The New York Times
January 20, 2004
Broader Health Coverage May Depend on Less
By Milt Freudenheim
With the number of uninsured Americans rising to new heights, some policy makers and influential health care experts are saying that the best way to give health coverage to more people is to give some people less.
Experiments in several states are establishing stripped-down packages of basic benefits intended to be affordable for employers and uninsured workers, including young, middle-class people who have dropped out of the health insurance pool. Some officials say that government health Benefits could be extended to more people, too, if the benefit package were narrower.
Some experts warn that cutting back mandated benefits will neither yield enormous savings nor slow the increase in costs associated with medical advances.
“There is very little in health care that you can trim off,” said John Sheils, a health policy expert at the Lewin Group, a consulting firm based in Falls Church, Va., that has advised health care advocacy groups in several states. “If you develop a new procedure that does some good,” he added, “ultimately all the insurers are going to have to recognize it and pay for it.”
Comment: John Sheils is one of the nation’s most noted authorities in the analyses of health care reform proposals. His microsimulation models have demonstrated that little savings can be achieved by reducing the level Of services covered, if the resulting product continues to protect individuals from the excessive financial burdens of health care.
Many proposals today call for ensuring “basic” coverage for everyone, as if that were a lower-cost, isolated segment of health care that people “really need.” But when attempts are made to define what should or should not be covered, the process falls apart. Theoretically, beneficial services Should be covered and ineffective services should not. But, in fact, much of health care cannot be readily assigned to one of these two categories.
Thus, the concept of “basic” services really should mean that patients must have unimpeded access to physicians and other providers and to the institutions and services that they control. The ultimate decision for appropriate services should be made jointly by the patient and his or Her health care professional. This process is not amenable to meat cleaver economics.
If eliminating non-basic services is not an effective option, then how can we control costs? Placing the entire health care system under a global budget will determine the capacity of the system. The budget allocation process will determine capacities for segments of the health care system. That process may well limit the number of total knee replacements in nonagenarians. But isn’t that process better than depriving many of us of beneficial services merely because they fail to meet an arbitrary threshold of just what a basic service is?