James G. Kahn, MD, MPH, a professor at the Institute for Health Policy Studies at the University of California, San Francisco, responds to the comments on the Kaiser poll on the desire for affordable health care:
Don – you are so right. I would add that the respondents’ focus on affordability means that they are ripe for believing reforms that appear to control costs (premiums, anyway) by (quietly, surreptitiously) restricting benefits and/or excluding the sickest from coverage. – Jim
Comment: Jim’s point is absolutely crucial. Much of the discussion about affordability in health care has centered around the affordability of premiums. That is a very different issue than the affordability of health care.
Employers, individuals and even the government (FEHBP, Medicare + Choice, etc.) have directed attention to keeping premiums affordable. This can be done only by reducing coverage, through a reduction in benefits, an increase in patient cost sharing, or through measures to exclude high risk patients from coverage.
As Jim mentions, the control of premium rates is frequently engineered through quiet, surreptitious manipulations. Defined contribution programs, tiering of services, providing options of streamlined (i.e., bare bones) coverage, and offering low premium, high deductible coverage with some form of health reimbursement arrangement (similar to MSAs) are only a few of the manipulations that are designed to make premiums more affordable. The problem, of course, is that they do nothing to make HEALTH CARE more affordable. They merely shift costs to those with the greatest health care needs.
In our debates over the model of health care reform that should be adopted, we must diligently challenge those that claim affordability when they are referring only to controlling premiums. Those supporting employer mandate or individual mandate models of “universal” coverage will claim that they are controlling costs when, in fact, their current models will only control premiums. These models make health care UNaffordable by shifting costs to individual patients.
A universal, publicly administered program can make global health care costs affordable through mechanisms such as global budgeting, reduction of administrative waste, rate negotiation, and bulk purchasing. And with equitable funding, whether you call it an income-related premium or a tax, health care can be truly affordable for everyone.