Yep, and both perspectives are important. A couple of thoughts.
I appreciate CH's experience a lot, but one quibble I have. While I certainly agree that cost share affects utilization, I don't believe that utilization in and of itself is a major problem. Our utilization is largely in line with other developed countries with far cheaper and better health care systems. The primary problem is costs. I have no doubt that increasing cost sharing would decrease ED visits, and we know from the Oregon Medicaid study that increased coverage does not decrease, and in fact, may increase ED visits. But I think cost sharing is the wrong lever to press.
One, ED visits cost far too much, which needs to be addressed.
Two, many of the patients who take advantage of heavily subsidized or free care end up in the (more expensive) ED due to education and access issues, or other failures of our social safety net. Congress steps on its own dick when it does things like
letting funding for community health centers lapse, where many of these patients could potentially be treated far more cheaply and stay out of the ED. Hell, cities have gone so far as
to pay peoples' rent! because it is cheaper to house the homeless than continue to treatment in the ED.
Three, we have good evidence that patients are already delaying care and suffering significant hardships due to costs. And not just anecdotes like the guy who won the lottery and finally was able to afford the doctor, only find out he had stage IV cancer and died shortly thereafter, but larger datasets that shows things like
spikes in health care spending after tax refunds are available, and there have been mountains of data published on the financial toxicity associated with illness in our country (
an example for patients with cancer).
Finally, to this quote from above
Primary care, chronic condition management, emergency/trauma care, and preventive visits should be free for everyone. Very few people are going to overutilize those products, and more primary care and prevention utilization drives costs down in the long run.
I agree with your first sentence, but for a different reason. Many people (myself include, previously) believe that preventive care drives down costs. The data actually don't support this.
There was a good piece in the Upshot about this the other day. But even if it isn't a cost saver, it's still the right thing the do. The last lines from the piece:
But money doesn’t have to be saved to make something worthwhile. Prevention improves outcomes. It makes people healthier. It improves quality of life. It often does so for a very reasonable price.
There are many good arguments for increasing our focus on prevention. Almost all have to do with improving quality, though, not reducing spending. We would do well to admit that and move forward.
