Who is gaming the system? Surprise, it's the corporations!

I recently participated in a panel discussion following a presentation on the impact of the Affordable Care Act (“Obamacare”) by UC-Berkeley economist J. Bradford DeLong. Unsurprisingly, Dr. DeLong, who worked in the federal government as Deputy Assistant Secretary of the Treasury for Economic Policy in the early years of the Clinton administration, during an earlier attempt to pass comprehensive health reform, took an economic point of view. He described the economic theories behind each of the approaches to health reform, how the ACA was put together, how it most resembled the “RomneyCare” model implemented in Massachusetts and endorsed by Hillary Clinton but abandoned by the Republicans; he also showed that the Obama administration miscalculated the near-unanimity of Republican opposition. He also looked at how the implementation of the ACA has been more successful than many feared (or hoped) and how the economic analysis behind it was distorted by the Supreme Court decision to allow states to not expand Medicaid, which has resulted in an enormous transfer of wealth from the “red” states that have not to the “blue” states that have done so. Apparently, the ideological commitment by many states (including my own, Kansas, and neighboring Missouri) to harm its people and give away money is puzzling from a purely economic, as well as a human, point of view.

One of the themes Dr. DeLong notes coming especially from “conservative” economists and Republican politicians (and we hear a lot) is the need for people to have “skin in the game”, by which they mean co-pays, deductibles, and other ways of people paying out of their pockets. As Dr. DeLong noted, the only large, well-designed, and meticulous study of the impact of such “skin in the game”, the 1983 RAND experiment (which I have previously discussed; see Insurance company profits up and patient care down, May 17, 2011*)  showed that even small out-of-pocket payments discourage people from seeking care for both minor and major conditions, ultimately cost much more to care for, and harm the health of those people. As noted by one of the audience, current requirements in many “high-deductible” plans for “skin in the game” cost-sharing are far greater than those studied by RAND (and can be 45% of a person’s income!) and are thus even more likely to have a major negative health impact.

Another common “game” meme, mentioned by one of the other panelists, is concern with people “gaming the system”. If this conjures up images of elegant gamblers in formal wear playing roulette with James Bond in a posh casino on the Riviera, that is the intent. Like Ronald Reagan’s “welfare queens” and Kansas Governor Sam Brownback’s “able-bodied adults who refuse to work”, it is meant to divide people by creating a “them” who are taking it easy while the hard-working “us” pay the price. Of course, this is nonsense; most of those individuals so “gaming the system” are merely trying their best not to break their budgets paying for health insurance until they get so sick that they need it. Yes, this is certainly contrary to the concept of insurance (everyone pays and only some people benefit, but you never know when it will be you), and is a big reason that most countries have gone to a “social insurance” system that just covers everyone.

In fact, despite all the fooforaw about it, there is no data suggesting that there is massive “gaming of the system” by regular people. Michael Hiltzik’s Los Angeles Times column of February 27, 2016 makes this clear, focusing on “Special Enrollment Periods” (SEPs), times when people can enroll in or change their insurance outside of the usual ACA annual period. Huge insurance companies like Aetna and Anthem have asserted, without much evidence, that people are using these SEPs (mostly designed to allow changes when you get married, divorced, have a baby, move to a different state where your current plan wouldn’t cover you) to “buy to use”, in Anthem’s words, meaning you wait until you’re sick to get insurance. Hiltzik presents data that shows this is not significantly the case, and that it is absurd; he writes “Aetna must think the entire country consists of people plotting how to get a quickie marriage or divorce or have a baby just in case they get sick. The vast majority of SEPs cover a relatively trivial number of cases, unless you think there are hordes of people applying to become members of a Native American tribe after they get sick.”

Of course, people do game the system. But the big gaming is by the insurance companies themselves and the providers of care. These corporations, big insurance companies, health systems, drug makers, who have the clout to “game the system” do so all the time as part of their core business models. It is convenient for them to divert our attention to regular people, middle-class people, and especially poor people, as the ones gaming the system. In fact these are of course the folks who suffer the most harm, whose health is most affected, whose access to care is most limited, and who are stuck with crummy health coverage because this is all they can afford.

