Morgan T. Sammons, PhD, ABPP
The health care debate in this country is currently focused on who gets health care and how much they must pay for it. Both are incredibly important questions, but ignore a larger issue: quality. What are we getting in return? The American Health Care Act of 2017 is the first attempt by the current Congress to make good on campaign promises to repeal the Patient Protection and Affordable Care Act. The National Register is a non-partisan organization, and it is not my intention to provide a partisan analysis of what is, admittedly, a very partisan bill. That said, I’d like to provide a few highlights of this 122 page piece of legislation that by any objective standard should be of significant concern to psychologists and our patients.
As Dr. Tony Puente, current APA president, noted in response to an earlier version of the legislation, this bill will eliminate coverage for mental health and substance abuse for approximately 11 million lower income Americans. That fact alone should spur us all to stand up as advocates for our patients. But in truth, my issue is less with the substance of the bill than the basic premise underlying it, which seems to be that health care is too expensive for our country to afford, and therefore rationing care, whether excluding individuals from coverage or raising premiums on certain populations (e.g., moderate income elderly persons), is the only prudent way forward. I believe we should challenge the assumption that health care in the U.S. is not affordable, as it is not supported by the data.
Let’s start with a few basic facts. First, American health care costs, despite a flattening during the Great Recession, are escalating at an alarming rate and in the next five years are projected to top 20% of our nation’s gross domestic product. Importantly, the percentage of our GDP that we expend on health care is much higher than that of any other developed country, including those that offer “universal” health coverage. An important note here is that no developed country has truly “universal” health coverage. Even countries with national health services have a combination of public and private insurance. The essential fact to remember, then, is that the question is not who has access to health care (via single payer/universal or private payer/restricted plans) but it is what we are paying for. And that, it turns out, is a sad surprise for Americans.
Unless we change the fundamentals of the argument, I’m very much afraid that what we end up with is going to be what has defined American health care for some time: expensive, poor quality care. Life expectancy in the U.S. is lower than that in many developed countries, a fact most analysts ascribe to several variables–primarily, our increasingly sedentary lifestyle and a lack of access to health care. Universal health care saves lives. A recent study in Annals of Internal Medicine demonstrated that patients in Canada who suffer from cystic fibrosis live approximately 10 years longer than their U.S. counterparts. Why? Better dietary counseling and better access to health care, including lung transplants (Marshall, B. Annals of Internal Medicine, 14 March, 2017).
In the U.S., where we emphasize costly procedures performed by expensive providers in very expensive hospitals, quality lags significantly. Major drivers of health costs in the U.S. are hospitalization, the cost of procedures and physician providers, and prescription drugs. Costs for services by psychologists and many other non-physician providers are overall quite low–around 3% of the health care dollar. Sadly, in spite of how much we spend, the U.S. ranks consistently lower than most developed countries on established measures of quality. Denmark, which consistently is rated as having among the best health care in the world, spends around 10% of its GDP–half of the U.S.’s rate–on health care, per the Organization for Economic Cooperation and Development.
So we are falling behind on many major health indices, some ascribable to lifestyle, some ascribable to costly and, for many Americans, unattainable care. This fact alone, I think, should cause us to question the wisdom of any effort to roll back access. Yet in the U.S., all of our current initiatives seem to be aimed at limiting health care rather than expanding it. Seema Verma, previously a health care consultant, was confirmed this week as the head of the Centers for Medicare and Medicaid Services. In the past, she has espoused the use of health savings accounts. In the state of Indiana, she championed a Medicaid plan that rewarded low income individuals for contributing towards a medical and dental plan. This plan, while not an inherently bad idea, came with a $2,500 deductible, a significant deterrent to many lower income individuals, and a major barrier for our lowest income families.
Last month in this column, I speculated that the “moral hazard” argument would make a comeback in new iterations of affordable care, and so it did, but in an unexpected way. Utah Rep. Jason Chaffetz utilized a variant of the moral hazard argument by suggesting that consumers would need to make responsible choices between purchasing an expensive cell phone or seeking health care. But as we have seen, the economics of health care are not comparable to those of expendable electronic goods. Consumers have limited choice in health care pricing, being largely limited to either going without health care coverage (a possibility if the individual mandate of the ACA is repealed), or by purchasing plans with high deductibles. Individuals can defer the purchase of costly electronics, but it is perilous to defer the purchase of prescription drugs or medical procedures (and, as others pointed out, the price of a single episode of uncomplicated care is likely to exceed that of all but the most expensive cell phone). Further evidence is strong that substandard or unaffordable care costs individuals and society much more in the long run than granting access to needed services. Burdens on high cost emergency services will increase and the deferral of care can lead to preventable long term health problems. Just a few of the manifold examples include untreated hypertension or diabetes leading to end-stage renal failure, revolving-door emergency mental health care increasing the chronicity and substandard management of serious mental illness, or deferred dental care leading to increased susceptibility to infections and tooth loss, which can be a significant impediment in seeking better-paying jobs. Thus poorer health outcomes lead to decreased worker productivity, increased individual and family stress, and generally worsen the societal burden of disease. Other developed nations have figured this out. We must ask why we have not.
At this point we have no idea what the final version of a replacement health care bill will look like, so it’s important not to be alarmist. Given intense opposition from Democrats as well as from more conservative Republicans, who would like to see the government exit health care almost entirely, Senate passage of the current House bill is quite unlikely–the House has managed to pull off a rare feat and introduce a bill that makes almost no one happy. We can hope that in revising the introduced legislation, our representatives will not be tempted by arguments that are on target ideologically but economically and socially unsound. We trust that our elected representatives will understand that not only is comprehensive mental health care a sound long-term investment, it is the right choice for an enlightened, democratic society to adopt. Health care is expensive–and complicated. That is the reality of addressing the needs of a society of more than 320 million people. There are certainly ways of managing costs. Some of these are quite compatible with conservative ideologies, such as ensuring that health care guilds do not operate in anticompetitive ways, or driving down the cost of pharmaceuticals by disallowing unwarranted patent extensions on common drugs.
So let’s get back to basics. The data tell us this: 1. Universal health care is not ruinous to an economy, even for countries with GDPs far smaller than ours. 2. Expanding health care coverage saves lives–life expectancy goes up, and people with chronic illnesses live longer and healthier lives. 3. The moral hazard in health care is not really hazardous, and should not be a major factor in health care policy. 4. In the U.S., you don’t get what you pay for: Americans pay more for lesser quality than almost anyone, a fact that will not change if we make health care less affordable and less accessible to millions of citizens.
So it seems to me we’re approaching health care reform from entirely the wrong angle. Instead of focusing on the wrangle over who has access to our healthcare system, let’s commit to the larger–admittedly harder–task of reforming what we are granting access to. The experience of much of the rest of the world tells us it can be done. Unless we challenge the basics of our system–a reactive, often defensive and highly fragmented care system manned by extremely expensive providers–no legislation is going to provide a cure for American health care. Psychologists have a clear role to play. We must remind our representatives that mental health and substance abuse care is not a luxury, it is a necessity. We can work with colleagues in medicine and nursing to provide more economical, integrated care delivery that addresses psychological as well as physical illness. We can continue our basic and clinical research to improve the potency of our interventions and long-term patient outcome. These are but a few of the potential contributions our profession can make. For the sake of our patients, our profession, and our collective future, let’s put partisanship aside and get to work.