Sunday, March 11, 2012

Healthcare and the tentacles of government

One problem with Obamacare is that it greatly increases the role of the federal government in healthcare. But it's not that government's role is currently small. With Medicare, Medicaid, veteran's healthcare, and federal employees, the government's role hasn't been small since the early 1960's.

Private Sector Sprawl
This mirrors the growth of health insurance coverage in the private sector. If anything, the private sector has been in the forefront of increasing healthcare expenditures, and the federal programs only bring those spending patterns to the poorer parts of society. Private health insurance instituted coverage for prescription drugs long before Medicare Part D, so it's no wonder seniors wanted it too.

So the federal government is hardly the major instigator of insurance coverage for contraception. However, it is a significant step when government mandates that insurance companies have to provide them with no copay. I understand the reasoning: contraceptives are preventative care, and ACA mandates that insurance companies cover preventative care 100%. They are certainly cost-effective compared to maternity costs.

However, I question whether the country is going in the right direction to mandate that ALL insurance cover ALL care deemed preventative. We might make better decisions and save money if we had skin in the game. On the other hand, we might save some money in the short run by making bad decisions, like delaying treatment or skipping an uncomfortable screening test that also cost us money (insult on top of injury).

How Many Mandates?
So I'm uncertain. Should we go the libertarian route and leave the responsibility to the individual, or do we go statist and trust a government board to dictate what standard care and standard coverage should be? I actually think that the doctors in government agencies such as the Centers for Disease Control have done a good job, so I don't object on principle to the statist route.

Maybe it is best for medical experts to evaluate practices, their costs, and their efficacy and report which are best. I don't particularly care if the medical experts work for the government or for large healthcare groups like Kaiser or Mayo Clinic, or for large insurers. If they use good methods and find good savings in money and lives, I want to know and benefit. However, when it comes to legally mandating certain coverage, maybe it's better to go slow--don't require too much all at once. Choose to mandate the most effective preventative care, not the kitchen sink of preventative care. And also allow other experiments, like Whole Foods health account/catastrophic care insurance combination.

I hope ACA doesn't become a monster, with too many mandates and therefore hideously expensive. It doesn't have to be that way. Still, ACA was an important step to partially solve a huge problem in the US for those without employer-provided healthcare insurance. Just like Romneycare was a big step for Massachusetts, and it's now benefiting many, including people in my own family.

More Choice
In a time when our healthcare insurance market seems like feast or famine (employer-provided insurance or nothing affordable), ACA mandated something else. It opened a door. Now let's open some doors for other sorts of healthcare coverage too.

Preventative care: Catching the #1 cancer in women

Switzerland model, Singapore model with mandatory accounts.
CA mandates, CT mandates. Read them to see how much is mandated (a lot), and think about how you'd be glad it was mandated if you were in those shoes.
Read the sequel follow-up post.


Couves said...

I agree with much of this -- the mandates are a problem and they predate the ACA, particularly on the state level. It's also worth remembering that we have the employer-provided model because of federal tax incentives. Without those incentives, the model would probably be closer to what Whole Foods has, with perhaps catastrophic care provided by single-payer. The focus of health care policy should be getting everyone covered for serious illnesses and accidents -- instead we're debating coverage for birth control... pure lunacy, but I'm afraid we're already well down the path of total coverage of everyone for everything. Eventually, cuts will have to be made and coverage will be cut based on how good the political lobby is for any particular condition.

As a libertarian, I understand that the government is going to have some role in health care, but letting panels of experts decide what gets covered really concerns me. These are decisions that only the individual patient can make -- that should be the focus of any health care plan.

Anastasios said...

It is all very complicated and very difficult. The ACA is difficult, and going the route Couves describes is difficult. What is a serious illness, after all? What is a catastrophic expense? Would that approach even save any money? Plenty of experts say no, absolutely not. One of the clearest trends in the public health data is that preventIive care is by far the most effective way to spend money, an ounce of prevention and all that. And we are back around the circle again.

But eventually numbers can't be ignored, and we are up against some severe ones. We are spending far more money for far worse public health results than any other Western nation. That can't continue forever, and won't. The mandates do entail a loss of freedom, it's true, and perhaps that is unfortunate. Then again, perhaps it isn't. Maybe we overvalue freedom and simply need to be more rational. Overvalued or not, it may well be that the freedom in question simply can't be kept any way you cut it. Certainly the expense can't be kept. No matter what happens with ACA the money will dictate change sooner or later, whether within the framework of ACA or some other system.

