The Republican CARE Act and Health Care: “Common Sense?”
by Samuel Metz, M.D.
Despite the best efforts of a Democratic Congress, the Affordable Care Act (ACA, also “ObamaCare”) will still leave millions of Americans without health care and increase costs by billions of dollars. Or so predicts the Congressional Budget Office, and they should know. (1) Now Republicans offer their Plan B to replace what appears to be a failing Plan A.
Senators Burr, Coburn, and Hatch affirm their CARE plan (Patient Choice, Affordability, Responsibility, and Empowerment Act), as a response to the probable devastation of the Affordable Care Act, is founded on “common sense.” Common sense, they argue, dictates that when patients bear financial responsibility for their choices (“consumer-directed health care”), costs go down and health improves. (2)
That’s a remarkable statement. Is it true?
Unhappily, when Senators selling a health care plan say “common sense,” they mean “no data support this.”
And when we look at research attempting to show consumer-driven health care improves health and reduces costs, “no data support this.”
This is not a surprise. Health care disobeys conventional laws of supply and demand – as costs go up, needs do not change. Unlike shopping for refrigerators, most of us cannot guess when our cancer will occur, when our car will hit a guard rail, or when our child will fall from a tree. Most medical conditions cannot be deferred until interest rates are better or our paychecks are higher. We need care when we need it, not when we don’t.
The common sense world of CARE does not reflect the economic reality of our unique American private insurance industry:
• Patients need money for deductibles and co-pays, not just premiums. Without money for both, families picking a low cost, high deductible plan may still be unable to afford care, even with insurance policies.
• Most patients do not pick doctors: employers pick insurance companies and insurance companies pick doctors. Only wealthy patients paying their own way choose their own doctors.
• Physicians are financially motivated to avoid sick patients without adequate insurance, not to provide high value care. If you cannot pay, your physician choices are limited to those who provide free care.
Health care is not a free-market exercise, nor should it be. Every health care system in the world providing better care to more people for less money than we do ignores refrigerator economics. Instead, they apply the simple principle that all people should get the health care they need when they need it, not just when they can afford it.
All studies confirm that if cost drives decisions, patients make choices against their best medical interest:
• A 2004 Commonwealth Fund study concluded consumer-driven health care and high deductible private insurance “…cause patients to consume less care, even when that care is essential… lower-income individuals and those with serious health concerns will particularly be at risk…” (3)
• A 2007 JAMA article stated, “Increased cost sharing is associated with lower rates of drug treatment, worse adherence among existing users, and more frequent discontinuation of therapy.” (4)
• A 2012 Health Affairs article found consumer-driven health plans reduced physician visits but increased emergency visits; these plans reduced prescription compliance and cancer screenings. (5)
• A 2005 Health Affairs review found “…higher cost sharing, by design, shifts costs to sicker populations. The combination of poor health and low income increases the risk of both access barriers and financial stress.” (6)
• A 2007 Annals of Internal Medicine study said, “As the financial burden of cost sharing continues to rise, patients increasingly avoid necessary care, thereby contributing to the high morbidity and mortality of the U.S. population.” (7)
And so on. Limiting care to what patients can immediately afford devastates health and bankrupts families. No studies come to different conclusions.
What can we conclude about the “common sense” CARE Act insisting that consumer-driven health care improves health and reduce costs?
No data support it.
The CARE ACT is an act of desperation by Senators Burr, Coburn, and Hatch who exhibit little grasp of how constituents purchase health care.
Their disgust with the Affordable Care Act is understandable. President Obama’s grand plan lacks evidence it will provide better care to more people for less money. When that failed promise materializes, the US needs a Plan B.
However well-intended, the CARE Act is not that Plan B. We need not re-invent the wheel: Every other industrialized country provides better care to more people for less money. Perhaps our Senators might learn more from successful health care systems in other countries than from how refrigerators are sold here at home.
1. The Congressional Budget Office predictions for the ACA can be found at http://www.cbo.gov/sites/default/files/cbofiles/attachments/03-13-Coverage%20Estimates.pdf
2. The outline of the CARE Act can be found at Senator Coburn’s website:
3. Davis K. Will consumer directed health care improve system performance? Commonwealth Fund, Washington DC, August 2004. http://www.commonwealthfund.org/usr_doc/davis_cdhc-hsr_ib_773.pdf
4. Goldman DP, et al. Prescription drug cost sharing: Associations with medication and medical utilization and spending and health. JAMA 2007;298:61-88. http://jama.ama-assn.org/content/298/1/61.abstract
5. Fronstin P, Sepúlveda MJ, and Roebuck MC. Consumer-Directed Health Plans Reduce The Long-Term Use Of Outpatient Physician Visits And Prescription Drugs. Health Affairs 2012;32(6):1126-1134 http://content.healthaffairs.org/content/32/6/1126.abstract?etoc
6. Schoen C., Doty MM, Collins SR, Holmgren AL. Insured But Not Protected: How Many Adults Are Underinsured? Health Affairs Web Exclusive, June 14, 2005 W5-289–W5-302 http://www.commonwealthfund.org/Publications/In-the-Literature/2005/Jun/Insured-But-Not-Protected--How-Many-Adults-Are-Underinsured.aspx
7. Braithwaite RS, Rosen AB. Linking Cost Sharing to Value: An Unrivaled Yet Unrealized Public Health Opportunity. Ann Intern Med 2007;146:602-605. http://www.annals.org/content/146/8/602.full.pdf
One liner: The Republican Plan B for health care reform—no evidence, nothing new, no “common sense.”
Abstract: Three Republican Senators have come up with their Plan B as an alternative to the Affordable Care Act—their Patient Choice, Affordability, Responsibility, and Empowerment Act (CARE)—all empty words. Their claim for cost containment and improvement of care through CARE violates all evidence of the track record of consumer directed health care over the last 25 years.
Tag words: Patient Choice, Affordability, Responsibility, and Empowerment Ace (CARE); Affordable Care Act; Obamacare; Congressional Budget Office; cost sharing; health care markets; barriers to health care.