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POLICY/INTERNATIONAL: High co-payments prevent needed care, and not in the US this time

So charging at the point of care, another Zombie of health care policy, isn’t just a problem for the poor here—although it’s going to get a whole lot worse. It’s also a big issue in that place that the US loony right thinks will be where they ascend to heaven (or at least I think that’s what they think about it…who can tell with that bunch of nuts?).

Read up about the problems of paying for care in Israel.

Meanwhile if you want to know more about health care Zombies, read this great speech from Morris Barer

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  2. It’s interesting to me that people like people like Morrris Barer, who presumably view themselves as saintly in their tolerance and compassion, use such perjorative terms as “zombie” to describe ideas that diverge from theirs. It seems to me that the real zombies are the post Cold War adherents of socialist notions like single payer.
    To those with open minds, I submit the following, which I sent to Marilyn Clement of Healthcare-NOW, who is calling on the masses to rise up against George Bush’s State of the Union proposal that the market might solve the healthcare problem as it has all others in the history of human civilizatiton. Perhaps I was inspired by viewing a History Channel program about recently declasified Soviet records of thw “Worker’s Paradise” under Uncle Joe” Stalin.
    “The private sector efficiently and effectively meets virtually all our other needs for the necessities of life–food, energy, shelter. Why then do you argue that it cannot meet our healthcare needs? Conversely, if healthcare can only be provided “efficiently” by the state, why not food, and transport, and housing? Only a statist mentality can rationalize these contradictions. The allure of “free” healthcare is but one of the chimeras at the end of the yellow brick road to serfdom. At its end lays a Stalinist nightmare in which reliance on the state atrophies the freedom yielded by self-reliance. I prefer not to depend on the state as it eventually yields to omnipotent state power over the individual.
    Many who yearn for single payer healthcare are wary of intrusions by the state into privacy, human rights, and myriad other matters. They don’t trust the President, the Congress or the bureaucracy, perhaps rightly so. Yet they are eager to trust their very lives to the government by granting it all payor (thus all powerful) status.
    You decry Wall Street. It is the source of money, and thus power, that funds our multi-payer, multi-provider system that affords us freedom of choice. You decry marketing, which is the commercial freedom of speech necessary to the free flow of information prequisite to choice. You prefer the tyranny and information control of the state to the freedom of the free market. That war of ideas which I thought was decided with the fall of the Soviet Union goes on. But I am hopeful that a majority of Americans will refuse to foolishly put their lives in the hands of the bureaucrats who brought us the Katrina response, Medicare Part D and the Iraq occupation. You may wish to entrust your life to them. I, and I believe a majority of my fellow Americans, will trust private sector physicians and payors, who we can hire and fire at will, who must satisfy us to keep our business, who have no monopoly on health, but instead must compete with others to survive.
    The shape of things to come should we be seduced by th single payer siren song is the VA system. My father was forced to subject himself to its ministrations,until I was fortunate enough to pay for private care. You may counter that adequate funding would make a difference, but the politicians will never adequately fund it. Why? Because in reality the singele payer is us, the taxpayers. We aer also the electorate, and thus the politicians have to raise taxes on their paymasters, the ultimate conflict of interest which results in unfunded mandates and entitlements that are already unsustainable.
    Our health system, like capitalism, isn’t perfect, just better than any of the alternatives. When a better system is conceived, I’ll gladly support it. But single payer is not the answer. The problem isn’t price, it’s value and access to it. Perhaps the market, aided by regulation like Mitt Romney’s mandatory insurance proposal with subsidies for the lower income brackets, is the better direction.
    While I fear this falls on deaf ears, if you’ve read this far, I encourage you to reexamine your position with an open mind. Unless you are a statist, I think you may find that diversified decision making by millions of independent minds is far less likely to perpetrate disasters than one central planner, an economic verity that transcends industries, and applies as much to healthcare as agriculture.”

  3. Well Mat, actually if you read Revelations you would know…
    Got ya!
    I love throwing that out to liberals. Its funny seeing their eyes light up.
    Look discussions on policy of any kind seeks to affect people’s (or an organization’s) behavior. So whether it’s political or religous ideology, the outcome is to modify behavior. Religion is just an easy target for many to pick on.
    It’s amazing how religion has this polarizing affect on common sense people. While I like to consider myself as having common sense, my wife would take issue with me on that one.

