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By Dr. Christopher Hughes

Put me down as an optimist, but I do not think the Supreme Court will invalidate the individual mandate and I will be so bold as to predict a 6-3 decision or better. Having said that, I got a kick out of a New York Times article about Republican options for that famous "be careful what you wish for" moment  that will arrive if I am wrong.


Here are their takeaways from the health care reform death match that they caused over the past three years:


  • “If Obamacare goes away, it doesn’t mean that the problem of how you deliver health care affordably and get good access goes away”
  • Their approach is likely to set aside universal health insurance coverage as the main objective. Instead, they would focus on lowering costs as “the overriding goal,”
  • The moldy oldies are what is needed: "allowing individuals to buy health insurance across state lines, helping small businesses band together to buy insurance, offering generous tax deductions for the purchase of individual policies, expanding tax-favored health savings accounts and reining in medical malpractice suits."
  • These ideas, the CBO said, "would have provided coverage to 3 million people, leaving 52 million uninsured."
  • “The status quo is unacceptable,” said [Dr. Tom] Price, an orthopedic surgeon who is chairman of the House Republican Policy Committee. “Everybody agrees on that.”
  • They like letting young adults stay on parents insurance, like the ban on lifetime limits and rescission of policies, but really hate that mandate that they loved back in the stone ages 1990's.
  • But what do they really like? "The main feature of a Republican plan could be federal assistance for the purchase of catastrophic health insurance with high deductibles," Mr. Barrasso said. Oh, and "patients would face more up-front costs and would therefore have incentives to become more discerning consumers of health care, he said."


Oy. Here's the thing, the overarching theme of all of this is that some people just don't deserve to have access to health care and that "too much" health care is a bad thing. We've discussed the former point before, here and here, but the second one is worth a few more minutes of your time.


First, high deductable policies do not produce good quality health care. I like to point out that, in my admittedly anecdotal evidence base on this, most of us doctors are too boneheaded to wisely choose when to use our under-the-deductable dollars and will put off stuff we know we should be doing, so why should we expect lay people to do better? But, also people put off care because they cannot afford it. "Patients with chronic conditions who had high-deductible insurance were three to four times more likely to say they delayed or went without medical care because of cost, according to the findings of a Harvard University-Children's Hospital Boston survey published in the Journal of General Internal Medicine last month. Lower-income respondents were even more likely to go without, the study says."


Second, the "too much" health care reflects an underlying assumption about health care that, while not true, shapes much of conservative ideology and thus, policy formation, on health care. If you have not read Malcolm Gladwell's "The Moral Hazard Myth," you must. It tears apart this mythology limb by limb. A few choice quotes:


  • Policy is driven by more than politics, however.  It is equally driven by ideas, and in the past few decades a particular idea has taken hold among prominent American economists which has also been a powerful impediment to the expansion of health insurance.  The idea is known as "moral hazard." Health economists in other Western nations do not share this obsession.  Nor do most Americans.  But moral hazard has profoundly shaped the way think tanks formulate policy and the way experts argue and the way health insurers structure their plans and the way legislation and regulations have been written.
  • The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like Nyman this assumption is plainly absurd.  We go to the doctor grudgingly, only because we're sick.  "Moral hazard is overblown," the Princeton economist Uwe Reinhardt says.  "You always hear that the demand for health care is unlimited.  This is just not true.  People who are very well insured, who are very rich, do you see them check into the hospital because it's free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?"
  • If you think of insurance as producing wasteful consumption of medical services, then the fact that there are forty-five million Americans without health insurance is no longer an immediate cause for alarm.
  • A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy—a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper—has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers.
  • Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem.


I hope you'll take the time to read this article as it is, in my mind singularly important in how we discuss health care and the continued need for health care reform. If you recognize that a conservative's underlying assumptions about health care are driven by an assumption that we know, because we see the evidence in our offices and hospitals every day, is wrong, it is helpful in reframing the solutions.

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