March 1, 2007
Yesterday, I railed against the habit of blaming the uninsured for our health care crisis, rather than the broken system itself. Today, I'll defend the insured, who often get blamed for rising health care costs.
Yes, reader, some policymakers say that it's your fault... because, apparently, you use too much health care.
And in this Orwellian world, the solution to rising health costs is to impose more costs onto patients.
From President Bush on down, the trend toward so-called "consumer directed" care is to make patients more price-sensitive on using health care in the first place, through high deductible plans and other forms of underinsurance. Under the guise of patient empowerment, we see more Californians underinsured, in a thinly-veiled attempt to shift the risk and cost of health care from employers and insurers to individual consumers and families.
The theory seems to rest on the notion that people binge-shop at the emergency room. In fact, the data show that even insured patients underutilize medical services.
High-deductible plans offer the worst of both worlds. Patients with significant cost-sharing are half as likely to go to the doctor, fill a prescription, or get needed emergency careand thus they have worse health outcomes. Many Californians who live paycheck-to-paycheck face serious debt and even bankruptcy before meeting a $5,000 deductible. Yet except for the rare catastrophic event, they are paying a premium to be uninsured.
Governor Schwarzenegger's plan features some of this "personal responsibility" policy direction, offering tax breaks for Health Savings Accounts (HSAs)inappropriately using the tax code to encourage high deductible plans.
Those facing the mandate to buy coverage under the Governor's plan, without help from an employer or government, have two awful choices: a non-choice of buying comprehensive coverage that is simply out of reach for the vast majority of uninsured; or the option of buying a still-unaffordable $5,000 deductible plan that meets the requirement, but will not be affordable to actually use.
The Governor should know better. He appropriately talks about prevention, and how it is cost-effective for Californians to get care up front, before it becomes a bigger and more expensive problem. But these plans won't provide coverage for the preventive care known as disease management that really will save money with the big-ticket health costs: asthma, diabetes, obesity, heart disease.
Anthony Wright is the executive director of Health Access California, the statewide healthcare consumer advocacy coalition, which hosts a daily blog here.
Anthony, you make an important point about how some health services are underutilized. First on the list of what we need to encourage is prevention, and under Governor Schwarzenegger's proposal preventive care would be covered so people would have no financial reason to miss out on help in avoiding conditions like diabetes, obesity, and heart disease in the first place.
If we don't do a better job of preventing these conditions with relatively low-cost early interventions, there will never be enough money to pay for treating all these avoidable illnesses once they have set in. Those are treatments and costs to the system we all want to avoid. Meaningful reform must emphasize health care, not just sick care.
While we are underutilizing prevention, some medical interventions are in fact being used too much. A chilling instance of medical intervention run amok occurred in a hospital in Redding, where patients were being given completely unnecessary heart surgery on a regular basis. Less publicized occurrences of unnecessary treatment, over-prescription of drugs, and duplication of services are pervasive in our current broken system. And the consequences affect both the cost of health care and public health.
So meaningful reform cannot be built on the notion that more medical care is always in the best interest of consumers. Still we are in agreement that premiums, co-payments and deductibles must be affordable.
That is why the Governor proposes helping cover those who can't afford it themselves. Those who currently have no insurance, but can afford $100 per month premium, would certainly be better off with a $5,000 deductible than with hundreds of thousands in catastrophic medical bills resulting in bankruptcy for them and another bump in the hidden tax for those with insurance.
What Governor Schwarzenegger means by shared responsibility, including individual responsibility, is each of us maintaining health coverage we can afford. And doing all we can to stay healthy in the first place. Consider just one incredible statistic: A 2005 study by the California Department of Health Services estimates that if the number of physically active Californians increased by only 5%, we could reduce direct and indirect medical costs by $1.3 billion a year.
But beyond responding to what you wrote, Anthony, I want to answer today's question as well.
The biggest difference between our plan and Massachusetts' is that ours has no impact on the state budget. If we simply adopted the Massachusetts plan here it would cost our state budget at least $9 billion a year.
Massachusetts has also run into trouble because its plan sets goals for subsidized coverage that officials thought would materialize, but those proposals are coming in higher than they hoped.
Governor Schwarzenegger's proposal uses existing market prices and products as a guide, so we know that the mandated minimum policy can be bought today for about $100 a month.
We also have a much more robust and competitive market in California. Massachusetts has just four health plans to choose from. California, which has a strong reliance on managed care, has seven major players and many smaller ones that can help keep prices affordable.
Massachusetts also put its initial focus on getting everyone covered, opting to address cost containment later. Governor Schwarzenegger recognizes that both need to be addressed simultaneously.
Significant increases in Medi-Cal reimbursement, tax incentives and a host of other affordability measures will all help to ensure a more competitive, functional health care system and will stop runaway double-digit increases in premiums.
We all know this is not going to be an easy problem to fix, but by dealing with the issue in a holistic and comprehensive manner as the Governor has done, there's no reason to believe we can't have great success and be a beacon to the rest of the nation.
Daniel Zingale is senior advisor to Gov. Arnold Schwarzenegger and chief of staff to Maria Shriver.
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