Preventive Care Saves Money -- A Very Attractive Fairy Tale
Aaron E. Carroll writes in The New York Times:
The idea that spending more on preventive care will reduce overall health care spending is widely believed and often promoted as a reason to support reform. It's thought that too many people with chronic illnesses wait until they are truly ill before seeking care, often in emergency rooms, where it costs more. It should follow then that treating diseases earlier, or screening for them before they become more serious, would wind up saving money in the long run.Unfortunately, almost none of this is true.
Let's begin with emergency rooms, which many people believed would get less use after passage of the Affordable Care Act. The opposite occurred. It's not just the A.C.A. The Oregon Medicaid Health Insurance experiment, which randomly chose some uninsured people to get Medicaid before the A.C.A. went into effect, also found that insurance led to increased use of emergency medicine. Massachusetts saw the same effect after it introduced a program to increase the number of insured residents.
Emergency room care is not free, after all. People didn't always choose it because they couldn't afford to go to a doctor's office. They often went there because it was more convenient. When we decreased the cost for people to use that care, many used it more.
The reality as stated by Carroll:
Prevention improves outcomes. It makes people healthier. It improves quality of life. It often does so for a very reasonable price.
This is part of the reason I paid myself every month, sans employer, for healthcare through an HMO. I couldn't afford to buy a bed at the time, but I always paid my monthly health insurance tab.
Now, I'm paying for preventive care -- for myself as well as a fuckton of other people. Some of them have pre-existing conditions and couldn't get healthcare.
That's a bad thing, and maybe that was a thing the government should have stepped in on -- along with untying healthcare from employment.
But now, my previously affordable care is unaffordable because my rates have been raised through the roof to pay for preventive care for all of these other people. As I like to put it these days: "I still have healthcare; I just can't afford to use it."
As Ann Althouse put it in a post:
We don't generally pay to improve each other's quality of life. We expect you to work and pay for your own quality-of-life improvements.
Preventative care does not reduce costs. With a low-cost doctor visit, people visit the doctor more often, not less.
If your kid has the sniffles and a visit to the pediatrician is $100, you give him some cough medicine. However, if the visit is only $20, you head over to the doctor's office, better to be safe than sorry.
That's the logic that bureaucratic-minded people never understand. Changing costs (and risks) changes behavior.
Conan the Grammarian at January 30, 2018 5:21 AM
There is also correlation does not mean causation.
People who choose to get annual checkups from a doctor are healthier and live longer. But when you push more people to get annual checkups from a doctor nothing much changes for the general population, except more crowding at the doctor's office. Annual checkups don't improve health. People who worry about their health get annual checkups.
Ben at January 30, 2018 6:24 AM
Life expectancy, probably the best overall indicator of health in a country dropped for two years. Possibly an indicator of ACAs true effect.
https://www.npr.org/sections/health-shots/2016/12/08/504667607/life-expectancy-in-u-s-drops-for-first-time-in-decades-report-finds
Joe j at January 30, 2018 6:29 AM
Costs arent going down until we lose the PC mindset that you cant tell someone to quit self-medicating with crap food. Its an addiction like any other, the results are just more visibly obvious. 90% of the chronic crap we see people returning for over and over again are self-caused with food.
If youve got type 2 DM, and dont overhaul your life, your going to have a short, miserable, medically expensive life. No insurance can change that.
Momof4 at January 30, 2018 7:31 AM
I work in a County Health Dept. STD Office. All medical providers are required to report any positive STD tests to our county health dept. We get quite a few reports from emergency rooms in our county.
Dave M. at January 30, 2018 8:30 AM
Possibly an indicator of ACAs true effect.
How else were they going to bend the cost curve down? the people who use the most money are the ones who are either sickly, or live long lives and become sickly (old age, for instance).
The optimal solution is to have healthy people live a good long life, then keel over dead. Maximize contributions to the insurance regime, and minimizing the amount of actual care provided to them.
I R A Darth Aggie at January 30, 2018 8:56 AM
It might seem like preventive care saves money because better educated/richer (BER for short) people have better health. I propose that there is an alternate explanation:
1) BER tend to avoid meth, excessive alcohol, and smoking, all of which are really hard on the body.
