In terms of the higher costs reported by the CBO for preventative medicine (and the studies mentioned vary in their conclusions on which services are and are not effective in terms of cost), Elmendorf also says, ” Of course, just because a preventive service adds to total spending does not mean that it is a bad investment. Experts have concluded that a large fraction of preventive care adds to spending but should be deemed “cost-effective,” meaning that it provides clinical benefits that justify those added costs: Roughly 60 percent of the preventive services examined in the review cited above have additional costs that many in the health care community consider to be reasonable relative to their clinical benefits.”

I think the cost analysis should be based not only on what additional medical expenses might have been avoided, but also the ultimate economic gain from better health. What isn’t quantified is the economic downside of lost work time (for both workers and employers), lost school time, and the other non-productive results of ill health. Of course keeping people alive and healthy longer will cost more: on the other hand, that also means they are more productive for a longer period of time. Will it cost more to treat a depressed unemployed person? Yes. Are they more likely to work and pay their taxes? Yes. Does it cost more to give a child speech therapy (another battle I had with my insurance company)? Yes. Will the child be more likely to succeed in school and have a better income in life? Probably yes. Other countries have figured this out, but we continue to look at health as a commodity instead of an essential economic necessity.

My own experience behind the desk at a doctor’s office tells me that the waste is not in preventive care, but in the absurd amount of paperwork and red tape that processing insurance claims requires, but I don’t see the insurance industry going away anytime soon. In Switzerland they don’t have a public option, but everyone has at least basic insurance and care that the insurance companies must provide. Those below a certain income level are subsidized by the government (taxes). Makes sense to me.

Meanwhile, I personally consider it a national disgrace that we have so many uninsured. We can do better, but it will cost us more because of the way we do it. Many other countries have full coverage AND lower costs. It can’t be because they’re paying high copayments. They’re not.

As for the “growing notion that insurance should cover more, not less,” yes I am very aware of that notion, and I could not disagree with it more! That growing notion is a big part of the problem! It ceases to become insurance at that point. It is just third-party payment for predictable, planned expenses, which does nothing but add to the cost of those expenses due to the middleman taking a cut, encouraging over-utilization, and increasing the price since consumers are less price-sensitive. Doug Elmendorf at the CBO has already shown that preventive care increases cost, not lowers it. Paying for more preventive care does indeed “bend the curve”, but in the wrong direction.

If you want to argue it from a purely public health standpoint, that is fine. I don’t disagree that people need motivation to take action to improve their health. But the problem facing us now is out of control cost growth; making that growth even worse in the name of public health is not the direction we should be headed.

Also, Deena was talking about preventative care. There is a growing notion that insurance should cover more, not less, of that type of care as it is the most efficient way to promote health. Isn’t that the point?

I know the counter argument: No, it isn’t the whole point. Insurance is for financial protection against catastrophe. That’s valid and true. Health insurance should do that. But along the way we want to provide incentives for people and doctors to provide efficient care. Preventative care is hard to motivate since it occurs when people are symptom free. Adding substantial patient cost on top will discourage the timely use of appropriate care. That’s a valid public health issue that can and should be addressed. Why not do it through the insurance system?

Decades of our current system where people have been shielded from the true cost of medical care and ingrained with the idea that a $10 copay is all one should ever have to pay is a big part of the reason that care has become so expensive and our costs have grown astronomically.

Sure, there are people for whom the cost of even routine health expenses are prohibitive, but this is the minority, and we can find solutions to help the most needy (we have one already in Medicaid). But for the majority of us it does not make any sense to have a third-party intermediary for all of the routine annual expenses that we know with relative certainty that we’ll incur.