This author has been an advocate of healthcare even before it was fashionable.
Robin Williams jokes that he comes from an area in California where pets get better healthcare than 80% of the rest of the country's citizens. So it was with some pleasant anticipation that I looked forward to the political rhetoric of the 2009 campaign turning into some kind of reform platform. Even if it wasn't perfect, it had to be better than what we had, and at least someone was trying.
Another of my philosophies has been that people will do what you reward them to do. Sounds simple enough, but it is amazing to me how often politicians forget that. Insurance companies figured it out long ago, when they started surcharging policyholders who have unhealthy habits. I have had a lot more patients quit or try to quit smoking due to their insurance coverage surcharge premiums than because of all the education I have been doing over the years. Once it cost more to cover the whole family because someone was a smoker, it wasn't so attractive any more. Forget that Junior's asthma was made worse, Susie's allergies were aggravated, and chronic cough annoyed everyone and kept the spouse awake. But charge people enough extra for their coverage and in they come for help to quit.
A patient I will call Kevin came in after 4 years of no visits. He had been an athlete in high school, I had seen him every year for sports clearance, and we had treated his rather severe acne. Now he was 23 years old, a part-time employee of a large grocery chain, and going to college while living at home. Thanks to the Patient Protection and Affordable Care Act, he was now covered under his parents' insurance again, having been previously "kicked off" at age 19. Although we did not find any new or life-threatening health problems, his acne had been affecting his social life and his work life, and he wanted to be treated again. The lack of insurance had kept him from coming in or even calling for medication refills. And he was supposed to have regular echocardiograms, following up on a mild-moderate mitral stenosis. Not having any symptoms, he had been forgoing this testing as well.
Not 2 days later, in comes a young woman I will call Mallory. She graduated from college 2 years prior with a degree in nursing, and she was working full time at our hospital. But she had different insurance than the hospital provided. I asked how that could be. Had she gotten married without telling me and not changed her name? She explained that her mother, a teacher, was under the school's insurance, which was much better coverage than hers. And because she was only 24, she could be covered under the school's plan and get a cash-based payment from the hospital in place of her own coverage to boot!
At first I was appalled. Our school districts are so strapped, and here she was, using the system to her advantage at their expense. But then I applied my philosophy: Yes, people will do what you reward them to do.
Was it legal? Sure.
Was it ethical or moral? I am not so clear.
So what is my point? This outcome should not have been very hard to foretell. Unfortunately, most of our laws are written and passed by citizens who do not live in the real world. I have heard Washington, DC, described as "70 square miles surrounded by reality." So this kind of scenario is apt to be repeated many times over before the kinks are worked out of the program. We just have to be sure that while we are attacking the long overdue problem of healthcare reform in this country, we do not incentivize people the wrong way.
The author practices family medicine in Muskegon, Michigan. She is also a member of the Medical Economics editorial advisory board. Send your feedback to firstname.lastname@example.org