2) BER are quick to notice a health issue, realize what it is, and go to a doctor before it becomes too late.
Non-BER may be living too chaotic a life to be organized enough to go to a doctor (or their job doesn't give them time off) so if you make it available they will go to ER which is open whenever they can go. The extremely messed up person is very impulsive and also not likely to be compliant with doctor orders (very very bad if you are diabetic).
cc at January 30, 2018 9:04 AM
CC, I feel like both your points fall under "preventative care"
NicoleK at January 30, 2018 9:48 AM
"free checkups" were supposed to do this going on forty years ago.
But the people who had plans including free checkups (HMO} were in jobs whose average pay was pretty good. IOW, a checkup's cost was probably about the same as a monthly payment on the snowmobile.
They could have afforded it but some people don't like checkups.
Making the checkup free reduced for some any excuses they'd been making, but not by much.
Richard Aubrey at January 30, 2018 10:11 AM
I used to have a perception of poor and homeless people as these noble victims of harsh circumstances struggling hard to meet their most basic needs in a materialistic, uncaring society.
In 1995 I set up a sort of nursing triage clinic in a homeless shelter for families. The idea was to assess their general health and medical needs and then find someone who would provide the medical care for free.
To my surprise it was easy to find people, especially rich people, willing provide or pay for care for someone in need, especially when I asked them for help for a specific person with a specific need. Many people seemed downright eager to help somebody and happy to have the opportunity - like it just made their day.
I asked for and got help from community clinics, urgent care clinics, service organizations like Kiwanis and Scottish Rite Services, churches, pharmacies, labs, nurse practitioners, doctors' offices, and kind individuals... I arranged appointments for homeless and poor people within three days or less, all within a two mile radius of that homeless shelter. The homeless shelter would provide bus passes, and occasionally I arranged for a taxi to pick up someone and take them. I was astonished by how many people were willing to pay for a taxi to take someone to the doctor. I'm not kidding, you could go out to the sidewalk in front of the shelter and ask pedestrians passing by, and someone would gladly give you $5 or $10 for cab fare. No wonder there are so many people panhandling.
In the six months that I ran that little triage clinic I arranged services and appointments for 104 people in need of medical care, including men, women and children. The problems included things like chronic coughs, diabetes, asthma, ringworm, infected wounds, injuries, congestive heart failure, back pain, toothaches and abscesses, sexually transmitted diseases, mental illnesses, drug withdrawal, pneumonia, lice and scabies - all the crap that happens to poor and homeless people.
Guess what percentage of those 104 people kept the appointments and availed themselves of the services arranged for them. The answer --> 0 - that's z e r o . Not a single one. They all agreed to the place, date and time at which they would receive free care, and most expressed gratitude. But not a single one kept the appointment.
When asked why, reasons included things like: too sick to get up and go; used the bus pass to visit a friend; feeling much better and didn't need to go; forgot; kids were acting out. Some of these people later showed up at the emergency room where I worked, and I suppose others went to other emergency rooms in the area.
It was an eye-opening experience. I found out the reason a whole lot of poor and homeless people don't get medical care isn't lack of money or lack of insurance. They just have a different point of view about health and healthcare.
Ken R at January 30, 2018 2:07 PM
I admire the sincerity and modesty of your conclusion. I've been on a Jordan kick this weekend, as has (apparently) much of Western Civ. This discussion and its sources (Murray and Herrnstein) make it clear that a substantial portion of the American and world populations are never going to have the clarity to participate in the proficient & businesslike use of the services and opportunities that make worth living for the rest of us.
Crid at January 30, 2018 2:24 PM
...But I should have closed that link.
Crid at January 30, 2018 2:25 PM
Ken,
Not that I doubt your story, but I do have to question how you would settle for a 100% failure rate. I mean, after going through all those arrangements, and finding people who were more than willing to bend over backwards to give homeless people medical care, I would forget about allowing them the dignity of free will and get the more severe cases into those doctors' offices to get the treatment they need.
