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Dishonesty, ignorance, or what?

We hardly regard politics--certainly not the words of politicians--as a realm where truth and honesty are closely protected. Public ignorance undoubtedly often pairs with politicians' disregard for accuracy to allow lies to pass. It is still galling, though, when political process and public reflection are stubbornly resistant to the obvious. It is more disturbing yet if the ignorance seems almost willing--a deeper kind of dishonesty in and with ourselves.

By nature I am neither cynic, nor pessimist, nor one who disdains politics and public life because they can be infused with ignorance. In the last twenty-four months, moreover, I have been encouraged by the distance insurance reform has traveled, notwithstanding current efforts to repeal the most ideologically moderate of reform approaches. Nonetheless, I now find myself haunted by suspicions of a deep dishonesty in our culture. My original point of suspicion is the laudable requirement to admit patients to emergency rooms regardless of their ability to pay, but I can now add two related ones: the "insurance effect" fueling health care costs, and the mantra that prevention lowers costs (in particular, that reducing smoking will lower costs).

Since enactment in 1985, the Emergency Medical Treatment and Active Labor Act has required hospitals to admit patients for emergency care regardless of ability to pay. (1) It now provides a historical and legal anchor for a fairness and efficiency argument to mandate insurance to achieve universal access. The argument begins with the fact, achieved by EMTALA, that the United States already has universal access to emergency care. Exemplifying the underlying moral principle of rescue, this law has wide, deep support: first passed with bipartisan support in 1985, reaffirmed in 1998, and not politically challenged in all the tumultuous debates of 2009-2010.

If we agree that universal access to emergency care is a good thing, as we apparently do, then unfairness, free-riding, and inefficiency drive the argument to a mandate. Most of the cost of providing emergency care to those who cannot pay is shifted to people with insurance, who consequently pay higher premiums. These payers are not necessarily the parties from whom it is fair to extract the "tax" to fund this access. Moreover, the cost shift enables some to free-ride unfairly by escaping paying for insurance, knowing that emergency care will be available anyhow. In any case, emergency care often ends up substituting for primary and other care that is not accessible--a very inefficient substitution. In a context where universal access to emergency care is guaranteed but other basic care is not, the only feasible remedy for this unfairness and inefficiency is to mandate insurance for basic care more generally. (2)

An oddity thus created for our current situation deserves notice: a key link in the argument for an insurance mandate, now being challenged as unconstitutional, is itself a federal law that's not been challenged. Also, notice how sly or shrewd a step EMTALA may have been, in historical hindsight, for the cause of universal access: put in place access to emergency care, then let the momentum and pressure from it roll all the way to a broader access. Pull that off, moreover, without complicating the political prospects of the initial step by owning up to how to pay for access to ERs.

In retrospect it is not hard to understand why a society resistant to universal access (and to paying for it) might choose emergency care as one of its first major steps toward universal access. Not all that respectable, perhaps, but understandable: live up to the moral call of rescue by guaranteeing emergency care, but then dodge financial responsibility. (3) Here the mandate is easy to leave unfunded since an avenue of "backdoor" financing is available. Emergency care is provided by institutions (hospitals) that are large enough to absorb the immediate costs and shift them onto other payers. No such hidden financing is feasible for primary care, which is usually delivered in smaller institutional settings. With its financing thus "cheap" and politically enticing, it is hardly any wonder that access to emergency care became an irresistible early step in insuring the population under sixty-five.

Was this shrewd, or disingenuous and irresponsible? In 1985 it was not, I think, unwitting. Seeing how the requirement on hospitals would be paid for (by relatively invisible cost-shifting) was hardly rocket science, nor was the inefficiency of the overreliance on emergency care that would be caused by EMTALA hard to predict. Perhaps society's and Congress's initial and continuing determination to mandate universal access to emergency care reflects the fact that when the moral strings and human stakes are as strong and high as they are in health care, we think it excusable not to let cost and funding get in the way, grabbing any chance we can to fund them invisibly. Unfortunately, this implies not carefully examining and taking responsibility for cost, either.

