{"id":320,"date":"2014-08-15T11:12:00","date_gmt":"2014-08-15T11:12:00","guid":{"rendered":"http:\/\/admin.patheos.com\/blogs\/janetheactuary\/2014\/08\/avikcare-my-evaluation.html"},"modified":"2014-08-15T11:12:00","modified_gmt":"2014-08-15T11:12:00","slug":"avikcare-my-evaluation","status":"publish","type":"post","link":"https:\/\/www.patheos.com\/blogs\/janetheactuary\/2014\/08\/avikcare-my-evaluation.html","title":{"rendered":"Avikcare: my evaluation"},"content":{"rendered":"\n<\/head>

Yesterday I wrote up a summary<\/a> of Avik Roy\u2019s proposal to reform the exchanges but wasn\u2019t very organized with my commentary, so now I\u2019ll try to pull together some more organized commentary.<\/p>\n

I\u2019ve long had the pet idea of what I call \u201cVoucherCare\u201d \u2014 it was, in fact, my second post on this blog<\/a>, though, if I were to rewrite that post now I\u2019d modify the idea, but, at the same time, shortly thereafter I wrote about my doubts about catastrophic health insurance<\/a>. <\/p>\n

So why am I not falling all over Roy\u2019s plan? \u00a0In some respects the plan is too timid, but in others, it\u2019s too radical. \u00a0(Though, fair warning, I read this late at night \u2014 I may be misreading some aspects of the plan.)<\/p>\n

As a side note, before I start with the meat of his plan, he didn\u2019t do his homework (or is intentionally misleading) with respect to his international comparisons. \u00a0He cites Switzerland and Singapore as examples of his central principle that a market-based system can provide universal coverage \u2014 but in his graphic showing that these two countries have low healthcare costs presents only the public<\/i> cost. \u00a0When considering total cost, Switzerland\u2019s is second only to the U.S., with local concern about cost increases, so not a great model. \u00a0I don\u2019t know about Singapore\u2019s cost, but they\u2019re not a magical land \u2014 employer-sponsored healthcare is the norm there, just as here, and that<\/i>, not the magical impact of their healthcare savings accounts, is what fills in the gaps from the low state provision of healthcare. <\/p>\n

Let\u2019s start with his big idea: \u00a0put simply (perhaps too simply), it\u2019s to move everyone, or at least a large portion of the population currently receiving government-funded healthcare, onto catastrophic plans. \u00a0Is this the right thing? <\/p>\n

For educated middle-class Americans, catastrophic plans offer a certain amount of promise \u2014 if<\/i> the insurers can price-shopping tools up and running and provide their customers with the information they need to chose the most cost-efficient option, and, let\u2019s face it, there\u2019s still a long way to go before we reach this point. \u00a0If you find a hospital that advertises a price-match guarantee on its delivery rooms, I\u2019m all ears. \u00a0(See this instapundit-linked piece<\/a> in which the author describes his family\u2019s inability to choose in-network doctors because the in-network hospital is indifferent to whether its doctors are in the patient\u2019s insurer\u2019s network.) \u00a0And even in a perfectly \u00a0built-out system, much of the time Americans would be unable to act as consumers, when they need serious medical treatment, without delay or second-guessing.<\/p>\n

For the poor, it\u2019s really hard to imagine then being sophisticated consumers. \u00a0Yes, moving them to high-deductible plans might eliminate the horror stories in which a young woman goes to the ER for a pregnancy test, and, when she doesn\u2019t get it, claims an illness requiring pregnancy testing among several thousand dollars\u2019 worth of other treatments \u2014 or maybe not, if this is all \u201cthey have to treat you in an emergency\u201d care and she has no intention of actually paying the bills. \u00a0But will we hear more of the \u201csimple illness made worse because, for fear of the out-of-pocket cost, the doctor\u2019s visit was deferred\u201d stories? <\/p>\n