The insurers work every legal angle (and perhaps some not-so-legal) to figure out how to mostly insure relatively healthy, low-cost people (after all, 5% of people account for 50% of health costs and 1% for 20%, see my Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009, and Kaiser Health News report 2013),  while the high-cost patients are covered by Someone Else. Providers, especially health systems and hospitals, figure out how they can “upcode” to get maximum reimbursement from insurers, attract people who have high-profit-margin conditions to themselves, and encourage high-cost, low-reimbursement poor and poorly-insured people to find their care from Someone Else. Insurers blame providers for charging too much, providers blame insurers for paying too little. One of the other panelists, a hospital executive, complained about how insurers seek transfer risk, which is part of the definition of insurance, to the providers. Neither is blameless, and the other big players, pharmaceutical companies (and device manufacturers) make out like bandits, with no major candidate having a real plan to address this according to a report by Julie Rovner of Kaiser Health, (cited hereby Medpage Today). Of course, this equates all plans to “negotiate prices” and it is obvious that a single-payer health plan, such as that advocated by Bernie Sanders, will have a lot more negotiating clout than the multiple-insurer mess that other candidates support and exists today.

What did I say as a panelist? Basically, that the goal of the system should be to maintain and improve the health of people, and that the economic design of the system should be designed to achieve that goal, rather than having competing economic theory be the driver, and people the incidental victims. I said that spending money on providing health care to people was not a bad thing, but spending huge amounts on “health care” when more than half was going to profit was. I said that all this spending on medical care (and profit) limited what was left to be spent on creating the conditions that allowed people to benefit from medical care – like housing, food, education – the social determinants of health.

I think that this resonates with people, both at the event and in the world. Or maybe I’m one of those “hopeless idealists”. If the alternative is being cynically corrupt, I wouldn’t want to be anything else.

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* Citations from that blog post: “RAND Health Insurance Experiment (as cited in Freedom abroad, health at home: experiments in preventive health care, February 13, 2011; the study was published in the New England Journal of Medicine in 1983[1]; and it is summarized in an article by Joseph P. Newhouse, "Free for all?:  lessons from the RAND Health Insurance Experiment", RAND 1993.”

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Does prevention save money? Is that the right question?

Does prevention save money? That is, does increasing access to preventive health care, doing more screening tests on a larger number of people, end up saving more money in the long term by reducing the cost of caring for the diseases that are prevented? This is the question asked in “Conventional wisdom clashes with data on health care savings”, by Margot Sanger-Katz in the New York Times on August 7, 2015. Ultimately, she answers “no”; indeed, in the online version dated August 5 that the link above takes you to, the article is titled “No, Giving More People Health Insurance Doesn’t Save Money”. Although it of course depends upon which preventive test we are talking about; “Counseling on contraception is one [of the preventive interventions that actually do save money] because the costs of prenatal care, delivery and pediatric care associated with an unplanned pregnancy are so substantial. But a lot of the preventive health measures that we tend to value a lot — mammography, screening for diabetes — tend to cost more than they save.”

The motivation for this article at this time is clearly the Affordable Care Act (ACA), which not only resulted in more people receiving coverage but mandated that preventive services be covered with no co-pay. President Obama made the case for it in part by talking about cost savings; Sanger-Katz quotes his 2009 address to Congress: “There’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.”  But, in fact, the discussion on the cost vs cost-saving from preventive services is not new; it has been frequently addressed in the literature. I have written about it several times, including two sequential posts on February 2 and February 9, 2009: Prevention and Cost and Economics and Disease Prevention, that cited two important articles on the topic, by Russell in Health Affairs[1]and by Woolf in JAMA.[2]

Sanger-Katz also cites two studies to support the argument, one old and one more recent. The famous RAND health insurance experiment from the 1970s and 80s that examined the impact of providing free (to the patient) access to health care, and the more recent Oregon health insurance experiment, begun in 2008, where poor people who were not already on Medicaid were lotteried into receiving health coverage or not. As she notes, in both studies, people who got free or low-cost coverage used more care, and thus cost more money. This, she notes, is consistent with basic economic theory, and ”…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.”