And that pattern now spells trouble. The United States is facing a horrendous problem in the cost of health care. Not only are we already paying more than half again as much for care as other developed nations, though what we get is equivalent in quality, but we have apparently become prisoners of health care's cost growth. Health care spending is projected to outpace the growth of per capita income by enough that, even with the most optimistic projections of how the reform act will restrain costs, more than all of the real increase in per capita income in the next seventy-five years will be absorbed by health care. (4) Yes, folks: no increase in economic capacity for the total of everything else! And an enormous crimp on the federal budget.

Numerous causes fuel this growth. One, the "insurance effect," is particularly insidious in distorting cost-value relationships: once people are insured, their perception of the relationship of cost to value greatly changes. Insured patients--and often their providers, especially in fee-for-service reimbursement contexts--have an incentive to use every bit of care that has even the slimmest, pie-in-the-sky prospect of benefit, regardless of its cost. People sense, correctly, that their future premiums will not increase by more than micropennies because of their current use of marginal care.

The U.S. public has simply not grown up about this. The effect pushes up costs in any modern health economy in which most care is insured. But other nations seem to have recognized this and taken compensatory steps. By contrast, the reaction in the United States to restraining treatment when one is insured is likely to be "I've had insurance for years, that treatment is mine, I've paid for it already." This retort only begs the question: what is the it that we've bought with insurance? In a situation where insurance predictably distorts cost-value decisions, the it we've bought cannot simply be anything and everything that my providers and I regard as worth doing. And if we insist that it is and that I have "paid for it already," we have indeed come to think that when it comes to health care, we should not examine cost. Then have we not said we won't take responsibility for cost?

Another manifestation of not facing up to cost is a mantra about prevention. It will save medical expense, we think: effective prevention keeps us out of hospitals, away from surgeons' knives, and so on. Health economists have shown that only a few preventive measures actually save money, and many are no more efficiently productive of health than treatments that get questioned as too expensive. (5) Nicotine replacement treatments and counseling about smoking are often said to be among the most productive preventions, but such studies seldom look at the lifetime medical costs of smokers compared to the higher ones of nonsmokers, nor do they incorporate the savings in smaller aggregate pension payouts for smokers, who live shorter lives. (6) Little in this should be surprising: living longer costs money, including money for our health care needs in the longer years of life. Yes, prevention can efficiently produce good health, but even when it does, and in fact precisely because it does, it seldom reduces costs. We do not want to hear that. And even when we do hear it, we continue to talk as if we did not.

There are rarely free lunches, in health care as anywhere else. Will we be honest with our fellow citizens about that? Are we willing to be honest with ourselves about it?

(1.) U.S. Congress, The Emergency Medical Treatment and Active Labor Act, 1985, amended 1998. Pub. L. No. 99-272, 100 Stat. 164 (codified as amended at 42 U.S.C. 1395dd).

(2.) I present the full argument in "A Cultural Moral Right to a Basic Minimum of Accessible Health Care," Kennedy Institute of Ethics Journal 21 (2011, forthcoming).

(3.) On both EMTALA's foundation in moral convictions about rescue and its unfunded mandate, see T.M. Lee, "An EMTALA Primer: The Impact of Changes in the Emergency Medicine Landscape on EMTALA Compliance and Enforcement," Annals of Health Law 13 (2004): 145-78.

(4.) M.E. Chernow, R.A. Hirth, and D.M. Cutler, "Increased Spending on Health Care: Long-Term Implications for the Nation," Health Affairs 28, no. 5 (2009): 1253-55.

(5.) J.T. Cohen, P.J. Neumann, and M.C. Weinstein, "Does Preventive Care Save Money? Health Economics and the Presidential Candidates," New England Journal of Medicine 358 (2008): 661-63; L.B. Russell, "Preventing Chronic Disease: An Important Investment, But Don't Count on Cost Savings," Health Affairs 28, no. 1 (2009): 42-45.

(6.) One of the studies that does is P.H.M. van Baal et al., "Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure," PLoS Medicine 5, no. 2 (2008): e29 (comparing three groups, including smokers and healthy, nonobese nonsmokers).

This column appears by arrangement with the American Society for Bioethics and Humanities.
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Title Annotation:policy and politics
Author:Menzel, Paul T.
Publication:The Hastings Center Report
Geographic Code:1USA
Date:Mar 1, 2011
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