Ezra Klein: Missing The Point
This wasn’t Gawande’s point at all, and is something quite tangential to Klein’s point:
The reason most Americans hate insurers is because they say “no” to things. “No” to insurance coverage, “no” to a test, “no” to a treatment. But whatever the problems with saying “no,” what makes our health-care system costly is all the times when we say “yes.” And insurers are virtually never the ones behind a “yes.” They don’t prescribe you treatments. They don’t push you towards MRIs or angioplasties. Doctors are behind those questions, and if you want a cheaper health-care system, you’re going to have to focus on their behavior.
Yes, doctors are a driver — one of many — in the exponentially increasing cost of health care. Utilization is uneven, not linked to quality or outcomes in many cases, and may often be driven by physicians’ personal economic interests. All of this is not news, though certainly Atul Gawande wove it together masterfully in his recent New Yorker article. (I’m assuming you’ve all read it — If not, then stop reading this drivel and go read it immediately.) Nobody disputes that doctors’ behavior (and ideally their reimbursement formula) need to change if effective cost control will be brought to bear on the system.
But it’s completely off-base to claim that insurers aren’t one of the problems in the current system. There are two crises unfolding in American health care — a fiscal crisis and an access crisis. I would argue that insurers are less significant as a driver of cost than they are as a barrier to access. Overall, insurers have, I think, only a marginal effect on cost growth, largely due to the friction they introduce to the system — paperwork, hassles & redundancy and internal costs such as executive compensation, advertising and profits. It would be great if this could be reduced, but it wouldn’t fix the escalation in costs, only defer the crisis for a few years until cost growth caught up to today’s level. In the wonk parlance, it wouldn’t “bend the cost curve,” just step it down a bit.
But as for access to care, insurers are the biggest problem. It’s not their “fault” per se in that they are simply rational actors in the system as it’s currently designed. Denying care, rescinding policies, aggressive underwriting and cost-shifting are the logical responses of profit-making organizations to the market and its regulatory structure. Fixing this broken insurance system will not contain costs, but it will begin to address the human cost of the 47 million people whose only access to health care is to come to see me in the ER.
*This blog post was originally published at Movin' Meat*
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