I am teaching a class tomorrow entitled “Health Care Reform” to the first year medical students. I pulled out my slides from last year (January, had just come back from DC, was convinced that we would have something on the President’s desk by July) and made some changes. The good news was that I only had to add a couple of pieces of information to the talk. The bad news is that we don’t have change yet, but it may be closer than we think.

Why don’t we yet have health care reform? There was an article in the New Yorker  several years back that did a very nice job of describing the concept of moral hazard and why there is a policy dispute about health care as a social good. Gladwell points out that many feel (most fall on the “conservative” end of the spectrum although not all) that the uninsured who pay cash rarely have no health care expenses and  the very wealthy spend a lot on health care. In a market system those paying cash are paying closest to the true  value so it must be that those who are wealthy view health care as a luxury item. It would not be morally right to give all Americans access to this luxury.

The RAND corporation performed an experiment in the 1990s to see whether this would be the case. They found:

In general, the reduction in services induced by cost sharing had no adverse effect on participants’ health. However, there were exceptions. The poorest and sickest 6 percent of the sample at the start of the experiment had better outcomes under the free plan for 4 of the 30 conditions measured. Specifically,

  • Free care improved the control of hypertension. The poorest patients in the free care group who entered the experiment with hypertension saw greater reductions in blood pressure than did their counterparts with cost sharing. The projected effect was about a 10 percent reduction in mortality for those with hypertension.
  • Free care marginally improved vision for the poorest patients.
  • Free care also increased the likelihood among the poorest patients of receiving needed dental care.
  • Serious symptoms were less prevalent for poorer people on the free plan.
  • Cost sharing also had some beneficial effects. Participants in cost sharing plans worried less about their health and had fewer restricted-activity days (including time spent in seeking medical care).

In addition,  the experiment examined whether shouldering more of their own health care costs leads people to take better care of themselves. It did not. Risky behaviors were not affected — rates of smoking and obesity, for instance, did not change.

(An article in this week’s New England Journal of Medicine finds that increased cost sharing on the outpatient side in Medicare patients leads to delayed care and more hospital care as well. People tend to be penny wise and pound foolish when it comes to their health. A lesson learned in the 1930s and one of the reason that a group of physicians founded Blue Cross)

Mr Gladwell points out that the real objection to universal coverage, from a policy standpoint, is that some people (those with disease) will consume more resources than they will have been predicted to pay for. In other words, the objection is that resources are redistributed  from those who are healthy to those who are unhealthy. Susan Channick expanded this in an article on why we will never have a single payer system in this country. She lists the reasons as inertia, path dependence, the expense of the Medicare program, the American belief in looking to the private sector for solutions to even large social problems, the fear of big government coupled with the belief that government is the problem rather than the solution, the political preference for incrementalism over fundamental change, and cultural beliefs such as the belief that while all Americans enjoy equality of opportunity, only those able to capitalize on the opportunity are entitled to enjoy its fruits. This last one is the most profound, as the implication is that we Americans who are healthy deserve to be healthy and owe nothing to our unhealthy neighbors.

In an article in the New England Journal, Thomas Murray points out that the Judeo-Christian tradition as articulated in the Bible includes the concept of “stewardship.”  He says that “Landowners are instructed in Leviticus: “When you reap the harvest of your land, you shall not reap to the very edges of your field, or gather the gleanings of your harvest; you shall leave them for the poor and the alien.” The obligation is not limitless: the landowner does not have to prepare a meal for the “poor and the alien,” does not have to surrender the entire crop, and should protect the land to ensure that it remains productive. But when food is more than sufficient to feed all, allowing some people to starve is indecent and represents a failure to live up to universal moral duties.” Lets all try to live up to that standard.

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