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September 11, 2007
Health Care Mandates
More from Ponnuru's piece:
The tax code, as noted above, has shaped the private health-care market. Restrictions on who can perform medical services also keep their prices higher than they otherwise would be. And states have imposed an ever-larger number of mandates on insurers. Arkansas is one of thirteen states, for example, that require health insurance to cover in vitro fertilization. Add up such mandates, and the effect can be to price a lot of people out of the market. Duke University professor Christopher Conover estimates that the number of uninsured Americans would drop by a quarter if these mandates disappeared.
This idea that states force insurers to offer overly-comprehensive coverage is a common one. Sebastian Mallaby put it slightly differently when he snarked that Minnesota covers wigs and massage therapy, and what sort of health care system was that? So let's take a look at what these mandates are.
The Council for Affordable Health Insurance -- an industry front group -- puts out a yearly report on the mandates, and repeats this figure that one-quarter of the uninsured are uninsured because the mandates are so onerous. I picked a state at random -- Arizona, who's not too red nor blue, and who has an average number of mandates -- and collected all the conditions and treatments the state is forcing them to cover. Tell me which ones you'd want insurers to drop: Alcoholism, ambulatory surgery, breast reconstruction, colorectal cancer screening, contraceptives, diabetes care and supplies, emergency services, home health care, mammograms, maternity stays, maternity health parity, off-label drug use, infant formula, chiropodists, chiropractors, nurse anesthetists, nurse practitioners, nurse midwives, optometrists, occupational therapists, podiatrists, psychologists, and speech and hearing specialists. Additionally, they mandate that insurers offer coverage for adopted children, dependents, handicapped dependents, and newborns.
Certainly, you can pick a couple things to carve off. Maybe you'll take off chiropractors, though that may actually cost you money as patients opt for covered (and ineffective) lumbar surgeries over manual readjustments. You could take out midwives, but they're saving you money, too. And this stuff just doesn't cost that much: The benefit mandates (your wigs and in-viutro fertilizations and diabetes care), according to Conover, cost only $13 billion. The money comes in access mandates ($81.4 billion), which force insurers to cover the disabled, pregnant women, and let you go to psychologists, chiropractors, etc. And the calculated benefits of those mandates come to a bit over $70 billion. So here's my question for Ponnuru and others: Which of these services shouldn't be protected? And how will its absence improve the cost-effectivieness -- to be distinguished from the mere cost -- of medical care?
September 11, 2007 in Health Care | Permalink
Comments
Wigs and massage therapy for, say, radical mastectomy patients ain't all that outlandish. Just to cite one example.
Posted by: Jamey | Sep 11, 2007 2:30:20 PM
Good point; my mother - the occupational therapist, who taught me a great deal of what I know about healthcare - will tell you that the move is always to cut mandates for support services, like rehabilitation therapies (occupational and speech first, even physical), and mental health services (where, mandate or no, not much is covered anyway).
I'd also suggest that Ponnuru is kidding himself - and as an antiabortionist, it's a little odd - that invitro fertilization is at all a touchable mandate easily removed. You try telling childless couples - especially childless women - that rather than cover the expensive payments for a life giving (literally) service that they should instead suffer economically, or decide not to have kids simply because of the bills for conception... and I bet that proposal will pretty much be DOA. Covering invitro, as I recall, is something the right pretty much likes - it's the contraception and abortion mandates they complain about more. But the larger point, as you say, is that much of this is tinkering on the margins; you want to go where the waste is, it's not getting Dad to learn to re-acquire hand strength after his stroke. And again, like your previous post, what this all comes back to is remembering that what we're really discussing here is the care people need, more than paying for it. Knowing what health care we feel is essential is very basic to then figuring out how to pay for it, and too much of our debate, I still think, fetishizes the latter and ignores the former.
Posted by: weboy | Sep 11, 2007 2:42:17 PM
"Tell me which ones you'd want insurers to drop."
How about all of them and let individuals decide which conditions they want their insurance to cover? If I want my insurance to cover alcoholism, cancer screening or anything else should be my decision, not politicians'.
Posted by: wd | Sep 11, 2007 2:42:35 PM
Perhaps chiropractors, though I doubt that's a large
percentage of total costs.
Posted by: K | Sep 11, 2007 2:46:27 PM
If I want my insurance to cover alcoholism, cancer screening or anything else should be my decision, not politicians'.
It will never be your decision, that's the point. This kind of coverage will not be offered in the absence of mandates. The market won't offer it because the people who need it aren't the people who are going to pay for it, i.e. the healthy and uninjured.
Posted by: Chris Howard | Sep 11, 2007 3:19:25 PM
get rid of the infant formula. The sooner those kids learn to fend for themselves, the better.
