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April 11, 2007

HSAs and Women

Alright, second interesting health study of the day. Health savings accounts are misogynistic. Here's the deal: Non-elderly men and women tend to use the health care system in very different ways. Men rely on it for events-based care, physical traumas and serious illnesses and the like. Women tend to deal with it much more routinely, requiring mammograms and pap smears and reproductive health care on a fairly regular schedule. So when you put men and women into high-deductible plans, where the first X amount of health spending comes out-of-pocket, you end up seriously disadvantaging women.

A new study by a group of Harvard Medical Researchers actually ran the numbers. They found the median expense for men under $45 in HSAs was around $500, while the women racked up costs nearer to $1,200. The upward distribution ranged more widely for women as well. About a third of men spent over $1,050, while 55 percent of women broke the same barrier. Dr. Steffie Woolhandler, the lead author of the study, summed up the findings this way: "When an employer switches all his employees into a consumer-driven health plan, it's the same as giving all the women a $1,000 pay cut, on average, because women on average have $1,000 more in health costs than men."

That's pretty significant. Add in that women are already paid less than men, and the move towards high-deductible health plans begins to look grievously unfair, particularly because what accounts for the differing routine costs are health expenses that we tend to consider meritorious: mammograms, cervical cancer screenings, etc. Which all goes back to what I was arguing in the previous post: There may be a role for cost-sharing in health plans, but it needs to be very thoughtful about which procedures and treatments are included. Widespread adoption of standard HSAs would, among other things, amount to a serious penalty on being born female.

April 11, 2007 in Consumer-Directed Health Care | Permalink

Comments

Along the lines of my comment in the immediately below post, women would be discriminated against, but that is just the start of who would be disadvantaged. Pretty soon 'gay' diseases, or sexually transmitted diseases, or diseases that are genetically linked to certain population segments (jewish, black, hispanic, etc.) would be added to the list of those not favored.

I return to my point: pass laws with little discretion that apply to all of the population, and can't be gamed for partisan advantage. If high deductibles or copays really hurt certain groups more than others, then eliminate the deductibles and co-pays, instead of trying to legislatively or administratively determining who gets favored or disfavored.

Posted by: JimPortlandOR | Apr 11, 2007 2:22:21 PM

Adding to my comment above: one of the major contributors to Social Security's continued support by the public at large is because everybody benefits. If Soc Sec. were made into a 'support for the poor' (or lower income) program, it would be politically vulnerable. Ron Reagan's' attack on welfare was successful because only that population benefited - and it was framed as being support for only black unwed mothers too lazy to work.

Gotta learn those lessons....

Posted by: JimPortlandOR | Apr 11, 2007 2:35:18 PM

Good. At least one guy agrees with me that this is unfair. I blogged about this last week and got completely shouted down in our comments.

Posted by: Becks | Apr 11, 2007 2:36:35 PM

Not to be a pedant, but can HSA's really hate women?

Posted by: Bob | Apr 11, 2007 2:37:32 PM

Why should we think that the current system, which advantages women at the expense of men (taking each group as a whole), is the "natural" comparison set?

Women make costlier health care choices, and in turn they live longer, healthier lives. Why it would be an injustice to reduce the expenses men pay, especially given the shorter, less healthy lives they lead, isn't clear to me. It would taken an argument, and so far one hasn't been given. I'm skeptical that one can be, but I'll wait and see.

Posted by: Thomas | Apr 11, 2007 2:42:38 PM

"the median expense for men under $45"

Presuming that's intended to be 45 years of age, the $ is probably unnecessary.

"Women make costlier health care choices, and in turn they live longer, healthier lives."

Eh? The 'choice' is the avoidance of catastrophic illness (cancer) and healthy management of pregnancy, neither of which is a 'choice'. Further, the higher up front medical costs for women presumably offset lower medical costs later on, since they've screened out a larger number of catastrophic illnesses. Without adding in the post-45 medians, you can hardly call them 'costlier health care choices'.

Posted by: sidereal | Apr 11, 2007 3:44:54 PM

Women should pay extra for being healthier and living longer? That doesn't make a lot of sense - if anything that argues for the notion that men should be paying extra, since their short, unhealthy lives probably cost more in doctor's visits and hospital costs. If anything, the problem here is that good preventive care - like regular checkups and tests, should be the real incentive here, and costs for those should be reduced to encourage more people to avail themselves of them.

I hadn't really contemplated what Ezra points out... but of course it makes perfect sense - especially since gynecologists in most health plans are considered specialists and can't substitute for a primary care doctor, meaning women will have two main docs, and two sets of costs. That would be the beginning, plus mammograms and pap smears and other tests... it certainly would add up. Add to that the notion that the workplaces that are pushing people into high deductible, HSA-based plans probably rely on a higher percentage of single mothers, and you're talking about care for them, and their kids (or the general age group of getting pregnant, as well).

I'm curious, though, whether the right folks know what to do this - it strikes me that this issue alone could finish the job of shifting power in Congress and win 2008, if it's done right, encouraging a lot of working class women who might not other wise to go if only to help their own interests. I suspect, though, that the Dems who run campaigns in DC won't really know how to handle this effectively. Just a hunch.

