No to Apple Pie and Free Preventive Care

By Kim Bellard, October 28, 2010

Much has been made about the recently effective provisions of the Patient Protection and Affordable Care Act that require health insurance plans to cover many preventive services without cost-sharing.  Increasing the use of preventive services, and removing financial barriers that might prevent people from using them, are the kinds of things that most people – in both political parties -- seem to automatically approve of.  It’s practically un-American not to favor the idea.

Well, I’m as patriotic as the next person, I love my mom, but I don’t like apple pie and I don’t think free preventive care is necessarily a good idea.

While some studies over the years have found that increased use of certain preventive services is cost-effective, the evidence is neither universal nor entirely clear-cut.   For example, Joshua T. Cohen, PhD. and his colleagues raised this question in an article in The New England Journal of Medicine, and concluded that many preventive measures are not cost-effective.  They urged that care be taken to target cost-effective measures, which the new law purports to do, by focusing on “evidence-based preventive services.”  Still, not everyone is persuaded that even this focus will deliver intended savings; for example, the American Academy of Actuaries raised several good points in their response to the Interim Final Rules promulgated by HHS last summer.  Ambiguity about interpretation, over treatment, and cost-shifting to preventive service coding are cited as examples of potential problems that could have the result of increasing costs.  

I’m not going to try to argue on either side of that particular debate; I’ll leave that for the researchers, actuaries, and other number-crunchers.  My skepticism is whether making access to these services without cost-sharing via health insurance is good public policy. 

In their background on the new preventive care rules, HHS says that Americans only use preventive services at about half the recommended rate, citing a study by McGlynn, et. al.  However, as best I can tell, that study talked about recommended care on a number of fronts, and did not cite financial barriers as the key problem.  The McGlynn study is indeed very troubling, but it left me wondering why physicians were not doing a better job giving their patients recommended care, not why patients were failing to show up for it. 

Preventive care is something that most Americans should be able to afford.  If it is too expensive for at least middle class Americans to pay for directly, then we have an even bigger problem, because paying for it via health insurance is still going to require that middle class to pay for it, along with everything else insurance covers.  I get frustrated when policymakers and pundits seem to think employers and insurance companies pay for health insurance with “their own” money.  These entities aren’t like the federal government, which can print money and/or borrow money from China.  It is a poorly understood truism that insured people pay for insurance; the insurance companies essentially redistribute the money from people who don’t use services to those who do.  Money for employer-based health insurance is coming out of workers’ paychecks; they just don’t always realize it.

That’s the basis of the problem.  We are getting further and further divorced from the cost of health care.  Health care is scary because no one knows if tomorrow they’ll get hit by a bus or feel a cancerous lump, and be faced with bills that are hundreds of thousands or even millions of dollars.  That’s why people have historically bought insurance: to protect against unforeseen and potentially catastrophic expenses.  

Preventive care isn’t like that.  The expenses are not usually huge, nor are they unpredictable.  These should be budgetable expenses, like scheduled maintenance for one’s car.  Yes, there are lower income people for whom even these expenses are unaffordable and who do need financial assistance in paying for them, but removing the apparent financial obligation from everyone as a way to solve that problem is not only overkill but expensive overkill.  Health insurance is not a good vehicle for income redistribution; it is a mechanism to redistribute money to people using services from people not using services.

I also have to wonder: if preventive visits are so important, why aren’t we including dental check-ups or eye exams?  Certainly the same arguments used to justify medical preventive visits should apply here too, especially given the increasingly accepted linkage between oral and overall health.   I say that with a wary eye to the slippery slope we’re already on; whatever preventive services will be covered initially, one has to strongly suspect that it will only be the beginning.  There is not much political will to take away a benefit once given, so services are likely to only be added to the list, not removed if/when new data comes out to challenge the efficacy of the service.  If you don’t agree, just ask Jerry Brown about the wisdom of questioning the efficacy of mammograms…

The oft-used argument is that preventive visits will pay off in the long run, although – as the studies cited above indicate – that is not always the case.  The argument posits that making it “free” now will incent people to obtain the care.  The hidden premise to this argument is that people don’t view preventive care as being of value unless it is free.  I.e., they are not smart enough to take care of themselves and won’t take the right actions for their best long-term health.  Well, in a country with 33% obesity rates and 20% smoking rates, that does appear to be a valid argument – but I’m skeptical that those people are going to be motivated to act in that interest simply by removing cost-sharing for their annual exam either.  

I hate to sound like a Grinch by not supporting “free” preventive visits, but they’re not truly free.  To me, the core issue is how to make people care about taking care of themselves, with part of that including getting appropriate care.  Call me a cynic, call me uninformed, but giving away “free” preventive care seems more like just bread and circuses for the masses compared to the underlying problem of motivating people to be responsible for their health and well-being.