Posted by: JasonC | Sep 11, 2007 3:25:15 PM
weboy:
Actually, the right wing hates in vitro, both for theological reasons (because it involves humans "playing God") and for practical ones (because it creates a lot of excess embryos which have to be aborted or indefinitely frozen).
They don't emphasize this position because of its unpopularity, but it's there.
(Full disclosure: I don't like in vitro all that much, but for a different reason: I think we shouldn't spend a lot of time and money catering to couples' desire for a BIOLOGICAL child. It's important that people are able to have children if they want them; it's not important at all that the father gets an ego trip from having donated the sperm or the mother gets an ego trip from having gone through the birthing process. Better to promote adoption and even surrogacy.)
Posted by: Dilan Esper | Sep 11, 2007 4:13:16 PM
wd, at the risk of stating the obvious, insurance is about covering costs you haven't anticipated. Even if I'm 100% convinced I'm never going to be in a car accident, that doesn't mean it's true. Just because someone's convinced they're never going to get cancer doesn't mean they shouldn't get cancer screenings. In fact, to keep the population healthier and the cost of health insurance *down,* we should be trying to get *more* people screened, sooner.
Posted by: Persia | Sep 11, 2007 4:18:48 PM
I assume that the formula requirement is for some particular types, like maybe soy-based for babies with milk allergies?- seems like food isn't usually a part of health coverage, except meals while hospitalized.
Other than that, we should probably keep in mind that there are almost certainly a lot of exclusions within these categories, too-- even though I'm not in AZ, I've never seen a plan that didn't have very miserly restrictions on podiatry, substance abuse, mental health, and occasionally contraceptives. Maternity & vision coverage are often separate riders; just because an insurer has to offer them doesn't mean that they can't be priced out of market for employers.
Posted by: latts | Sep 11, 2007 4:35:57 PM
Ezra,
This is exactly consistent with my earlier point. Without any knowledge of the details, Ponnuru's logic above sounds very "thoughtful."
The details, however, make his points fairly ridiculous-- I'm curious if there is a part of his piece that is insightful AND consistent with the reality of health care.
If so, please post-- otherwise, I'd rather spend time on a slew of other proposals that merit discussion (what was the one you promised to review a month or so ago?)
Posted by: wisewon | Sep 11, 2007 4:48:24 PM
Sebastian Mallaby put it slightly differently when he snarked that Minnesota covers wigs and massage therapy, and what sort of health care system was that?
If you're a woman receiving chemotherapy, it's a health care system that respects your dignity and gives you a relatively inexpensive boost in spirits.
But Mallaby's too much of an asshole to consider that.
And the reason for mandates is that the state will presumably end up burdened with the costs -- direct or indirect -- of many conditions related to those services if they're not covered.
Posted by: pseudonymous in nc | Sep 11, 2007 5:04:06 PM
You guys drive me crazy. There is ZERO reason for mandates on in-vitro, chiropractic, lumbar surgery, etc. Those things are either totally elective and not health-related OR they just flat out dont work, OR they are so expensive for such little benefit that its not worth it.
Do you guys have ANY IDEA how much one round of IVF costs? Please get a clue.
Multiple studies have shownt aht chiropractice is no more effective than NSAIDS and back exercises. NSAIDS are cheap, and a handout to give patients on how to do back exercises is even cheaper. There is zero reason for insurance to cover it.
"it's a health care system that respects your dignity and gives you a relatively inexpensive boost in spirits."
Are you fucking kidding me? My wife gets a "boost in spirits" by getting her nails done. I guess that should also be mandated or covered by Medicare too. Wigs, even for cancer, are fucking COSMETIC and should not be covered. Some of those wigs arent as cheap as you think they are either. Custom wigs can go upwards of $2,000.
I'm so sick of the general attitude on this thread that "its only a small part of overall costs." Using that logic, I demand the govt give me a check for 10 million dollars. After all, its only 0.000001% of the federal budget, surely we can afford it right? That would do a lot to give me a "boost in spirits" and a boost in spirits is good for my health right so that makes it a legit idea.
BTW, infant formula is covered under WIC. All kinds of infant formula are coverd under WIC.
Posted by: joe blow | Sep 11, 2007 5:24:14 PM
My wife gets a "boost in spirits" by getting her nails done. I guess that should also be mandated or covered by Medicare too.
Oh, fuck right off. Either you're ignorant of the effect of hair loss during cancer treatment, usually after the false hope of a couple of rounds of chemo, or you do know and you're a callous, misogynistic bastard.
But Ezra noted that bullshit line a year ago, so I don't have to.
Posted by: pseudonymous in nc | Sep 11, 2007 5:40:26 PM
BTW, infant formula is covered under WIC. All kinds of infant formula are coverd under WIC.
