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Making a mandate more palatable
- Article by: VIRGINIA DALE
- Updated: April 21, 2012 - 7:04 PM
Offer options. If a healthful lifestyle is as effective as high-tech medicine -- which it may be -- shouldn't that be on the health-plan menu?
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Last month, as the U.S. Supreme Court held oral arguments over the so-called individual mandate in President Obama's federal health care reform law, the justices looked for a logical basis to determine whether and when Congress has a proper constitutional power to make people buy things.
Using a much-discussed metaphor, Justice Antonin Scalia sounded relieved when he felt that he could distinguish the law's mandate to buy health insurance from a hypothetical mandate to buy, say, broccoli.
But in fact that's just the problem with the individual mandate. It does not require the purchase of broccoli -- which might actually improve people's health. But it does require the purchase of many highly technical medical interventions that do nothing useful.
The argument for the mandate goes something like this: Health care is different because even if we don't want it now, eventually we will all need it. So Congress isn't forcing us to buy anything; it is merely requiring us to pay for our inevitable use of health care rather than leave the cost to someone else.
I agree that we should share the benefits and burdens of health care as a society. And I understand that if we prefer to use private insurance to achieve universal coverage, we need an individual mandate to make it work.
Here is what I object to: a mandate that we pay not only for health care -- but for a lot of snake oil, too.
It is well-known that the cost of America's current system is approximately twice that of other developed countries -- 17.9 percent of GDP compared with an average of approximately 9 percent -- and that, in spite of this, we do not have better health (let alone twice as good).
The Congressional Budget Office has estimated that up to 30 percent of care delivered in the United States is unnecessary and potentially harmful.
Medicine itself is beginning to come clean on this. In its "Choosing Wisely" initiative, the American Board of Internal Medicine Foundation, in collaboration with nine physician specialty groups and Consumer Reports, recently identified five tests or procedures in each specialty that are commonly overused and that patients and physicians should question.
These include such things as routine EKGs, early MRIs for back pain and antibiotics for mild sinus infections. Similarly, the American College of Physicians recently published a report of 37 common clinical situations in which unnecessary testing is frequently carried out.
Procedures that are adopted with little evidence persist even once their lack of value has become clear. Consider percutaneous vertebroplasty, a widely used invasive procedure to treat painful vertebral fractures by injecting bone cement into the spine.
Even after rigorous double-blind randomized controlled trials reported that this provided no better pain relief than a sham procedure, insurers' coverage of the procedure continues unchanged.
The rates at which clinical interventions are used vary significantly by geographic location, with no relationship to outcomes. Physicians' adherence to published clinical guidelines, which take account of costs and benefits, is also inconsistent, and is influenced by multiple factors, including, at times, financial self-interest.
In other words, we know that the cost of a typical employer health plan -- which the minimum "mandate" package is likely to be modeled on -- is significantly inflated relative to the health benefits it provides.
While it is true that we are all vulnerable, and may all need access to health care at some point, using our basic human need for care as a rationale for requiring us to purchase a product that is greatly inflated relative to its benefits -- which includes many expensive technologies that do not in fact improve our health -- seems like a shameful misuse of our vulnerability.
It is similarly well-known that the epidemics that are poised to overwhelm us -- financially and physically -- are lifestyle-related. Neither the causes of nor the remedies for these diseases are best addressed by the current medical system. Our current system, instead, seeks and proffers highly technical damage control for the ravages of our lifestyles.
These facts are increasingly recognized and acted upon through community development projects, such as those promoted by Healthy Community Forums, and the Diabetes Prevention Program of the Centers for Disease Control and the YMCA. These efforts effectively address the underlying causes of our lifestyle epidemics. And yet they are generally left to seek funding outside of traditional insurance coverage.
It is true that the Affordable Care Act contains many provisions aimed at improving the value and effectiveness of the current system. However, requiring us to buy in while we wait for medicine to heal itself is small comfort. How long might this take? Will politicians have the fortitude to accomplish this?
Consider that the ACA itself forbids the Patient-Centered Outcomes Research Institute -- which the law establishes for the purpose of "assisting patients, clinicians, purchasers, and policy-makers in making informed health decisions" -- from using a cost-benefit analysis (dollars per "quality adjusted life year") in determining what to cover in the basic mandated plan.
This may seem like a humane position -- cost should be no object, right? But what it means is that we will be required to purchase products that are known to be significantly less beneficial to us than other things that we could choose to purchase with those same dollars.
The political rhetoric that has inhibited policymakers from limiting coverage for highly technical, marginally beneficial health care may be misleading -- it overrepresents vested interests and vocal minorities.
Members of the public are not generally asked about their preferences regarding health care until they have a need for services. And then the "choices" they get are restricted to those that the medical system has placed on offer.
Studies have shown, for example, that cancer care near the end of life is more aggressive than many patients prefer. Many who would prefer supportive care in a home environment instead spend their last days receiving intensive therapy in an sterile intensive-care unit.
The public has not, to date, had a real opportunity to participate in shaping the care it receives.
There is a simple measure that could simultaneously improve our health, raise the ethical standing of mandated participation, and enhance our ability to make the difficult decisions that will be required to control health care costs.
We could ensure that at least some products that meet the mandate's requirements for minimum coverage offer low-tech, nonmedical alternatives that are known to improve public health as tradeoffs for ineffective high-tech interventions. These would be services like the Diabetes Prevention Project, which support the kind of lifestyle changes we need in order to achieve actual health.
And at a minimum, if we are to be required to purchase health insurance, we should be allowed the option of a product that, while adhering to established clinical guidelines, uses reasonable cost-benefit guidelines to limit coverage and cost.
If we were to offer real choices that affect care -- not just choices about deductibles and copays -- we might learn that the public is more amenable to tradeoffs than they are presumed to be. Even if politicians find such tradeoffs unpalatable, individual consumers should be allowed to make sensible choices for themselves.
If we really want a market-based solution, why not let the market do its magic by forcing high-tech medical care to compete on a level playing field with low-tech, nonmedical interventions of equal or greater benefit?
Given the chance, Americans might choose fresh vegetables and community-based end-of-life care over genetically specific statins and down-to-the-wire chemotherapy. If they did, it is likely they would be better off.
The individual mandate should be accompanied by an opportunity for individuals to do for themselves what others have been unable to do for them -- to make rational choices about their health care costs.
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Virginia Dale, M.D., is a pathologist at North Memorial Health Care and a student at the Humphrey School of Public Affairs.
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