Posted by: weboy | Apr 11, 2007 3:45:21 PM

Wait, they HATE women? It's not anything else, the HSAs and the people that created them presumably, they HATE women? Right? That's what you're saying?

Aren't you dumbing down the meaning and value of the term "misogyny?"

Posted by: jerry | Apr 11, 2007 3:50:01 PM

They found the median expense for men under 45 in HSAs was around $500, while the women racked up costs nearer to $1,200. ... About a third of men spent over $1,050, while 55 percent of women broke the same barrier.

To take up Thomas's point, this appears to show that more women will benefit from a plan with a $1,000 dedectible than men will, and that the women who benefit will get larger benefits. These benefit packages cut both ways.

Posted by: Sanpete | Apr 11, 2007 3:53:42 PM

That’s an interesting point of view: a policy that would cost women more than men is per se sexist and unfair. I would imagine it also would affect elderly people more than the young, and therefore is ageist and unfair; and some races more than others, and therefore is racist and unfair; and people generally with more health problems than average, and therefore is ableist and unfair.

Posted by: ostap | Apr 11, 2007 4:06:48 PM

Sanpete, I don't see how this follows - more women pay more for basic care than men in a similar plan... how does that suggest that they get more benefit? The way I read this, more women have to put more money into their HSAs then men do, because their costs will be higher, and while they may use up their high deductible, the point in these plans is that you shouldn't have to use up your deductible for basic care; the idea is that the insurance kicks in only in truly catastrophic instances. If women's health, normally, pushes them into using the deductible up, something's not working. Can you clarify your point? I'd like to understand what you mean...

Thanks

Posted by: weboy | Apr 11, 2007 4:10:26 PM

Ostap, the elderly aren't affected by these HSA plans because their companies push them into Medicare as soon as they are eligible. And, in Medicare, their costs are almost completely covered. You could argue that possibly older workers may pay more prior to entering Medicare... but I suspect that healthy older workers may not have such higher costs, and that tehse plans are generally aimed at younger members of the workforce. That's a guess. It may well be that for workers between 45 and 65 (I don't recall if you can enter Medicare at 62 or not), costs are higher than for younger workers.

Posted by: weboy | Apr 11, 2007 4:14:50 PM

"Women make costlier health care choices, and in turn they live longer, healthier lives. "

I'm not a doctor, but I think this has more to do physiology than health care choices they make.

Posted by: FoolsMate | Apr 11, 2007 4:16:38 PM

Sanpete: No HSAs I know of have a $1,000 deductible. The average is significantly higher.

Also (to Thomas), remember what HSAs are meant to do: Increase cost sensitivity and decrease unnecessary use of the health system. Unless we think using birth control and having mammograms are frivolous uses, we don't want to open them to increased exposure.

Posted by: Ezra | Apr 11, 2007 4:16:40 PM

What you're neglecting, Ezra, is that under HSAs, men wind up having to pay for most of their Viagra out of their own, um, pockets. Balances it right out.

Posted by: Glenn | Apr 11, 2007 4:41:37 PM

Weboy, women spend more before they reach the deductible, which is a loss to them overall compared to men, but they probably also receive more once the deductible is met, which is a gain to them overall compared to men. From what Ezra says, the losses probably currently outweigh the gains, though it could be the other way of women's care is just more expensive across the spectrum of costs.

I suppose the plans could be tweaked so that the deductible is at a break-even point for men vs. women, but that's probably not the best criterion by which to fashion a plan. The deductible should be low enough so that people will get the care they need, not because it favors or doesn't favor one sex over the other.

Posted by: Sanpete | Apr 11, 2007 4:49:17 PM

Healthcare for women does cost more than it does for men for those under 45. But as time goes on, men far outpace women. As Ezra points out, an HSA is almost always going to have a deductible higher than $1,000, making women under 45 pay more out-of-pocket expenses than men under 45.

But as others have pointed out, this doesn't mean that it balances out in the end. Medicare kicks in at 65, when men's costs really skyrocket. Since premiums and benefits are not based upon gender, a particular man will end up paying far less than a particular woman over the course of their lives.

As far as the proper, technical meaning of misogyny, if you have to preface your remark with "not to be a pedant," that means you're being a pedant. And jerry, when criticizing someone's writing, do try to not use sentence fragments.

Posted by: Stephen | Apr 11, 2007 4:59:49 PM

Ain't criticizing writing. uh uh. Criticizing hiz thinkin'!

If he wants words to have meaning, he might wish to behave that way and not just turn misogyny into more marketing speak.

Get a new pink HSA now with less misogyny!

Posted by: jerry | Apr 11, 2007 5:19:51 PM

It was actually overstatement for effect, but it didn't reall work, I guess. Ah well, you get what you pay for with these blogs...

Posted by: Ezra | Apr 11, 2007 5:56:47 PM

Ah well, you get what you pay for with these blogs... I know what you mean, but I've got a class action suit meant to address that.

