High deductibles keep patients from seeking NECESSARY care.

[feuervogel]

While pro-market conservatives like to say that high deductibles keep costs down because people will "think harder" about asking for expensive, potentially-unnecessary tests, the main effect is to keep people who need treatment but can't afford the up-front out-of-pocket payments from going to the doctor to get that little thing taken care of before it becomes a huge thing, or for routine preventive care.

Via the Mad Biologist comes a story from the New York Times about people foregoing necessary care because they can't afford to meet their deductibles.

For someone like Shannon Hardin of California, whose hours at a grocery store have been erratic, there is simply no spare cash to see the doctor when she isn't feeling well or to get the $350 dental crowns she has been putting off since last year. Even with insurance, she said, "I can't afford to use it." Delaying care could keep utilization rates for insurers low through the rest of the year, according to Charles Boorady, an analyst for Credit Suisse. "The big question is whether it is going to stay weak or bounce back," he said. "Nobody knows."

High deductibles also can be daunting. David Welch, a nurse in California whose policy has a $4,000 deductible, said he was surprised to realize he had delayed going to the dermatologist, even though he had a history of skin cancer. (emphasis mine)

Mike: I understand the need to cut down on unnecessary spending--and many plans' 'unnecessary' ER deductibles are low, especially in the People's Republic of Massachusetts--low for me, anyway*. But for some people, they can't even afford a $100-$200 deductible. That is what poverty means. This 'efficiency' is going to get people killed. (emphasis mine)

So all you folks blithely saying that high deductible plans are great and that health insurance ought to be only for unforeseen catastrophes, not routine care or prescriptions (or even things like physical therapy and psychotherapy, because those aren't, like, CANCER or a broken leg), what you're actually saying is that the poor deserve to die from completely treatable medical conditions.

If you want more transparency of costs, I'm with you, but when someone has food poisoning or a heart attack or is involved in a car accident, they're not going to be shopping around for which hospital has the best rates. They're going to go wherever's closest, or wherever the ambulance takes them.

(This is why medical care cannot be likened to buying a washing machine. Aside from the disparity of information (doctors vs patients), someone in an emergency situation is NOT going to do a little comparison shopping before getting in the car/ambulance. For elective care, like knee replacements, sure, but price isn't the only factor.)

Comments

[krait]

I wish there were some way to sneakily subscribe certain of my family members to your health-care tagged posts. :P I avoid talking politics with my family, but I suspect a number of them fall on the side of "washing machine" here... part of why I avoid discussions in the first place.

[feuervogel]

I dated a Libertarian for 6 months last year. It may not have been the smartest thing I ever did.

[a-nightengale.livejournal.com]

Earlier this year, a friend of some work colleagues died from a heart attack because she didn't have insurance and was afraid of huge medical bills she couldn't afford:

http://open.salon.com/blog/scifigamerchick/2011/02/03/can_you_afford_your_heart_attack

Even *with* good insurance, my own heart attack cost well over $100,000--and we're still paying off the deductible from it (thankfully the hospital worked out a payment plan for my husband and me).

[feuervogel]

It's appalling, really.

Last year, while I was dating a Libertarian (I know, what was I thinking? Even mecha anime and kung fu movies can't bridge that gulf), he said something to the effect of "libertarians focus on theory, liberals focus on outcomes." Which, fucked if that isn't true! In their vaunted theory, the Free Market and Perfectly Rational Consumer (with, let's not forget, Perfect Access to All Necessary Information to Vote With Their Wallet) will lead to a wondrous utopia where property rights are the only rights that matter! While, of course, liberals are disgusted, because we understand sociology and how actual real humans behave, and we look at history to see the results of some of these policies and say what a horrible thing that would lead to.

I feel a need to write the anti-libertarian dystopia that Snow Crash should have been. Also as an antidote to Sarah Hoyt.

[kirin]

It's been a while since I read it, but isn't Snow Crash pretty dystopic as is? I mean, it's a cool action-adventure, and it has some kick-ass early cyberspace stuff, but to the best of my memory most of its "real world" settings were not places I'd want to actually live.

