The Search For a Villain in Health Care Affordability

It is unfortunate that, during the Democratic debates, private health insurers were targeted as the only villain contributing to the fact that the United States spends so much more on health care than other developed countries, with outcomes that are no better. Here is how Elizabeth Warren explained her support for a single-payer system.

I’m with Bernie on Medicare for all. And let me tell you why.

I spent a big chunk of my life studying why families go broke. And one of the number-one reasons is the cost of health care, medical bills. And that’s not just for people who don’t have insurance. It’s for people who have insurance.

Look at the business model of an insurance company. It’s to bring in as many dollars as they can in premiums and to pay out as few dollars as possible for your health care. That leaves families with rising premiums, rising copays, and fighting with insurance companies to try to get the health care that their doctors say that they and their children need. Medicare for all solves that problem…

…the insurance companies last year alone sucked $23 billion in profits out of the health care system, $23 billion. And that doesn’t count the money that was paid to executives, the money that was spent lobbying Washington.

CNN did a fact-check on Warren’s statement about insurance companies taking in $23 million in profits last year and found it to be true. But Kevin Drum put it into perspective by pointing out that “total health care spending last year was $3.5 trillion. This means that insurance profits amounted to 0.6 percent of the total.” Josh Barro added even more perspective.

Since we spend about twice what our peer countries in the OECD tend to spend for approximately the same outcomes, our excess health spending is about $1.8 trillion. Abolishing health insurer profits would take us roughly 1 percent of the way to getting in line with our peers on costs.

While no one is ever going to defend private health insurance companies, it is clear that, when it comes to the cost of health care in this country, they are not the sole villain.

Barro joins others in identifying a different villain.

I understand the impulse not to name the key villain, the key element in our health care system that’s making it unaffordable, which is providers and the payments they require. People feel positively about doctors and hospitals; they do not feel positively about insurers. But when you try to implement a single payer system, you will have two options: Fight the providers, or pay them whatever they want, in which case the shift to single payer won’t save much money and will require enormous tax increases.

But even Barro identifies one of the issues driving up the cost for providers.

[Providers] depend on the higher rates from private insurers to offset the lower rates they get from Medicare and Medicaid. If every patient’s insurer paid like Medicare, they’d close.

Research has found that one quarter of health care spending in this country is spent on patients in the last year of their life, the vast majority of whom are on Medicare. So it is not simply the lower reimbursement rates for Medicare (and Medicaid) that affect private insurance. That has to be combined with the higher rates of expenditures for people on Medicare, primarily during the last year of their lives. That is where the movement towards palliative care is an important ingredient towards making health care more affordable.

“The news that palliative care can significantly improve patient experience by reducing unnecessary, unwanted, and burdensome procedures, while ensuring that patients are cared for in the setting of their choice, is highly encouraging. It suggests that we can improve outcomes and curb costs even for those with serious illness.”

Palliative care provides patients suffering from life-limiting, complex illnesses with pain and symptom management, communication of care options before and after discharge, and patient-centered guidance with treatment options.

Despite its potential to ease patient concerns and better treat terminally ill patients, hospitals have yet to integrate palliative care into routine care delivery. About one-quarter of Medicare beneficiaries die in acute care hospitals, and a significant portion of these patients undergo expensive, intensive healthcare services in the last weeks of life, a 2013 JAMA study showed…

“Costs are increasing because of not only increasing prevalence of serious chronic disease but also increasing unit costs of medical care, including hospital care,” they wrote. “Reforming a system originally designed to provide acute, episodic care is essential for its long-term sustainability.”

One health insurer in Michigan found the following results when they began an initiative to include home-based palliative care coverage.

* a 38 percent decrease in inpatient stays
* a 52 percent decrease in emergency department visits
* a 35 percent decrease in total cost of care
* 46 percent fewer specialty care visits

An embrace of palliative care is difficult for health care professionals, as one doctor explained to Terry Gross.

I went into critical care because I really wanted to save lives. I wanted to rescue people from the jaws of death…

[W]hen you’re a palliative care consultant and you’ve got people who are really focused on – I would almost call it hero medicine. I say it because that’s how I sort of see it in the ICU. Yeah, I want to be doing this heroic stuff which I really care about. And I’ve seen it do such great things so many times in so many cases. And so you want to focus on that piece of it. And then, you have somebody coming around and saying, hey, wait a minute; maybe we should talk to your patient about the fact that we’re not going to be able to do, you know, an 11th-hour save here. And people can bristle at that.

None of this is to suggest that the answer to the problems with our health care system can be solved by providers becoming more comfortable with palliative care. This is but one example of how the search for a single villain that, when vanquished, would solve the issue is misleading at best. Like it or not, the problems we face with health care affordability are much more complex than that.

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Nancy LeTourneau

Nancy LeTourneau is a contributing writer for the Washington Monthly. Follow her on Twitter @Smartypants60.