HEALTH CARE/Joan Retsinas

Zooming Down the Slippery
Slope of Cost-Effectiveness

Massachusetts just made the kind of bold decision that makes health care news: it elected to cover low-income people who are HIV positive -- whether or not they are sick, whether or not they are disabled. Massachusetts is the first state in the nation to do so. Its argument is simple and convincing: Right now MassHealth covers people who have AIDs. With coverage of HIV, more people will get the care they need to stave off AIDs. The state will not only save lives, but save money.

The first assertion -- that early coverage will save lives -- probably did not sway bureaucrats. After all, "saving lives" smacks of compassion, and government-as-agent-of-compassion smacks of a Democratic age. This is a decidedly Republican age, with a government-as-business mindset. It is the "saving money" assertion that doubtless swayed bureaucrats. After all, cost-effectiveness is the hallowed mantra of a business mindset. Will a program save money? If it is compassionate to boot, great. But compassion alone -- much less justice -- will not sway our leaders, who want to spend money to save money.

In crafting health care policy, we seek "cost-effectiveness." Here are a few more cost-effective strategies.

1) Extend Medicare to everybody, regardless of age and income, who has diabetes, nephritis, high blood pressure.

Medicare already covers everybody, regardless of age and income, who is on kidney dialysis. The End-Stage-Renal Disease component of Medicare has been working efficiently for decades, assuring people with failing kidneys that, whatever else they need to worry about, they don't need to worry about bills for dialysis. Why not cover people before their kidneys fail? By delaying those patients' need for dialysis, Medicare might save money. Of course, that policy change will usher thousands of people, of all ages and income, into Medicare, pushing it towards universal health insurance. But this would be a politically palatable push, done in the name of cost-effectiveness.

2) Eliminate "pre-existing" exclusionary periods from private insurance policies.

Most private insurers don't pay to treat new enrollees' "existing conditions" when those enrollees sign up for the first time for health insurance. Instead, the insurers impose an "exclusionary period," often up to a year. If the patient needs treatment for a "pre-existing condition" during that time, the insurer won't pay. At least in the short run, the insurer saves money. These conditions (e.g., arthritis, diabetes, heart disease, hypertension, asthma, Parkinson's), though, can often be controlled if the patient follows sometimes complex, always costly regimens. In the long run, the insurer that helps the patient get early treatment might spend less money on more intensive care in the future. So, in spite of Insurance Axiom #101 to delay paying for everything, insurers should shelve the pre-existing condition time-outs -- in the name of cost-effectiveness.

3) Pay for preventive care for everybody.

Physicians know how to screen for skin cancer, breast cancer, colo-rectal cancer, prostate cancer -- yet since insurers don't routinely cover all screenings (and the uninsured don't get coverage at all, unless they are eligible for a specific program in their state), why not give every American preventive care, hooking him/her up to a primary care physician, paying for all the tests, check-ups, and scans that modern medicine offers? At the same time, throw in vaccinations -- not just for newborns and toddlers, but for adults. We have vaccinations for diphtheria, tetanus, rubella, hepatitis, influenza -- which insurers may or may not cover. At the end of a decade or two, we can see how much money insurers saved.

4) Meld the gaggle of insurers into one.

In a pro-business climate, with hundreds of for-profit health care companies busily writing out campaign checks, this is the hardest step -- but business-minded leaders should take that step boldly. Right now the country has a gaggle of insurers, each with its own billing forms (visit a hospital billing department to glimpse accounting anarchy), its own pre-authorization forms, its own premiums, its own administrative overhead, its own advertising budget. Why not plunk everybody into one mega-insurer, thereby eliminating the multiplicity of paperwork and "managers." We would certainly save money. Since the hallmark of a business mindset is the search for efficiency, we should embrace efficiency even if it means returning health care to the public sector.

The slope is slippery. We will end up with national health insurance -- but under a mantra of "cost-effectivness," a mantra in tune with this business-minded era. The muse of irony smiles.

Joan Retsinas is a sociologist who writes about health care in Providence, Rhode Island.

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