[feuervogel]

Me either, but it wasn't exactly deconstructed in so many words. I mean, it's the logical consequence of letting corporations run the country and privatizing everything, but Snow Crash was so over the top (in the privatization aspects primarily) that it felt more humorous than anything else.

[leora.livejournal.com]

How is a need for psychotherapy, or more generally mental health care, not like a need for cancer treatments? The lack of either one can kill you.

[feuervogel]

I agree that it's necessary care, but one of the things that never gets mentioned is how one defines "unforeseen." Does that mean smokers don't get to claim their lung cancer treatments? Or obese patients, well, anything at all, since /everyone knows/ they were just asking to get diabetes or heart disease? (sarcasm) It's medical Calvinism: you get what you deserve, with an added dash of "and I ain't paying for your life choices."

Looking at the sorry state of mental health coverage today should give a good idea of just how necessary insurers (including the state through Medicare/caid) believe it is. Magical Libertarian Paradise Fantasy Land won't feel it any more necessary than they do today.

[leora.livejournal.com]

Yeah, I know. I just hate the stigma against mental health issues. But you can't even make the smoker-cancer argument for mental health generally. It's not like people choose to be depressed or to have anxiety. Depression and anxiety have huge mortality rates, plus even when they don't kill the massive amount of harm they do to quality of life and ability is vast. If you compare it to various other health issues, it's really a major one. There's very little people with it can do to influence it, other than seeking treatment if they can access treatment, and not much in the way of risk factors under people's personal control. So, really we just don't help people with it because we randomly decided mental health is special and different and we don't care about this category of problem as much. I have tons of sympathy for anyone suffering with an aggressive cancer, but I also have tons of sympathy for anyone suffering with a persistent depression or anxiety issues. Any of those are horrible. And I hate the game some people try to play where it somehow is belittling to people with problem X if you also take problem Y seriously, because that makes no sense.

And when you think about it, as far as quality of life goes, there are very few health issues that can compete with depression for harming quality of life. You can make a case for dementia and other things that cause severe cognitive losses. But you can have cancer and still enjoy your life while you have it; depression by definition sucks away your enjoyment of life[1].

[1] Well, technically bipolar depression can include manic and hypomanic episodes, which while also being issues do not necessarily suck the enjoyment out of life, but that's a technicality.

[feuervogel]

The number of people out there who think people with depression (for one example) just need to "think positive" and pull themselves out of it is appalling.

If we could start by destigmatizing mental illness as well as educating people that yes, it's real, and it's not like "the blues" that you just "get over," that would go far.

[leora.livejournal.com]

I honestly do believe that this is happening. It's just a slow cultural shift with a huge amount of progress still to go. I think mental health issues were far more stigmatized if you go back several decades, and I think the general understanding of depression, while still poor, is better than it used to be. I do think this will keep improving for a while (although not always in a straight forward manner, there will be setbacks, of course). It's just one of the things I really, really want. The way we deal with mental health is really poor. And we have so many misunderstandings about it. It really bothers me the way we treat mental health problems as not real health problems. It also damages health care for non-mental health issues, because there is a tendency to take any new and poorly understood health problem and dump it into the mental health bucket, and then say it's not a real problem. If we treated mental health problems as equally important, then if we had a new health problem and misfiled, and we saw that it was resistant to mental health approaches, we would be more likely to look for more physical approaches. I think it would drastically improve health care overall. And instead of fighting over whether something is a "real" problem when it is obviously causing dysfunction, we could focus on what is the most effective way of treating the problem. Sometimes that will be therapy, sometimes it will be medication, sometimes that will be a mixture of the two... and I would give you really good odds that you'll find those lines between what we think of as physical and psychological will stop looking so clear. Because medication-based approaches do help with a lot of "psychological" problems, and adding therapy as a supplemental treatment in addition to more standard treatments often helps with problems we think of as purely physical (I forget what the example cases were, but I think it may even have been cancer, being on theme for our examples). Not that it's surprising to me that cancer would take both a physical and a psychological toll and helping with both would yield better results. I just don't think people are comfortable with the extent to which we live in physical bodies and that things going on physically affect our emotions, memory, and other things we think of as too intimately part of our identity.

