I am aware of all you say. However, that many doctors operate in CYA mode does not increase my level of medical knowledge. Yes, I can try asking, and even grilling my doctor as to the value of a test. Maybe I can even take out a gun and force him to teach me all the medical knowledge he has he knows relating to my specific situation.

But I'm not likely, in real life and real time, to get that last. And so, with imperfect knowledge, how do I decide what my life is worth?

Posted by: Israel Silverman at January 16, 2010 5:53 PM
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