What I worry about is that if it is later the loss of freedom involved will go well beyond the kind of preventive care mandates we are discussing now. America is awakening from some of the dreams of industrial capitalism, dreams from which other developed nations were forcibly ejected by the events of the twentieth century. The awakening will be very harsh, and will not be welcome. It may well be put off for a time by political and economic developments. But the morning always comes, now matter how pleasant the dream, or how harshly people curse the alarm clock.

ModeratePoli said...

@Couves, I'm not sure a system where 'the individual patient decides' what is covered is workable. Individual patients don't have the medical knowledge. And would an insurance company go for that?

Ideally, individual doctors would be the closest, best advisers. But some doctors put their business interests above reasonable, cost-saving measures. That's why some of the cost savings from ACA were supposed to come from the IPAB boards, since they are supposed to recommend where less expensive procedures are effective.

Both parties want to see procedures trimmed. But the Republicans want the insurance companies to do it (hence the Medicare vouchers) and Democrats want government-sponsored boards to do it. Whoever has responsibility for trimming expenditures faces a lot of pressure not to trim from: AARP, AMA, medical equipment manufacturers, politicians who can get elected by demagoguing healthcare.

It is so complicated, I'd hate to have to figure out how to make it work. Maybe that's why I'm respecting ACA more as I learn more. There are a lot of good elements to it. Strip out the favoritism, and it would be a damn amazing idea (current opinion only, liable to change).

Couves said...

Hi Anastasios,

Catastrophic insurance already exists - as noted, it’s part of Whole Foods’ health care plan. It would only become difficult if we were to have a nationwide plan -- then people would start to debate what constitutes “catastrophic illness” on Fox News.

You’re right though, it all comes down to the fact that health care costs are unsustainable. But it’s the mandates themselves that are largely responsible for this - the more insurance is required to cover, the more it costs. We also need to ask middle and upper income Medicare recipients to contribute more. And Medicaid costs could be brought down by just introducing very small copays. We can do all this without forcing people to forego necessary care.

I’m not sure I share your apocalyptic prognosis… but there’s definitely something wrong with our current iteration of industrial capitalism, which seems to be based on maximizing corporate profits by encouraging wasteful consumer and government spending.


I was just talking about doing something along the lines of what Whole Foods has - I forget the details, but routine expenses come out of a medical savings account and more serious (and expensive) illness is covered by insurance.

Expenses will have to be controlled one way or another - it will either be by individual patients or boards of experts.

Anastasios said...


I don't agree that insurance mandates drive most of the costs of insurance coverage. They probably have an effect at the margins, but health insurance is an upstream business driven by the costs of care, and the costs of care are driven by medical culture, the economics of medical technology, and it is true (and this makes my argument somewhat circular) by a peculiar health care finance system that manages to satisfy the majority while enriching the few and hiding the true costs from almost everyone.

As for the apocalypse, I don't think we are looking at fire and blood. But look at the reaction that came out of the entirely common-sense attempt to encourage end of life counseling. If people go into hysterics over totally harmless and relatively cheap initiatives to provide information, how are they going to react come the day when real hard decisions arise?

ModeratePoli said...


First, the quick answer. In the post, I have a link to an op-ed about the Whole Foods plan.

I don't know if mandated care makes our healthcare so expensive, or redundant diagnostic tests, or the expense of tech-heavy care. Also, how much of the expense is being thrown into hopeless cases? (The 2 weeks of intensive care for an elderly patient who is almost certainly going to die anyway.)

To make a full evaluation, I'd also have to find out how often the mandated care is very effective in saving lives and/or drastically improving lives. Same with the diagnostic testing, and the tech-heavy care. With 2 good friends recently saved respectively by chemo and high-tech radiation therapy, I'm worried that the trade-off might money vs. lives, not just trimming back waste.

By the way, I'm adding some links to lists of mandates. Contraception mandates can't be what's breaking the bank. But what is????

Couves said...

MP, I certainly don't want to deprive anyone of cancer treatment. But I agree that there is definitely too much unnecessary testing going on, much of which would be eliminated if patients themselves had a financial incentive to only do what was absolutely necessary.

Anastasios said...


