Thursday, August 20, 2009

Is healthcare reform a win or a loss for Americans?

Although the media has been focused on repeating the same town hall meeting shouting matches, one should look carefully at other thoughtful pieces appearing in business magazines like Fortune and Money which claim to have the objective truth about healthcare reform.

Because they have it wrong as well.

Shawn Tulley, editor at large for Money, wrote "You'll lose 5 key freedoms under health care reform" specifically indicating that Americans will lose the ability to have high deductible insurance plans funded by health savings accounts (HSAs) as well as the ability to seek specialty care without first being evaluated by a primary care doctor.

My concern about HSAs is a philosophical one, but important. Do patients understand when they can safely skip and when they need to be seen by a doctor or get the preventive tests they need? Unlike auto insurance, having a dent in the car left unchecked is one thing, but what about one's body? Research shows those most likely enrolled in HSAs are doctors and accountants which makes complete sense. The former know when to seek care and when to safely skip. The latter understand the tax advantage of HSAs. Patients in high deductible insurance plans are generally less satisfied, would prefer to return to comprehensive health insurance if given the opportunity, and typically avoid getting necessary testing or treatment done due to cost.

I've heard the argument that consumer driven healthcare will make people better consumers. Please. We've tried this with retirement planning. Employers jettisoned their pension plans and moved workers to 401k plans where employees would have more responsibility and skin in the game to do the right thing and plan for retirement well.

Companies discovered that people don't do what is in their best interest. Many never enrolled. Others invested simply in cash unaware that they needed to make investment decisions. As a result, employers are requiring new employees to opt-out of the 401k program rather than opt-in and changing the default investment to a target date mutual fund. It isn't that people don't want to do the right thing. They do. But if they can't handle retirement planning, how well do you think they will do with healthcare planning?

Which leads to the next cherished freedom that supposedly will be given up. The freedom to choose your doctors. Certainly having a trusted primary care doctor who can help get you better and help you navigate the healthcare system is critically important much the same way a trusted financial adviser can help people avoid pitfalls and traps. Was it poorly done a decade ago? Yes. No one I know of goes to medical school to become a "gatekeeper". We all train to become doctors. Some of us become primary care doctors - family physicians, internists, pediatricians, obstetricians / gynecologists - while others become specialists.

Mr. Tulley makes the mistake that many patients do in believing that getting the best care means "freedom" to access all tests, hospitals, specialists, and imaging studies. Is that what people really want or do they simply want the right doctor, the right care at the right time?

The supposed freedoms given up would not as be terrible Mr. Tulley claims since they are responsible for allowing the US to have the worse healthcare outcomes of any industrialized country in the world, highest costs per capita, and shut out millions from accessing medical care by being uninsured.

It's this kind of misinformation that is troubling. The quiet thoughtful analysis which is dead wrong.

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