I think that hyperbole is just fine, however, I note several sites on your blogroll whose owners might not realize you were exaggerating.

Posted by: jerry | Apr 11, 2007 6:38:25 PM

When I read your post and saw Steffie Woolhandler described as a "Harvard researcher" I immediately became suspicious. As noted in some of the reports, she is the founder of the Physicians for a National Health Program - and advocacy group for single payer - not the kind of unbiased person that I would be wanting to evaluate HSAs and high deductible plans. I first refer you to this, a medline search, of her work where you see much of her career, over 90% of her papers have been advocating single-payer health care. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Search&db=pubmed&term=woolhandler+s
I have found PNHP using arguments fraught with intellectual dishonesty - even when you can argue for single payer in an honest way.
So, as any good physician will do, I went to the source paper, which is available free here.
http://www.springerlink.com/content/34171371tjn31m47/fulltext.pdf
The first point I'd like to make is that Woolhandler did not study HSAs. They looked at health care spending, broke it out by age, gender and diagnosis and determined how many people would fall under various thresholds. Surprise, surprise - sicker people, older people and women spent more money. But we knew that already. And this paper says nothing about how HSAs affects that behavior *because they did not look at people in HSAs* This is not Woolhandler's fault so much as the writer for the AP. Furthermore, they also dismiss the other side of "Consumer driven health care" which is the tax-free "use it or lose it" accounts which can be used to pay for deductibles. Presumably women or the chronically ill would avail themselves of the ability to use tax free dollars to pay for the deductibles.
Now, I am not a big fan of the HSA/high deductible plans as a broad-based solution. However, I think this blog aspires to a higher level of discourse regarding healthcare. The "study," if you read it, 90% opinion. "People who utilize more health care will pay more - so that is bad." That is the problem I have with Woolhandler. There is nothing wrong in saying single-payer best serves social justice - that covering everyone equally and sharing the costs by income is the morally right thing to do. That is the most compelling argument for single-payer. But that is an argument, not a "scientific" result for a study.

Posted by: umbrelladoc | Apr 12, 2007 1:35:05 AM

gynecologists in most health plans are considered specialists and can't substitute for a primary care doctor, meaning women will have two main docs, and two sets of costs.

Couldn't you fix this by training primary care doctors in routine screening tests like mammograms and pap smears, and only referring to a specialist gynecologist if those tests produce a problematic result? It just seems odd to have a "primary care doctor" that you're just bypassing for one part of your health care.


In any case, it seems to me that the fundamental argument here is not a factual one. It's about whether or not the higher health care costs of one group (in this case women) should be shared by everyone or borne only by the group that needs the extra health care. That's not really a question that can be settled with facts or studies.

Posted by: Chris | Apr 12, 2007 12:15:41 PM

Widespread adoption of standard HSAs would, among other things, amount to a serious penalty on being born female.

That is not true! There are two possible reasons (not mutually exclusive) why women might have higher health care costs than men, each exonerating HSAs from the "penalty on women" accusation.

1) Women might inherently require more health care than men do. If this is the case, then it is God, or the universe, or whatever, not HSAs that impose "a serious penalty on being born female." HSAs would just stop men in aggregate from subsidizing women's health care. Women don't subsidize men's life insurance, even though men are more likely to die; why should men subsidize women's health care? And even if they should, why should this subsidy be burried in the details of our health care system? If we want to subsidize whichever gender is more expensive to be, let's just make the tax and subsidy explicit.

2) We may have done a better job so far of developing preventive care for "womens' diseases," so we spend more money on these treatments because they're the ones that have been invented. If this is the case, it's actually a bonus to be born a woman rather than penalty. Unless you think that inventing preventative treatments for diseases imposes a hardship on the people that buy them.

Posted by: Sasho | Apr 13, 2007 3:27:53 PM

I found this through a post on ADHR's blog.

I'll agree with you that HSAs are biased against women. However, that's not a reason to scrap a good policy - why don't we just make preventative measures free for both men and women, within certain set limits? (Every so often, people of a certain age get a free physical.) This would lower costs overall - the last thing economists (who favor HSAs) want is people holding off on preventative measures in order to save money, only to spend 10x that amount later.

HSAs encourage people to take care of themselves, but it's possible they could encourage people to avoid preventative measures - we should implement a policy which has all the right incentives. An HSA in which preventative measures a free would do that.

By the way, I have an HSA. The result is that I don't get procedures done that I would really like to have (all sorts of blood, hormone, and vitamin tests) because, to be honest, I'm pretty healthy and I'm not willing to pay the few hundred bucks. Under an HSA system we would have a whole lot less people getting things done that they don't need done. The benefits of HSAs include the following, in order of importance:

1) Consumer awareness of price - hospitals can become competitive, raising price and quality.

2) Consumer incentive to maintain health.

3) Downsizing of the wasteful bureaucratic middleman - leading to increased patient freedoms, awareness, and eventually more people in the healthcare business rather than the healthcare insurance business.

And I'm sure there are more.

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