And for the elderly: \u00a0not everyone ages at the same rate. \u00a0Some people could do just fine with a high-deductible plan, but I suspect that most people, as they age, would find it increasingly difficult to accomplish the tasks that high-deductible plans are supposed to push us to do, such as asking doctors whether there\u2019s a cheaper treatment, or whether the test is really necessary and, if so, where the cheapest place is to get it done. On top of which, I\u2019m not keen on means-testing old-age benefits based on lifetime savings; unless it\u2019s done very carefully, it\u2019s an incentive not to save.<\/p>\n

The level of deductible he proposes is also much higher than I\u2019m accustomed to seeing ($7,000), and he really seems to presuppose that an individual has the opportunity to \u201csave up\u201d for the deductible before any health crisis hits, so that they use their savings but don\u2019t take a direct financial hit. \u00a0I\u2019m all for high-ish deductibles, but does this level really make sense? <\/p>\n

Of course, the \u201cconsumer-driven\u201d approach is simple in design, but most people would be better off with integrated healthcare systems in which the doctors, hospitals, and other providers are watching out for patients in a coordinated way, to provide the best healthcare in a cost-efficient way, rather than expecting patients to make medical decisions beyond most people\u2019s capacity. \u00a0Philip Bredesen outlines such a system in Fresh Medicine<\/a>, which dates to 2010 but I thought at the time was quite compelling.<\/p>\n

What about his other proposals?<\/p>\n

With respect to the exchanges themselves, his changes are modest. \u00a0He would preserve nearly the whole of the modified community rating, only allowing a greater price differential between old and young (why not allow full underwriting by age, at least?). \u00a0He would solve the anti-selection issue by limiting open enrollment to 6 weeks every two years (doable, as long as there are no loopholes around status changes, such as entering or leaving employment with employer-provided healthcare, but I\u2019m not sure if that\u2019s enough of a stick). \u00a0He proposes, somewhat vaguely, that the range of required benefits be narrowed to incorporate cost-effectiveness considerations, especially for drugs. \u00a0He suggests that states not create their own exchanges but funnel benefits to individuals through existing private \u201cexchanges\u201d (e.g., online insurance agents). <\/p>\n

He doesn\u2019t really solve the issue of employer-sponsored healthcare. \u00a0So far as I could tell, he envisions the employer-sponsored system remaining pretty much unchanged and running parallel to the exchange system. \u00a0If he has a reform in mind for the tax inequities between individual and employer-purchased coverage, or for the unfairness issue that individuals receiving exchange subsidies come out ahead over those who get employer-sponsored insurance at a cost of lower wages, I\u2019ve missed it. <\/p>\n

And we\u2019re supposed to take on faith his statement that his way of delivering premium supports would be fairer and without the existing penalties as people\u2019s income grows.<\/p>\n

Some of his proposals are rather disconnected to the question of how our healthcare system should be organized: \u00a0improving the FDA\u2019s drug approval process, reducing Medicare fraud, moving long-term care for the poor to the states with block grants, breaking hospital monopolies by reducing barriers to new hospitals.
So that\u2019s it. \u00a0I don\u2019t really care about the arguments about whether Roy fails the ideological test of dismantling Obamacare sufficiently, but I don\u2019t think these proposals get us where we need to go, for other reasons.<\/p>\n<\/body><\/html>\n","protected":false},"excerpt":{"rendered":"

Yesterday I wrote up a summary of Avik Roy\u2019s proposal to reform the exchanges but wasn\u2019t very organized with my commentary, so now I\u2019ll try to pull together some more organized commentary. I\u2019ve long had the pet idea of what I call \u201cVoucherCare\u201d \u2014 it was, in fact, my second post on this blog, though, […]<\/p>\n","protected":false},"author":2209,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-320","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"\nAvikcare: my evaluation<\/title>\n<meta name=\"description\" content=\"Yesterday I wrote up a summary of Avik Roy's proposal to reform the exchanges but wasn't very organized with my commentary, so now I'll try to pull\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.patheos.com\/blogs\/janetheactuary\/2014\/08\/avikcare-my-evaluation.html\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta 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