Like the rest of your comment, this has nothing to do with anything.
I would imagine that the infant formula mandate is for situations in which it's medically necessary to put the baby on formula in the first place, not to cover soy vs. milk-based, since formulas almost all cost the same now. That is to say, if you're planning on formula anyway, then having to use soy-based or lactose free formula isn't a hardship. But if you were going to breastfeed and there was a medical reason why you couldn't, then I could see infant formula being covered as part of the treatment, as it were, for that condition.
Posted by: Stephen | Sep 11, 2007 5:56:31 PM
Yes, I want coverage for hangnail surgery. Those little devils hurt. *And* when I can get on the public insurance dole as the Dems want us to all be on, I want taxpayers to subsidize my drinking issues, too. It's all important.
Why, we should also follow the lead of San Francisco city and madate coverage of sex-change operations as well. That's a health issue, too....right??
Posted by: El Viajero | Sep 11, 2007 5:57:26 PM
Well, health policy debates aside, chiropractors and osteopaths are a bunch of quacks. They ought to be shut down.
Posted by: chris | Sep 11, 2007 6:24:24 PM
Osteopaths? Really? Are you sure you're talking about osteopathy, and not homeopathy?
'Cause my doc is a DO, and she's very well-regarded in this area.
Posted by: Stephen | Sep 11, 2007 6:30:23 PM
The bottom line is that insurance and Medicare/Medicaid/socialized medicine should cover what is MEDICALLY NECESSARY, not what is cosmetically necessary or what makes people "feel good" or "have their spirits boosted"
They can buy a cheap fucking wig at Walmart. Its ridiculous for the public or insurance to pay for that crap.
and please spare me the "its cheap and a very small part of the overall budget." Using that logic we could put in a bunch of bullshit that only contributes 0.1% to the overall cost. But after you add 40,000 of those little things, that 0.1% incremental cost increase starts to add up.
Posted by: joe blow | Sep 11, 2007 6:58:30 PM
Breast reconstructive surgery should not be covered either. Cosmetic effect period. Breasts are not necessary for health.
Posted by: joe blow | Sep 11, 2007 6:59:12 PM
The only reconstructive stuff that should be covered is facial injuries such as burns. Everything else can be covered.
Posted by: joe blow | Sep 11, 2007 7:10:10 PM
Drop chiropractors, replace with physical therapists. A whole lot less woo-ey.
Osteopaths? Really? Are you sure you're talking about osteopathy, and not homeopathy?
'Cause my doc is a DO, and she's very well-regarded in this area.
Osteopaths are tough, because while today they're trained almost exactly like MDs (in the US at least), their whole profession is still based on a non-scientific, discredited therapy: manipulation. Your DO is probably fine, but you should just be sure she's not going to refer you to a homeopath or a reiki healer, or she's not trying to cure your cancer by cracking your back.
Posted by: Cain | Sep 11, 2007 7:16:19 PM
Why just burns? Following your argument about breast reconstructive surgery, screw the victims if they can't live with the scars, right? And we don't have to worry about damage to parts of the body we can live without, right? So what if you have your hand mangled? Much easier to just amputate.....
No wonder Libertarians have reputations as selfish beasts. Because they are.
Posted by: tzs | Sep 11, 2007 7:16:50 PM
Your DO is probably fine, but you should just be sure she's not going to refer you to a homeopath or a reiki healer, or she's not trying to cure your cancer by cracking your back.
I used to manage a coffeeshop that had a bunch of students from the local DO med school come in, and I'd give them free coffee and stuff. They explained to me that being a DO is about trying to look at the body as a whole instead of just whatever part happens to be under scrutiny at the time. None of them talked about "curing cancer by cracking a back" or anything.
My own doctor is pretty much like an MD.
Posted by: Stephen | Sep 11, 2007 7:26:54 PM
"They explained to me that being a DO is about trying to look at the body as a whole instead of just whatever part happens to be under scrutiny at the time."
Thats just marketing bullshit. DOs treat high blood pressure the same way MDs do. They dont take extra time to "consider the whole body" or other such nonsense. The AAOMC which is the organizing body behind DOs has been using marketing ploys like that to try and claim that they are "better" than MDs.
Most DOs are OK, but they do have a stronger link to quackery than MDs do. Some MDs are quacks also, but the percentage is higher in the DO group. HOwever, chiropractors are by far the quackiest of any of them. Their treatments are total shams.
Posted by: joe blow | Sep 11, 2007 8:01:14 PM
MDs used to bleed people to release bad humors or give them Mercury and Arsenic, so when Osteopathy started Manipulation wasn't a bad alternative to getting poisoned to death. Quackery knows no bounds.
Posted by: Dingo | Sep 11, 2007 9:07:29 PM
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