  4. Tell us how much you charge to come and talk to a group of people Matthew. There are 2 guys here in Tampa that have started an HSA health insurance company. It will be the 1st new insurer in Florida in 5 years. They started with $900,000 of their own money and raised $6 million to start with. So that’s not much. I wish I owned the insurance company. Maybe I’ll go down and apply to be their National Sales Mangager. Having the guy who enrolled the first MSA in 1996 might come in handy for them. They are rookies who are old Oxford people, it’s pathetic. They say they want to target small employers who don’t like rate increases, ha ha.
    Come on Matthew, you get $.00001 each time somebody “CLICKS” your fun easy links. I could spend all day clicking away here and you would get $.01. That’s a poor waiste of your customers time. Quit being so self centered.

  5. I’m left wondering if there would be no need for sizable co-payments if everyone received the most cost-effective treatments and preventative care. Eliminating excessive and ineffective interventions, dramatically reducing medical errors and omissions, using less-costly alternatives with comparable efficacy, improving diagnostic accuracy and tying it evidence-based guidelines that promote effectiveness and efficiency, enabling providers to spend the time and use the tools to understand their patients’ problems and needs better, enabling better collaboration between practitioners and researchers, and doing a better job informing patients how to care for themselves … are some examples of what our country has to focus on in order to deliver cost-effective care.
    It just seems to me that any debate of fiscal-based strategies should focus primarily on ways to optimize care cost-effectiveness; anything less prevents us from solving the healthcare crisis and we keep chasing our tails as we have been for the past decade.

  6. Trapier — I totally agree with you that care levels do not directly effect outcomes. Sadly the RAND experiment BOTH confirms that co-payments affect the poor’s use of health services more than the wealthy (as do numerous real world studies and common sense) and more importantly, that they were as equally likely to forog needed care as “unneeded” care. My point was that the behavior of the poor changes more with POS co-payments, as you’d expect it would, and that it has little impact on overall costs. Because of course those overall costs are to do with the people who are actually sick….the old chestnut that we continue to debate here at THCB while no one else seems to notice.
    The secondary point is that the only country with real experience at POS user fees (America) has the most out of control health care costs, which is good enough to suggest to me that this ain’t a solution.
    But the concept won’t go away, which is why it’s a zombie!

  7. John C — I’m quite happy to bash Evangelical Fundamentalists until they go back to minding their own business and not trying to impose their views on the rest of us while we’re minding our own business. Something that’s increasingly unlikely with the new justice in the Supreme Court as of today. It’s not their religious views that I have trouble with, it’s the fact that they want to control the behavior of the rest of us. When they go back to leaving religion in the Church, then I’ll shut up.
    If you want to have an argument over economics, incentives, free-markets, etc using evidence — then you are not in the looney right, and I fully expect you to hold your corner. If you want to, say, base US foreign policy on accelerating the acopalypse as foretold in the Book of Revelation, then you are a looney, and we cannot have a rational discussion.
    I assume that you are in the former group not the latter!

  8. Re: “Rubbish. Payment at the point of service uniformly (in Rand study and in real life) massively impacts the behavior of the poor, and does nothing to affect overall health care spending, however much Eric thinks it ought to.”
    With respect, Matthew, that isn’t an accurate interpreation of the RAND study. The RAND HIS found that those in the co-payment group used 2/3 of the care used by those with more comprehensive coverage and that the health outcomes of the two groups were almost equivocal [1]. So, yes, co-payments do reduce health care spending; and, no, the affects aren’t always so bad.
    Trapier K. Michael
    http://www.marketplace.md
    Pres. & Founder

    [1] From Charles E. Phelps’s “Health Economics,” 3rd Edition (called the “gold standard” for undergraduate health economics textbooks by Alan Garber of Stanford)
    “The low-coverage group used about two-thirds of the medical care used by the group with full coverage. Given that difference, we can ask, ‘what health differences occured between these groups?’
    “The answer, although mixed, is generally ‘not much, if any.’ For adults, virtually every measure of health status was the same for the full-coverage group and the partial-coverage group except two: the low-income full-coverage group had better corrected vision that their
    counterparts in the partial-coverage group, and they had a very slightly reduced blood pressure.”