[beth_leonard]

And why does care cost so much in the first place? That's a big piece of the equation. What is the shortage which is driving up the prices?

--Beth

[corpsefairy.livejournal.com]

There's a person on the WELL who has done a ton of research on the state of US health care, and he's made extensive and in-depths posts about it. Really interesting stuff. I can't even begin to summarize, and I cancelled my WELL account so I can't go look it up.

However, I think you'd find it really interesting. A WELL account for a month costs $10; I don't know if it's the sort of thing you're into, but there's a lot of valuable and fascinating stuff there.

[feuervogel]

The shortage is in primary care providers, because our almost-entirely-privately-run medical school system (even UNC med school is expensive) leaves doctors with $250k+ in debt upon completion of 4 years of college, 4 years of med school, and 3-5 years of residency, so most of them go into high-paying specialties instead of low-paying general practice.

There are two ways to address this shortage, both of which involve copying European models, which will never work, because USA! NUMBER ONE! USA! NUMBER ONE! doesn't need to copy those pansy-ass European communists. First, we reform our public school system to meet the academic rigor that Europeans already have, so that when they start university, they go directly into their majors, rather than playing catch-up for 2-4 years (med school and pharmacy school are four-year programs in Germany, and you start immediately your first year of college, rather than after the completion of a BS).

Second, we overhaul the funding of secondary education in this country so that it doesn't cost people $20k/year to get an education, but that involves OMG TAXES, which CENTRAL PLANNING, and we can't have that.

(BTW, tiurin asked you to elaborate more on the central planning post, and I'm also curious.)

[beth_leonard]

I would love to break the doctors guild. I consider that a government created problem -- "practicing medicine without a license" is quite a crime, and there's no alternative way to offer licenses.

If there's one type of doctor that takes 11 years to get a license post high-school, and another one that only takes 4 or 6, that might go a long way towards addressing the shortages. If, as a doctor all you do is preform colonoscopies all day, why do you need 11 years of training to do that? The current system is very broken, and I'll agree with you 100% on that. We disagree on remedies.

I forgot about tiurin's comment, I'll have to go back and find it. It was during rummage sale week when I wasn't doing anything unnecessary.

--Beth

[feuervogel]

There's no such thing as a doctor that just performs colonoscopies all day. Gastroenterologists do a lot more than that. Rad techs already do most of the ultrasounds and mammograms, but anything that goes into the body takes a bit more training in case something goes horribly wrong.

The AMA and state boards of medicine are very resistant to change. If Medicare rules or the health reform bill included requirements to have nurse practitioners manage chronic diseases (diabetes, heart failure, etc)--because there's a lot of evidence that having monthly or bimonthly visits with a provider to check up on how the diabetes is going and adjust meds as necessary, as well as see how the lifestyle interventions are going, saves a LOT of money on the expensive things like hospitalizations and amputations and dialysis--that would go a long way to forcing them to stop being jerks as well as freeing up MD time for acute ailments and other such positive things.

[botia.livejournal.com]

From your link:
And the number of recreational colonoscopies performed is actually very low.

awesome

And I wonder if the shortages mentioned by another comment could be addressed by making sure that, regardless of their level of privilege, EVERY person who had the desire AND the mental/physical ability to become a doctor had absolutely no trouble getting into medical school--with lots of tuition assistance and grants to keep them from graduating with a mountain of debt that they can't dig their way out of. It would allow doctors who are true humanitarians, who really want to heal, to go and do that. The ones who want it for the prestige and money will still go off into specialties, but we'd get a ton more GPs with such a plan.

[feuervogel]

That would be socialism and central planning, so we can't have THAT, now.