Fayd at January 30, 2018 4:06 PM
Joe J,
It looks like the reduced life expectancy tied to Obamacare is a direct result of opioid overdose. Essentially people got on medicaid and then got prescriptions for pain killers, abused them, and then died. The funny thing is virtually all of those people were already eligible for medicaid. They just hadn't signed up. Obamacare didn't change that. But it did put out a lot of advertising that got people signed up.
Ken R,
I'm surprised it was zero. Near zero is what I expected. I thought you would have found one or two. I sometimes offer financial advice to people. Essentially if they ask for my help I offer what I know. The most common response I get is, 'That all sounds great. But I don't want to do that.' I.e. save any money. Instead they want some magic answer on how to get rich while spending all of their money the moment they make it. Sorry, but the world just doesn't work that way.
Ben at January 30, 2018 4:17 PM
Fayd: I would forget about allowing them the dignity of free will and get the more severe cases into those doctors' offices to get the treatment they need.
And how would you do that?
My 100% failure rate didn't mean that my homeless clients never got the healthcare they needed. As I said, they have a different point of view about health and healthcare, about what they need, when they need it and how to go about getting it. I saw some of them later in the emergency room where I worked, suffering the crisis I'd hoped to prevent by arranging free healthcare services for them; and I'm sure others went to emergency rooms at the other three hospitals in that city.
Healthcare wasn't a very high priority for them unless it was an emergency. They weren't into preventative care or maintenance. They came to me only when they were feeling sick. If they were feeling a little better when it was time for their appointment they didn't go to it. When the problem became a crisis they went to the emergency room. I think they didn't find me very useful because I couldn't give them what they needed right then and there, like they could get at the emergency room.
A woman in her 30's with epilepsy ran out of her anti-seizure med. She came to me the morning after her third seizure in 10 days. A pharmacist agreed to dispense to her that morning a week's supply of her med. A nice man at Scottish Rite Services agreed to pay for it. A doctor gave her an appointment in two days. A nice taxi driver agreed to take her to the doctor for free. When the taxi came to pick her up she was nowhere to be found. Two nights later she showed up at the ER where I worked after having two seizures and falling on her head.
A woman in her late 20's with diabetes ran out of insulin. I made three appointments for her at the community clinic five blocks from the shelter, but she could have walked in anytime she wanted. They would have given her insulin. She never went to the clinic but eventually was taken by ambulance to the ER.
A man in his 50's with congestive heart failure. He was short of breath and his ankles were swollen. I wanted him to go to an ER but he didn't think he needed to. The nurse practitioner at the community clinic said she could see him the next day during her lunch break. She arranged for a cardiologist friend of hers to be there on his lunch break to see the man for free, but the man didn't show up.
One sort of success story: A married couple with four kids - two boys 15 and 11 and two girls 13 and 9 - staying at the shelter, all had lice for months. The kids wanted to go to the homeless school at the YWCA, but weren't allowed because of the lice. Somebody somewhere gave them six bottles of Nix. The director of the shelter found the Nix in the garbage and gave it to me. The shelter director gave me the exclusive use of a shower room for a whole day. They arranged for the family to move to a different room at the shelter after they were treated for lice. I spent an entire day getting the lice off of that family, getting all of their clothes washed and moving them to a clean room. The kids got to go to the homeless school.
Ken R at January 31, 2018 12:53 AM
I remember studying a little on medical care costs and preventative care. I recall at a society level it takes quite a long time for preventative care to pay-off...I am thinking around 20 years. And yes, initially you have increased costs.
The Former Banker at January 31, 2018 8:25 AM
Ken R: your story is exactly what I was talking about above--the homeless and very poor in general often suffer from disorganization, lack of impulse control, inability to plan ahead, etc. They may be homeless because they can't show up for work on time or can't hold onto a dollar. Such people can't utilize preventive care. Catastrophic if you have diabetes or epilepsy. This is why preventive care as a way to save medical costs doesn't work: those who are organized and educated do their own preventive care but those who are not won't use it even if free. It is like home ownership. The middle class own homes but giving a home to someone with bad credit does not make them middle class.
cc at January 31, 2018 8:48 AM
I'm not surprised by Ken R's rate, I used to run a St Marys Food Bank community distribution point and you would not believe the stories I could tell
lujlp at January 31, 2018 9:12 AM
Ken, a couple of insightful posts. I hope some of the big government socialists on this board who think helping the poor and homeless is just a matter of tax payer money, and socialized medicine, might start to grasp the intractability of the problem. I doubt it though.
