Who's responsible for health care?

Amid all the controversy over the troubled launch of the Affordable Care Act's public health exchanges, another revolution is taking place in the much larger world of employer-provided health care. 

Andrew Krech/The Citizens’ Voice/AP
Young friends get set for a hayride at Hillside Farms in Dallas, Pa.

Most of us carry in our heads the prices we expect to pay for everything from a gallon of gasoline to an Egg McMuffin. If you’ll excuse the wonkiness, pricing is an amazing mechanism. The Royal Swedish Academy of Sciences thought so, too. It awarded the Nobel Prize in Economics this year to three economists who have delved deeply into how prices work and how reliable they are in decisionmaking.  

Should we buy? Can we make do with what we have? Will life be better after a purchase is made? A huge amount of human activity is involved in setting prices and reacting to them. The more we can get a fix on a price, the better our decisions.

Under way is a quiet revolution in health care that aims to put the price mechanism to work on the $2.8 trillion health-care system in the United States (see this Monitor Weekly cover story for details). Important note: This is not about the controversy raging in Washington and the media about public health-care exchanges to cover the 47 million Americans currently uninsured. It is about health insurance that affects the 150 million Americans with access to an employer-provided health plan.

Transparency about prices creates competition and informs decisionmaking. If you don’t know what something is going to cost, how do you know whether it is better or worse than an alternative? How do you know whether you even want it? As one specialist in the current system told the Monitor’s Harry Bruinius: “Health care is the only place, really, where the person who decides he or she wants something, and the person who delivers it, really don’t even have to talk about what it’s going to cost.”

The Dartmouth Institute for Health Policy and Clinical Practice has extensively examined today’s opaque system. Among its findings: More than 30 percent of US health-care spending is on unnecessary care. Not only that, overcoverage and overdiagnosis hurt more than they help. A 2012 book titled “Overdiagnosed: Making People Sick in the Pursuit of Health” describes this problem as “medicalizing life,” meaning interpreting ordinary experiences as diseases and always urging a medical remedy.

The media get some of the blame for promoting fear of disease and indicating that early, aggressive treatment is important (Hippocrates thought otherwise. “Doing nothing,” he wrote, “is sometimes a good remedy.”) Doctors who fear malpractice claims also play a part. They don’t stint on screening, treatment, and prescriptions. And patients with generous health plans often persist in unhealthy habits such as smoking, drinking, overeating, and not engaging in physical activity. In short, the current system is broken.

To be sure, there is a very real problem for low-income Americans who need but can’t afford treatment. Their safety net until now has been hospital emergency rooms. But it will be important to monitor the Affordable Care Act to see if it can strengthen that net without the unintended consequences of overdiagnosis that have infected so much of the rest of the system.

The private-side health-care revolution should nurture individual responsibility. As people shop for value, they should do what all but the most shopaholic shoppers do: Think about what health care they really need before spending. They might find that within their own closet – within a mental outlook that emphasizes health, happiness, affection, and balance – they already have a possession for which they would pay a great price.

John Yemma is editor of the Monitor. He can be reached at editor@csmonitor.com.

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