I think the problem with giving patients financial incentive to only do what is necessary is that the average patient, being an average person, is not competent to decide what is necessary. They simply do not have the information, the expertise, or often the cognitive habits necessary to make those decisions on their own. Nor are they in any shape to do so when seeking medical care. Often they are in pain, frightened, and flustered. Trying to show them a list of prices and data and asking them to make a decision would result in tears of frustration, storms of anger, and one suspects often very bad judgment calls.

It would be bad enough if that resulted in tragedy for individuals. However, even worse is the fact that the outcomes of those bad decisions are going to end up socialized one way or another. Leave it up to the individual and you will end up paying for expensive cancer treatment that could have been obviated by a mammogram (a painful and awkward procedure that many women will understandably skip unless encouraged in every possible way) or a prostate exam (ditto for the men). You will have people dieing of colonic problems because the colonoscopy is enough pain and trouble without having to pay through the nose to have someone put a large hose you-know-where. You will have people presenting with advanced cases of bacterial infection because it was "just a cold" and they weren't about to "pay that snotty @#$! to put his son through school" (the last being a direct quote from my father, who refused to go to the doctor because of the co-pay for an office visit, and who almost died of pneumonia as a result).

Now, the progressive attitude to health care and much else is paternalistic I admit. But the truth is, as I have said elsewhere, that average people are, after all, possessed of average ability and average information and average education, and in most cases regarding medical care average just won't do.

I don't deny there is a dark side of that. I don't deny that many of the more progressive aspects of, for instance, European health care derive ultimately from social habits in which elites are comfortable deciding what is best for the commons. But we probably fetishize freedom too much, and we may well be to a point where rationality is more important.

Couves said...


I’m sorry about your father’s experience, but I think that’s a rather extreme example of stinginess. Yes, there are clearly certain tests that should be given to everyone at certain ages and to all sufferers of certain conditions. But with a health savings account, it’s not like you’d otherwise get to pocket any cash that you’d save by skipping a colonoscopy or a mammogram (If you’re already being seen by a doctor, prostate exams are as cheap as a latex glove). And strange as it sounds, having more of a personal investment in one’s health care will actually encourage some people to adopt healthier lifestyles.

And no, I don’t expect people in physical distress to do anything more than follow their doctor’s directions. But there are a minority of doctors who will order many expensive and unnecessary tests for patients who are not suffering -- I’ve had doctors like this.

You make a fair point about the inability of the average person to determine when a test is needed -- but a copay will prompt a patient to ask more probing questions and give the doctor some incentive to control unnecessary expenses for his or her patient. The Doctor-patient relationship is increasingly a conversation and there’s no reason why expenses shouldn’t enter into that discussion more. Prices, even small ones, have the amazing ability to prioritize the consumption of resources, and that’s exactly what our health care system needs right now.

Perhaps some people “fetishize freedom,” but freedom is part of our culture! As you point out, Europe has long had a culture that is more at ease with allowing elites to make decisions for everyone. This approach is just not going to work in the US and it’s unfortunate that we seem unable to seriously consider alternatives.

ModeratePoli said...

Contrary to Couves' experience, I've known first and second hand of MDs overtreating. My mother is nearly constantly resisting invasive cardiac tests with radio dyes.

MDs, like patients, don't know how much meds or procedures cost, often not even ballpark estimates.

I think we should change our medical culture so there is skin in the game, and we all know the costs associated with this stuff we do and take. Redundant testing, just to get a better picture or rule out the unlikely alternative diagnosis would happen less often.

Couves said...

"Contrary to Couves' experience, I've known first and second hand of MDs overtreating. My mother is nearly constantly resisting invasive cardiac tests with radio dyes."

No, that *has* been my experience. I agree with you on this - everyone needs to have more skin in the game. For some that would mean paying the full amount from health savings accounts, but for those on medicaid that might just mean paying a small copay.

Anastasios said...


1) I think the stinginess would prove much more common than you expect. The problem with skin in the game schemes is not that they don't work, but that they have more effect than people imagined. In many cases this is because the people effected are poor (my father was at the time) and middle-class and wealthy people have little understanding of how the poor think about money and what effect payment schemes have on their behavior. This is especially the case if you are talking of out of pocket expenses, with the accompanying sense of shame and inadequacy among people who are not able to pay no matter how low the cost. Data from Canada and the UK have repeatedly shown that the part of those systems participants label as most important for good care (and they get measurably better results than we do) is no out of pocket payment at point of service.

