Brian Balfour at Civitas’s Red Clay Citizen yesterday provided a good summary of the public hearing on HB2688 to create an “Access to Health Care Policy Council.” I was troubled by some of the assumptions underlying the idea to create a council and wanted to expand on my brief comments.
The proposed ?Access to Health Care Policy Council? raises many practical concerns of how it will operate, including the likely composition of the panel and the issues it will address. More fundamentally, the very idea for the council is based on a number of questionable principles and assumptions. Three in particular deal with the ability of any council to anticipate needs in a complex system, the value of integration, and the efficacy of preventive medicine.
First, it takes extreme hubris to think that thirty-one individuals with vested interests can make better decisions than nine million individuals around the state and millions more around the country who must match their monetary and health preferences every day. Some of the best quality and lowest prices for care are found in private, for-profit areas of care where consumers are more likely to pay their own costs ? optometry and LASIK surgery, cosmetic surgery and dentistry, bariatric surgery, and medical tourism. Providers, insurers, and consumers are finding new ways to improve quality and lower costs in other areas of the system as well; doctors who opt out of all insurance networks to avoid the tyranny of reimbursement codes, insurers who offer catastrophic care policies for ?young invincibles? who might otherwise consider insurance too expense, and patients who set aside money in some form of medical savings account to pay for current and future medical needs. No group of thirty-one could mimic or improve on the innovations that occur in the marketplace.
Spurring innovation, however, is counter to the council?s charge to move toward a more integrated health care system. There is no research to suggest that an integrated system of services will do a better job of providing appropriate and affordable health care for all. Here in North Carolina, we have tried for seven years to integrate our public and private mental health providers into a single system, with the result being again an expensive disaster. Even the integrated wholly public portion, the state mental hospitals, have been unable to provide appropriate and affordable care and have been subject to Department of Justice investigations and the loss of Medicare and Medicaid funds.
Michael Tanner of the Cato Institute summarized the argument for preventive care and the facts against it in testimony to the Wisconsin state legislature :
Preventive care advocates assume that if we focus on preventive medicine, we can prevent people from getting sick in the first place. And by emphasizing timely primary care, those who do end up with a chronic illness will develop fewer complications. By spending money up front to reduce the frequency and severity of illness we can reduce the amount of money needed to eventually treat those illnesses in the future.
As logical as this may seem, studies actually show that preventive care usually ends up costing money in the long run because there is no way to precisely target such care. For every disease that we prevent or catch early, we end up testing and treating many people who will never get sick. For example, Jay Bhattacharya, a doctor and economist at Stanford?s School of Medicine, estimates that to prevent one new case of diabetes, an anti-obesity program must treat five people. Similarly, a study of retirees in California by Jonathan Gruber, a health economist at MIT and long-time advocate of national health insurance, found that when retirees had fewer doctors visits and filled fewer prescriptions, overall medical spending declined. People became ill more frequently, but treating their illnesses was still less costly than paying for preventive care for everyone. Thus, increased preventive and primary care may well be beneficial for the individual in terms of health, but it is unlikely to provide a societal benefit in terms of reduced costs.
Other principles and assumptions underlying the council?s work, such as evidence-based medicine, have problems similar to those in the case of preventive medicine in that they sound like good ideas but can have unintended consequences when broadly applied.
It is laudable to want to improve health care cost, quality, and access, but more success might come from removing the rules that make health care less like other markets for essentials such as food, clothing, and housing.