I have a friend who has gone on several medical missions to third world countries. Helping those people is ten times more difficult. No infrastructure and anything valuable, drugs and medical equipment, even bandages have to be kept under lock and key with no access for the local clinic employees.
Isab at January 31, 2018 10:22 AM
So much of whether assistance will help or hurt is the attitude and mindset of both those giving and those receiving help.
Americans are a very generous people, we often give second, third and fourth chances. So it does not surprise me that Ken had such a low rate, by the time people reached that level those who had the attitude to be helped got their life back on the rails before then.
Joe J at January 31, 2018 11:26 AM
Health insurance: my proposal:
1. Make all medical expenses and insurance tax deductible. Kill some other deductions to compensate. I suggest putting caps on the mortgage tax deduction, so it is no longer an incentive for the very rich to buy ridiculously bloated mansions, nor for the upper middle class to buy more house than they can afford and call it an investment. That is, I would limit this deduction both in absolute amount and as a percentage of income.
2. As the main means of deducting medical expenses, make _everyone_ eligible for HSAs, whether or not they have insurance or an employer. Just like now, what you put into the HSA is non-taxable, as is any interest it earns. You can pay for your insurance through an HSA, as well as for all medical and dental treatments, devices, and drugs. Change the annual limit on contributions per individual to $5,000 plus all expenses paid through it - that is, encourage people to build up tax free savings in their HSA while they can afford more than they are spending.
3. Insurance should be separate from employment.
4. Insurance should actually be _insurance_. That is, it should pay off only on large expenses due to unexpected events. You use the HSA for routine stuff. You should never lose coverage because of illness, even when the expenses go on for years. (Unlike the current so-called insurance plans, which are sometimes comparable to a fire insurance policy that only pays for rebuilding your house if you can get it done before they can cancel it at contract renewal time.) Get a serious condition that is only treatable, not curable, and your insurance company can neither get you off the books nor raise your rates.
5. Insurance must be portable between states. You change jobs and move to another state, and you have the option of taking your insurance with you. If they don't have "in network" providers in your new area, including any specialists you need, they'll have to treat all the providers as "in network". Insurance companies will have one out - they can negotiate with other insurers to transfer your policy to one with a better local presence, but coverage must be as good or better, and the premiums can go up only to the extent that the federal plan ("CrappyCare", see below) rates the new location as a higher cost area.
6. Finally, what happens when the uninsured get sick (and don't have enough in their HSA and bank accounts), and what happens to people that never make enough to cover their medical expenses? We'll provide for them, but not generously:
7. Emergency rooms are still required to provide care for anyone brought in with a medical emergency. Hey, if someone conks you over the head and steals your wallet, you want to be cared for until you wake up and can tell them how you're going to pay. But they are no longer providing free care for the indigent and irresponsible, and no longer allowed to inflate the paying customers' bills to make up for the deadbeats. Instead, unpaid charges can be sold to the IRS for collection, at a 10% discount. (Preferably this is tied to a tax code simplification, so the IRS can transfer staff rather than expand.) There are limits on the amount, and an appropriation to cover those debts that cannot be collected, but lets make it quite clear that misusing an emergency room for a "free" visit to the doctor's office is going to cost you.
8. The ultimate fallback: CrappyCare (the federal healthplan, like an expanded Medicaid). Politicians will make a nicer name for it, but let's be honest in these pages: government insurance either busts the budget by allowing providers to raise their rates and "do everything possible", or it is crappy. Everyone is eligible, but there is a means-tested premium; it's only free for the very poor. You can pay from an HSA or with a checkoff on your income tax return. Pre-existing conditions are covered, and you can even sign up in the emergency room and have that and other recent expenses covered, but if you were uninsured before, you owe premiums for the last three years. Once again, if you need treatment now, you get it (whatever CrappyCare will pay for), and can pay later, but you do have to pay it and the IRS is the debt collector.
markm at February 9, 2018 2:06 PM
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