Whenever a discussion of health care policy is initiated, the importance of health insurance, of extending coverage, takes center stage. The need for insurance quickly becomes an undeniable truth, a universal imperative. And we never seem to question this premise enough before getting more patients fitted with shiny, new policies. This was precisely the case with the Affordable Care Act. But where is the evidence insurance plays any role in improving anyone’s health? Why is it assumed more coverage is always the answer, particularly for routine care? I would argue it is little more than a myth, one found nowhere else in our collective understanding of insurance.
Let’s consider our experience with insurance in other areas of our lives. In most states, it’s mandatory for drivers to carry automobile insurance. But it doesn’t reduce the incidence of accidents or extend the life of a vehicle, nor does it cover oil changes, car washes, flat tires, or any other form of maintenance or unfortunate mechanical reality. Similarly, homeowners insurance doesn’t cover the cost of repairs when your kids put a hole in the wall, the price of having your gutters cleaned, or the removal of mold due to leaky pipes or unsealed windows.
Why, then, do we expect health insurance to function any differently? There is no compelling evidence that insurance improves outcomes. In fact, of the few studies conducted, most have either failed to control for known determinants of health or shown, at best, a very tenuous relationship between the two. Access to health care matters, but we mistakenly assume more insurance is the best way to increase access. We believe coverage for routine medical care, for everything from checkups to preventive care procedures, improves our nation’s health. It does not; it only appears to because of numerous confounding variables.
What is known, however, is the total amount of money available for health care, generally some large percentage of our GDP. That number is static at any given time and cannot be magically increased. In fact, by definition, relegating any aspect of health care to insurance industry jurisdiction necessarily decreases the funds available at the bedside. These companies must extract a profit; that’s how capitalism works. Moreover, whenever the scope of coverage is increased, patients and physicians give up more control as to the nature, timing, and extent of the routine care provided.
All insurance, even health insurance, should be procured to protect one’s financial interests against catastrophic, unforeseen events. Engaging it for routine activities, including all but the most costly drug therapies and procedures, serves only to dilute valuable resources and relinquish essential control. Thankfully, Healthcare.gov offers some high deductible plans that encourage direct payment for routine care, but many of them are also HMO-type plans, plans where third parties determine the routine care that is or isn’t covered.
Physicians must regain the authority to decide what routine care patients need. Despite the increasingly popular, one-size-fits-all algorithms of evidence-based medicine, it remains a fact that, even for those of similar age, sex, race, and socioeconomic background, every patient is unique. We have conceded that the future of pharmacology points to personalized medicine, to therapies tailored to an individual’s unique genetic composition, and yet we continue to assume that generic algorithms should govern what is best for a particular patient.
And some argue that health care is too expensive for certain patients to handle without insurance. For many aspects of health care, that’s true. So strengthening our nation’s safety net, consistently scrutinizing the performance of Medicaid programs, for example, is critical. But the truth is insurance increases the cost of routine care. It raises physician and hospital administrative costs and artificially inflates prices in several other ways, not to mention the aforementioned profit reality.
Improving access to education, reducing unemployment and increasing household income by stimulating small business and innovation, limiting environmental hazards, reducing poor health behaviors, and increasing the number of primary care physicians available would have a greater impact on health than more coverage. These are some of the confounding variables that lead us to believe insurance is always the answer. And focusing directly on these true determinants of health status does not force patients to relinquish control or artificially drive up the price of health care services; insurance paradoxically does both.
For decades we have increasingly relied on insurance (public and private) in health care. The results have been perpetually rising costs, increased infringement on physician independence, and an ever growing psychological barrier that prevents patients from understanding the true costs of, or seeing the real value in, health care services. We have conditioned patients to believe a long visit with their physician is worth about twenty dollars. Meanwhile, most Americans accept that a similar session with any good attorney costs many times that number.
We need to embrace a system where health insurance is procured only to protect patients’ financial interests against catastrophic injury or illness and routine, less expensive health care services are paid for directly by patients. This would require a fundamental change in how individuals view their responsibility for their own health, an increased awareness that routine care must be budgeted for like any other household expense. But this shift would help control costs and empower patients to purchase competitively priced services from independent primary care physicians free of unnecessary administrative burdens.
Effective, efficient health care policy must adhere to three basic principles:
- No one knows how to spend an individual’s money more wisely than the individual does, not the government, not insurance companies, no one.
- No one is more qualified to determine the appropriate medical care for a given patient than a well-trained, independent physician.
- The introduction of any intermediary between a patient and his or her physician will, by definition, always decrease the amount of money available for medical care without adding anything of comparable value to the process.
I tend to believe in people, in the individual. And I believe a well-educated, fully employed, free individual, in consultation with plentiful, well-trained, independent physicians, will generally make the right choice. In our society, however, it is their right to make the wrong one, and, thankfully, no insurance policy will ever change that reality. Unless we limit our reliance on insurance, costs will continue rising, physician reimbursement and therapeutic autonomy will continue declining, and patients’ understanding of, and control over, their own health will continue to wane. Insurance is great if used judiciously, but let’s not continue to assume more of it is always better; it isn’t.