  9. Matthew, c’mon are you degrading into just seeking out “stuff” that only supports your political, personal ,and now religious views? Look, I know its your blog and you can say whatever you want (and I’m sure you will continue to do so which is great), but using it to bash people’s religious beliefs is kind of juvenile.
    Poor people in this country have access to Medicaid and they DON’T have copays! What is the problem here? Are you upset that someone with a household income of $60-80k has to pay for $15 dollars for prescriptions? On that train of thought, you can make the same argument for any other supposed entitlement looney liberals, on the verge of become die-hard socialist, support. For example, gas prices are too high and they disproportionately hurt the poor. The cost of higher education, the cost of groceries, on and on and on.
    Believe me, I know that being poor sucks. And guess what, there are numerous programs available to help them. But to use the bleeding heart routine of the plight of the poor to promote your view that copays are bad is nonsense. The poor under Medicaid have no copays!
    Now, if you are making the simple argument that increases in cost sharing have proven to impact treatment and compliance I am in 100% total agreement. Should it be addressed, I believe so. Should it be a NHP…no. I believe public financing for health care should be provided on a sliding scale based on income and need. I don’t believe someone making $100k a year should have free health care, unless they have a serious illness which has the ability to bankrupt them, but that’s what stop-loss insurance is for. I believe this individual’s taxes should contribute to free health care for the poor (as the current tax system supports). And this is coming from someone you would consider the looney right.

  10. Rubbish. Payment at the point of service uniformly (in Rand study and in real life) massively impacts the behavior of the poor, and does nothing to affect overall health care spending, however much Eric thinks it ought to.
    It’s a Zombie. Pure and simple

  11. Let me propose a new prerequisite to the presenting of study and survey results (and this ought to hold true for any serious medical journal): complete disclosure of any possible bias of the researchers.
    The major journals have moved to disclosing any financial conflicts of interest for study researchers (ie. Dr. Jones is a paid consultant for company X or own shares in company Y), but it is a footnote, not a headline.
    Clear ideological leanings ought to be disclosed as well (ie. when Dr’s Himmelstein and Woolhandler publish health policy studies in health affairs or NEJM) (they are major players with Physicians for a National Health Program).
    The first question that needs to be asked when anyone reads a study is: who wrote it? This is medical journal reading 101.
    The linked article gives no info about the researchers of their organization.
    The disclosure does not necessarily make findings less true, but we must put the results in context.
    And, as Tom has put so well above, we do not know what other factors might be confounding the data (spending priorities).
    People spend 30-50 dollars every few months chainging the oil in their cars because failing to do so can be very expensive and the government will not bail them out. Many in the US promote a culture where investing in one’s healthcare is felt to be less important because the government will bail them out. (BTW, the so-called medical bankruptcy study is a perfect example of my initial point, for those who want to argue this issue using that data).
    The broader problem with copays and lack of cost transparency is that people view the cost/ benefit of a medical service without understanding the real cost to the system and themselves. For example, if a medical visit has a $10 copay, the cost to the patient is $10, not the $50 it will cost the insurer.

  12. I understand the human problem here, but sometimes wonder what “can’t afford” means. Does this mean a choice between a copay and DirecTV? In this case, and I am sure Drs. Novack & Newberry will help me out here, it seems to me a double problem: inactivity leading to poor health, and simultaneously draining our wills and pocketbooks of the resources to cope. Other examples abound.
    If patriarchy is bad and choice is good, we will do nothing about it. People will overutilize DirecTV and underutilize medical services, and their health will suffer for it. If paternalism is good and choice is judged according to what is chosen, then we will adopt some variation on a European approach.
    American culture has been marked by two impulses: Rugged Individualism tempered by Neighborliness, which seems to have been with disastrous consequences forgotten of late. Europe, being in its heart of hearts Catholic, is marked by an attitude of Solidarity, and is more accepting of both free-riding, and paternalism expressed through government. We will have to decide how we want to be.
    t

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