But, while true, this misses the most important point. I have written about both studies before, I discussed the RAND study in Insurance company profits up and patient care down, May 11, 2011, and also refer to it in my discussion of Oregon, The Oregon Lottery: Far from enough, but at least they are doing something, July 19, 2012. In the latter, I quote from a June 22, 2012 New York Times article by Annie Lowrey, “Oregon Study Shows Benefits, and Price, for Newly Insured” that the study “has found that gaining insurance makes people feel healthier, happier and more financially stable,” and that “The insured were 25 percent less likely to have an unpaid medical bill sent to a collection agency and 40 percent less likely to borrow money or skip paying other bills in order to cover their medical costs.” This is the truly important point; people are getting medical care that they need, and are not having to cut back on their other basic needs (remember, these are poor people who don’t have lots of discretionary income) to do so. It echoes the findings of RAND, which were basically: yes, people who got free health care used more care, and indeed used more care that experts considered “inappropriate” (the classic “going to the ER for a cold” trope). But it also found that, and this is the real take-home message, they used more appropriate care; the corollary trope is going to the ER for chest pain, instead of staying home and hoping it would go away because you’re afraid to incur the cost. Free health care not only saved lives, it improved health.[3]

Ultimately, as Sanger-Katz points out, everyone dies. While provision of preventive services may save lives from one disease “…every time you prevent people from dying from one disease, they are likely to live longer and incur future medical expenses. The patient who benefits from the cholesterol screening may go on to develop cancer, arthritis, Alzheimer’s or some other costly illness.” This may seem obvious, but only if you think about it. In the 1980s, I was the only physician student in a class on Health Administration; the other students were planning on being health administrators but did not have a medical background. In one class, a student reported that we were likely to save money in the future because people were adopting healthier lifestyles – eating better, exercising more, not smoking as much. I pointed out that the opposite was true; this would mean people lived longer, and were more likely to develop long-term chronic diseases leading them to, for example, long hospitalizations and nursing home stays. If you truly wanted to save money, you’d encourage a high-cholesterol diet, no exercise, and 2 packs of cigarettes a day, so everyone would drop dead from a heart attack in their late 40s and be done with the cost.

This may sound macabre, but the point it makes is that cost is not the only issue. Examining the cost of providing free health care, as in RAND 40 years ago, or free preventive care, as in ACA, is a legitimate activity, but it is not the only, or even most important outcome. Access to health care, prevention of premature death, and improvement in quality of life are also critical considerations. Cost is important, but cost control cannot be measured in such crude ways as “does prevention save money”? First, as Sanger-Katz noted, different preventive services have stronger evidence behind them, and have a smaller “number needed to treat” (NNT) to have an impact on either cost or lives saved or quality of life (thus a high priority should be expanding access to contraception and contraceptive counseling). Second, there is the expansion of indications (reasons for doing a test), either through providing preventive services to a larger group of people than those shown to have the most benefit in studies, or by ratcheting down the “goal” for things like cholesterol, blood pressure, or blood sugar. These both have the same effect; they decreases the average long-term benefit while increasing the cost (and, not coincidentally, the profits for the manufacturers of the drugs and purveyors of the tests).

Third, and by far the most important in terms of both cost and justice, is the application of different standards to different populations, based on insurance status, wealth, and race. Performing preventive services for people who are unlikely to benefit is a problem, but performing much more expensive interventions for people who almost certainly won’t benefit just because they want them, and they (or their insurer) can pay for them, and because the providers doing them make money, is a far greater issue for cost. In addition, there is the question of “what is a fair price?” for any service, preventive or therapeutic, indicated or not (well, if not indicated, the fair price is zero!). In The high cost of US health care: it's not the colonoscopies, it's the profit, Jul 28 2013, I cited the work of Elisabeth Rosenthal of the New York Times, on this topic; she presents the wide variation in costs for this and other procedures. Thinking of the myriad types of preventive interventions as if they were all the same and of the same value is like thinking of “cancer” as one disease, rather than hundreds; it is simple and it is incorrect.

Ultimately, the cost issue is addressed by equity. Everyone should have access to all interventions that are likely to help them, and no one to those that will not. 

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[1] Russell, LB, “Preventing chronic disease: an important investment but don’t count on cost savings”, Health Affairs, Jan/Feb 2009;28(1):42-45

[2] Woolf SH, “A closer look at the economic argument for disease prevention”, JAMA 4Feb2009; 301(5):536-8. (9th)

[3] Brook RH, et al., “Does Free Care Improve Adults' Health? — Results from a Randomized Controlled Trial”, N Engl J Med 1983; 309:1426-1434

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