RAND PAUL ON HEALTH POLICY


by Joshua Freeman, M.D.


While politicians are rarely elected to office because of their profession, the fact is that often fellow legislators often turn to their colleagues with expertise in a certain area to understand bills with technical implications. Legislators who are physicians, nurses and pharmacists, for example, may have influence on bills related to health care. Thus, physicians like former U.S. Senate Majority Leader Bill Frist, a cardiac surgeon, had great influence on medical matters.


So it is relevant to look at statements by Sen. Rand Paul (R. KY) about health care. He is known as a prominent libertarian conservative and Tea Party favorite, as well as a probable Republican presidential contender. He is an ophthalmologist, an eye surgeon, and thus may be presumed to have credibility on health care issues. This does not seem to be diminished by the fact that he has not been Board-certified by the mainstream American Board of Ophthalmology since 2005, being rather certified by the National Board of Ophthalmology, which, coincidentally, he founded and leads as its president.


So what does Sen. Paul have to say about important health policy issues? Unsurprisingly he is a strong opponent of Obamacare, the Affordable Care Act (ACA) and, for that matter, any universal health care system. He has authored his own book, Government Bullies. I heard him discuss it at some length with John Oliver on a “Daily Show” appearance on August 12, 2013. His main point is that, unlike “most legislators” who have “dinosaur syndrome -- small brains and big hearts”, he can help solve problems because he is not in that mold. He called upon his experience as an eye surgeon to demonstrate how the “market” controls costs by referring to how it led to big price drops for two major services in his specialty, Lasik® surgery and contact lenses. 


With regard toLasik, he notes that competition among ophthalmologists has led to dramatic decreases in charges (and costs) from over $2,000 an eye to less than $500. The competition for contact lenses was with large retailers like Wal-Mart, which forced him to drop his charges in order to compete. Neither was covered by insurance, so he uses them as examples of how this could work for all the other things that are covered by insurance and to which people are price-insensitive.


All but the last of these assertions are true as far as they go. The cost of both Lasik® and contact lenses have indeed dropped. So, will this work for all health costs? No, absolutely not. 


There is a reason that these two services are not covered by insurance; they are both elective and thus, like cosmetic surgery and many consumer items, can be reasonably subject to market forces. One has a much cheaper and effective option that works for the medical problem—wear glasses. If you are considering Lasik or contact lenses, you can choose to not buy them now and wait until prices come down. However, most of health care is not elective (thus more like food and housing). Emergencies are emergencies and need to be addressed now, by the most available provider.


Mark Ebell, M.D., a family physician and expert in evidence-based medicine, notes a more apt comparison: “If you have a stick in your eye, I doubt that you are price shopping or waiting for ads on the radio to advertise a special for removal of sticks in the eye.” While not all necessary health care is about emergencies, most of it is not about elective procedures. Chronic diseases like hypertension and diabetes need to be treated in order to prevent their progression to serious outcomes. Preventive care like screening for cancer and immunizations are only of value if they happen before the onset of disease. Neither Lasik nor contact lenses prevent either disease or its progression. 


The empiric evidence is there—both in comparisons to other developed countries and in internal comparisons between state and local government and insurance programs in the U.S.—providing comprehensive health care at costs that do not discourage or make it impossible for people to access it improves health status. Conversely, there is excellent evidence that obstacles to health care access do discourage people from seeking it and do result in worse health outcomes, for individuals, populations and nations.


The danger in an argument such as Sen. Paul’s is two-fold. One is that, coming from the Republicans’ most prominent physician, it will reinforce the beliefs of those who already think that the market will solve the health care crisis. The other is that people who are not such ideologues but whose exposure to the health system, because of a fortunate combination of relative youth, good health, and economic security, is largely for such elective, minor or episodic care, may say “yeah, that seems right”. But it isn’t; it’s wrong. 


A recent NPR “Marketplace” show focused on the ACA’s requirements for individual health insurance policies that preclude many low-coverage, high-deductible options currently available.[1] It featured a self-employed Californian who noted that he was having to pay much more for insurance now, even though he was never sick and, in the last 14 years, had visited a doctor only a few times. It didn’t give his age, but whatever it was he will, in the future, be older. And, as we get older the probability of needing health care increases. The old maxim about the stock market – that past performance is not a guarantee of future performance – is even more true for one’s health. It is at best risky and at worst foolhardy. The more apt comparison may be to the person who falls off a 20-story building and is heard by people as he passes each floor saying “so far, so good”. Making public policy on such a basis is nonsensical.


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Tag lines: Rand Paul, legislators, Obamacare, Affordable Care Act, competition, cost of health insurance, individual health insurance