This morning on Washington Journal was a discussion with Marogt Sanger-Katz of the NYT Upshot blog. She wrote a post: No, Giving More People Health Insurance Doesn’t Save Money. It’s a controversial title for sure, but there is some interesting points that I know are often mentioned on a few email lists I’m on for my profession.
Let me just say I’m am a bit cautious of her writing after listening to her answer regarding why the nation did not get a single payer system in her interview this morning. She was correct there was not the political will, but she suggested that it was do to a lack of interest/drive on the part of the people. She states most of the people do not want single payer. My understanding is that is was more the politicians involved namely President Obama and the congressional dem leadership that flat shut down any talk of single payer and then the Medicare option. Ms. Sanger-Katz did not mention this at all. Here is the clip:
In her article however, she does mention the issue of “number to treat”. This is a big issue in health care and has been ignored generally. When the move was on to control costs, medicine began to promote prevention, only it was not prevention by means of better food, better life environment via a reduction in the risks of life (security of housing, income, aging). If you think about it, to promote better food requires going up against our industrialized food system. To promote a better life environment would mean going up against the entire economic model we have been deriving policy from that has lead to the life people are living today.
Medicine did not promote the science that looks at the natural functions and relationships of biology and promote a model based on that while acknowledging that at some point life ends. Medicine promotes a model that comes from its historical approach to health and healing. Its model is fully dependent on performing diagnostic testing because its model over all is about the diagnosis which then leads to a treatment. No judgment here. It is what they do, and it is a fact of living that something will go wrong and need to be figured out and then treated. To back this approach up to an early moment in life when nothing is going wrong in a crisis nature and apply it to everyone if possible ignores what should have been a natural most basic question: What about all the false positive test? Such questioning would have lead to “numbers to treat”. We are not talking vaccination here, let’s be clear.
Such is I believe, the better part of Ms. Sanger-Katz’s article. How many do we have to test and treat for the treatment to save one life? When viewed this way, the theorized (and they were theorized as it was a model promoted based on simply extending what was being done in a crisis model) savings are not so much.
Joshua T. Cohen, the deputy director of the Center for Evaluation of Value and Risk in Health at Tufts Medical Center, said: “We’ve all heard it before: ‘An ounce of prevention is worth a pound of cure.’ It doesn’t really play out when you analyze the numbers, and the reason for that is that you have to give a lot of people those ounces of prevention to end up with one person who’s going to get that pound of cure.”
It may be that we, society decide that we will spend the money regardless of how many need to be tested, and how many will be falsely treated and not treated do to false negatives because one life saved is the humane way to live life. But, we are not having this discussion and that leads me to another point of her article that I find to be bogus. As more people have health insurance, more people use it. Well dah! Are we not about “prevention” via early detection and thus more use of the predominate health care model of crisis care/intervention? She quotes:
…this one of uninsured low-income people in Oregon. Low-income Oregonians who wanted to sign up for the state’s Medicaid program were placed in a lottery. Only some got the insurance, but the researchers tracked both groups. In the first year, they found that the lottery entrants who were given Medicaid spent more on health care than those who remained uninsured.
Amy Finkelstein, a professor of economics at M.I.T. and one of the authors of the Oregon study, described this finding as their least surprising result. “There’s overwhelming evidence from our study and others that when you cover people with health insurance, they use more health care,” she said.
Did fewer people buy houses when people got easier access to credit? Are we not an economy based on consumption? I could be over reading her writing but she is certainly brushing up against that class concept of helping those who need help just means more cost than not helping them at all. That is, providing aid results in dependency. You know the arguments.
started in the 1970s by the RAND Corporation, was designed to answer this exact question. It found that the less expensive you made it for people to obtain medical care, the more of it they used. That follows the pattern for nearly every other good in the economy, including food, clothing and electronics. The cheaper they are for people, the more they are likely to buy.
One other thing missing from the issue of health care cost that goes back to her incorrect statement regarding single payer is the adverse incentive the insurance companies have. Their power, which is their asset is purely dependent on the cost of the policy. Other than the rules now in place from the PPACA, there is little if any natural market force pushing the insurer to find real methods for lowing the cost of health and healing. To due so would reduce the premiums and thus the amount of money managed. With the consolidation happening, it will only get worse even with the ACA rules because the data streams will be more homogenous. That is, there will be less creative thinking happening as to how to lower cost in order to attract that additional customer away from your competitor as a result of a different cohort. It is the natural course of moving to a private sector free market monopoly.
In the end, though, the article is at least attempting to bring into the public a discussion which has been simmering within the world of those who actually do the health and healing.
Some are now managing chronic and potentially life-threatening health conditions. But those benefits don’t mean we should be surprised by the actuaries’ recent findings on spending growth. More people in the health care system means more dollars spent on health care. The increase doesn’t mean that Obamacare is leading to runaway costs, or that it’s failing to reform the health care system to make it more efficient. But it does mean that we can’t think of the coverage expansion as free.
The full scope question is how do we assure the lowest expenditures on health care in an ever increasing population? We’re going to spend money on health and healing. To look at producing savings, that is a reduction in the acceleration and velocity of the costs is proper. To view the obtaining of savings as the same as cutting utilization is to be blinded to the actual model presently used for defining what is health and healing. It is not a bad model, it is a model being inappropriately applied. But, all that testing certainly will make the commercial enterprises who supply all the stuff used in the model very happy.
The honest answer to obtaining the most efficient health care system is going to have to look at much more than the system used to get the money from the patient to the provider. We won’t be able to write enough rules and regs. The honest answer is going to buck up against not just the entire health care industry but the entire ideology of our economy. We can not ignore our environment and the way we use it to generate income, wealth and growth such that people can sustain their lives because health and maintaining it starts with biology (chemistry at its most basic) which leads to physiology which is the result of the environment. Physical health, mental health, it’s all the result of the environment it lives in. Yes, even genetics has an environmental component.
Garbage in, garbage out certainly. Though making the selfish choice only leads to a greater number of problems to solve than would have been otherwise. It may not be you having to experience the “externalities” of your selfish choice but someone will. Just look at the Republicans current conundrum for proof.