Manadated Coverage May Solve Nothing

There are three factions in the war over health care in our country.  In one corner are the advocates of universal single-payer care, which is my favorite team and what all other developed countries provide their citizens.  It is simple, less-expensive, and more effective in delivering health care.  Any American who is proud that the quality of care in our country is on par with Cuba should have their head examined for termites.  Somehow, one of the poorest countries of the world, long hampered economically by a boycott from the United States, is able to provide care as good as we get in this country at a tiny fraction of the cost. Hip hip … um… hooray?  We have 47 million people without health insurance and medical care costs are more than double the costs in other developed countries. 

Universal health care has been branded as socialized medicine by the evolutionarily inept.  To appease those with small brains, even smaller hearts, and no functioning conscience, politicians have looked for bandaids to put on gunshot wounds.  Mandated coverage is the new trojan horse.  Make insurance companies cover people and make people buy their terrible products as the way to increase coverage and presumably give us better health outcomes.  Never mind that forcing people to buy insurance does not guarantee that insurance companies will pay the claims. 

A recent study from Duke illustrates some of the problems with mandating coverage.  The study examined “the use of mental health and pharmaceutical benefits by employees who have identical insurance benefits, including equal co-payments.”  In other words, in a perfect mandated coverage world, with people getting the same insurance benefits on paper, would it translate into equal access and care?  The study, with Barack Richman as lead author and published in the September 11 issue of Health Affairs, answered this important question.

Focusing on mental health coverage is important because of pending legislation in Congress.

Congress is now considering the Mental Health Parity Act of 2007, a renewal and extension of a 1996 law that required certain employer-provided insurance plans to offer mental health benefits that are equal to those provided for medical and surgical care. Several states also have instituted similar mandates. Such mandates might alleviate disparities in health insurance coverage, Richman writes, but until now little has been known about whether equalizing insurance benefits translates into equalizing levels of health services use.

It turns out that mandated coverage does not eliminate health care disparities, even when the benefits on paper are the same. 

Richman found that low-income and minority individuals did not utilize these insurance benefits as often as their white and higher-income co-workers. As a result, insurance companies disbursed more healthcare dollars to whites and higher-income individuals, leading to a likely “wealth transfer” from nonwhites to whites and from low-income to high-income individuals, Richman said.

In other words, mandated coverage increased or contributed to disparities in health care utilization. 

Richman’s study examined the insurance claims of more than 20,000 employees of Duke University and Duke University Health Systems from 2001 to 2004. About 68 percent of the employees were white and 24 percent were African American, and the median annual income rose from $36,000 to $40,500 over the four years of the study. These figures roughly reflect the demographic profile of both Durham County, where Duke is located, and the state of North Carolina.

The study showed that whites were significantly more likely than African Americans or Asians to file claims for mental health benefits.

Income also factored into employees’ use of benefits; as incomes rose, employees became significantly more likely to file claims. Similarly, whites were more likely than African Americans and much more likely than Asians to use pharmaceutical benefits, and as incomes rose so did use of drug benefits.

As a result, whites received nearly four times the annual insurance dollars that African Americans received and more than three times the dollars that Asians received in health insurance disbursements for mental health claims. Whites received $140 to $225 more in insurance coverage for drug claims than African Americans did, and about $500 more than Asians.

The question becomes why these disparities exist, which the Richman study was not designed to answer.

This study did not attempt to determine the causes of the gap in use of healthcare benefits, but Richman offers possible explanations, including the stigma surrounding mental illness, varying attitudes toward traditional healthcare and differing preferences for delivery of care.

These psychological factors blame the victim.  There are other possibilities.  Physicians may be less likely to ask about mental health issues and make appropriate referrals for people of color and of limited income.  In short, the attitude problem may be in the provider, not the patient.  Maybe medical management of chronic conditions, such as diabetes, hypertension, and coronary artery disease, which tend to be more prevalent in African-Americans, kept the focus of care on immediate life threatening issues. 

These explanations do not address why fewer claims were made and paid for pharmaceutical benefits.  This is perhaps the most surprising finding of all.  Were physicians writing more scripts for generics for African-Americans and Asians?  Were whites and higher income patients given scripts for newer drugs, still under patent?  Maybe the co-pays were still too high for lower income patients, particularly for newer drugs.

A major limitation of the study is that it did not track denied claims.  The numbers were strictly generated from paid claims.  One hopes that insurance companies are blind to race and socioeconomic status, but the cynic in me cannot dismiss the idea out of hand.

The third faction in the health care debate are the free market assholes that think that profit will solve everything and if poor people suffer, too bad. Here is one of the biggest assholes on the planet pushing profit for pigs.