2) It would seem what you are talking about, and what Whole Foods uses, is not really a savings account, but rather a regulated self-insurance scheme for routine care. Okay, but the operative part of that is "regulated." Who would control it? What could it be used for? Could it be used for co-pays? Are employers required to contribute? What about the government contributing? How do you keep this from becoming a bonanza for investment bankers who will surely want to use the accounts as a source of funds - it seems like an open invitation for faud and predation beyond anything possible under ACA? Will persons using the accounts get breaks in billing like insured people do? Who will negotiate those breaks? Who will police them? Are insurance companies, God help us, going to be allowed to offer and control accounts as part of total insurance packages, in effect pocketing the same money for less service than under standard plans? All of this will greatly increase the burden of insurance regulation under ACA or any other scheme, since most people will stay in traditional plans and supervision of those will have to continue. In short, the benefits are possible but questionable, and the risks are very real albeit possible to control. Then again, much the same is true of any reform scheme, and if we are talking a controlled experiment I don't see the harm.

3) We have had certain kinds of freedom in American culture because we, as a country, have been rich enough to tolerate the waste and inefficiency they bring. We aren't so rich now, and never will be again. I suspect there is much we are going to have to learn to live without before we find a sustainable equilibrium, and some traditional freedoms and expectations may well be unaffordable going forward. In some areas of life less free and more elite driven cultures are wiser and better than we are (more intelligent, more compassionate, better social and govenmental systems, more stable and livable) and we will probably have to learn from them whether we want to or not.


It depends on whose skin in what game. In general, this is a place where conservatives have a strong argument and liberals get cowardly. We really do need tort reform and an end to defensive medicine. Liberals in effect want European health care without European tort restrictions, while conservatives want European tort systems without European health regulations.

Couves said...


Waste and inefficiency comes from a system that purposely eliminates any market incentives to economize... hence the need to compensate with top-down control. More personal freedom and responsibility is the alternate solution.

Anastasios said...


I agree that market-oriented experiments are certainly worth trying. At this point most experiments that aren't silly or malicious are worth trying. But the hallmark of good policy, or at least one of them, is to go with existing evidence. Overwhelming data shows that other modern democracies are much superior to us when it comes to providing affordable health care to all their citizens at sustainable cost.

They are not perfect, by any means. No system is perfectly fair or satisfying to everyone. And yes, there are facts about culture and geography and size of population that have to be taken into account. But the fact of the superiority of their systems to ours on the parameters of affordability, access, and public health results, elitist and top-down and imperfect as their systems are, is supported by such a crushing weight of fact as to be unarguable.

We cannot ignore that evidence any longer. The money just won't allow it.

ModeratePoli said...

@Anastasios, re: tort reform

I strongly agree on tort reform, but I've never been satisfied with GOP proposals that cap pain/suffering payouts at a quarter million. To me that doesn't seem enough if you'll never see again, walk again, or be in intense pain for the rest of your life. But they never moved from that proposal. I believe in a cap, but not such a low one.

Anastasios said...


I agree that the cap is too low. Perhaps, with regard to tort reform, we need to look at the process or tort claims rather than the amount.

One workable system might be something like that of Japan. I heard about this long ago, and I could be completely wrong, but I think it works like this: a malpractice claim is automatically sent to arbitration before a panel of experts in law and medicine (and in some cases the relevant medical technology). The panel makes a determination as to whether malpractice has occurred, then a recommendation for compensation. There is an appeal, I believe, within the arbitration system and then one can go to the courts, but only after the arbitration has played itself out.

Now, I don't think we would have as much success as the Japanese have had (many Japanese doctors do not, for instance, even know what their malpractice insurance premium is since they buy it as part of their membership in the Japanese version of the AMA). Japan has strong cultural and institutional barriers against mounting the kinds of lawsuits we see routinely. If I recall correctly, it's also true that many people in Japan feel that the arbitration system is strongly stacked in favor of the physician (after all, the people sitting on the panel are from the same social and educational background, and have the same professional training, so they are strongly inclined to favor the doc).

I don't think that type of thing would play out as smoothly in the U.S. One can see all sorts of ways in which conservatives and liberals would both decry the system, then attempt to game it. However, something of the kind might help, particularly if there was local citizen representation on the tribunal as at least a nod to local sensibility. Zoning boards, parole boards, and public service commissions use that kind of mixed representation, and manage to deal with highly emotional issues with some degree of success.

Couves said...


For better or ill, I think we'll probably end up socializing most health care costs and decision-making eventually. I nominate Vermin Supreme as the “friendly fascist” to run the system: