Consumer-Directed Health Care and The Disadvantaged

Writing from his aerie as a law professor at Georgetown, M. Gregg Bloche takes a dim view of high deductible coverage, tax-subsidized health savings accounts (HSA’s), recently added to the payment mix for health care in America.  He reasons that the poor and minorities (all too often one and the same) generally earn too little to set aside money in consumer-directed health plans (CDHP), they have imperfect information, they lack access to the best-quality health care, and they may well wind up subsidizing the inpatient costs of the middle and privileged classes.  The author suggests relieving the burden on the poor by providing them more lavish tax subsidies, charging well-off patients more for their health coverage, and giving the poor advantageous prices for “high-value” care.
Where the Case for the “Disadvantaged” Falls Short
Ultimately, Bloche rests his arguments on a shared philosophy of should’s and ought’s, that a civilized society must ensure equal access to the best medical care.  This is a perilous stand, an ideal paradigm of social justice that has extremely elastic boundaries.  As a law teacher, Bloche is concerned chiefly with equity.  Taken to a logical conclusion, such a stand obligates health care leaders to provide addicts disposable needles as the Dutch do (and never mind if they do not want to enter a rehab facility), make injected opioid therapy freely available to heroine addicts (Britain), and permit legal abortion to teenagers without benefit of parental consent (U.S.).  In short, the author may be well-meaning but he presents his case in the realm of political and legal ideology.

America has always stood for protection of the oppressed.  Given how minorities have suffered bias, prejudice and outright repression, Bloche argues, their poverty is not of their own making.  They should not be forced to pay for health care by digging into money they need for basic necessities: food, shelter, and utilities.  This argument is weak in three respects.
First of all, the income disparities are not as wide a gulf as he makes them out to be.  In the 2005 Census, mainstream White households had median incomes of $49,000 (Census Bureau, 2006) compared to $34,000 for Hipics and $30,000 for Blacks. But the real story is that the fastest-growing minority, Asians, recorded a median income exceeding $57,000.  Here is a minority that has endured prejudice and residential segregation too but has pulled itself up by its collective bootstraps in America.
Second, African-Americans may be twice as likely to be unemployed (8%) as Caucasians (4%) but they are only slightly more prone to go “bare” where health insurance is concerned:
In 2004, 55 percent of African-Americans in comparison to 78 percent for non-Hipic Caucasians used employer-sponsored health insurance. Also in 2004, 24.6 percent of African-Americans in comparison to 7.9 percent of non-Hipic Caucasians relied on public health insurance. Finally, in 2006, 17.3 percent of African-Americans in comparison to 12 percent of non-Hipic Caucasians were uninsured (Office of Minority Health, 2007).
While conceding the fact that a good one-fourth of African-Americans rely on public health insurance, the comparable incidence is just 4 percent to 11 percent for Asians and this is notwithstanding the fact that some of the latter are unemployed or live below the poverty line.
Third, Bloche also wears blinders in conveniently ignoring the fact that CDHP’s are only one element in the insurance or subsidy mix that include Medicare and Medicaid.  He argues for subsidies and tiering to favor the poor but, in conceding that these will probably not gain traction, he raises a straw man of despairing liberal ideology without offering a workable alternative.
Hence, the flaw in his argument ensues: ignoring the fact that CDHP’s are voluntary.  In an analysis conducted at one multi-choice firm, Greene et al. (2006) revealed that those who elected the high deductible CDHP (there was a low-deductible option) were healthier anyway and were better educated than those going with Preferred Provider Organizations (PPO).
One concedes that the promise of marketplace reform in lieu of government-imposed restructuring dating from the Clinton presidency has not succeeded yet (Gordon & Kelly, 1999).  Health care costs continue to spiral out of control and there are quite simply not enough physicians and nurses to render meaningful, high-quality care all around.  And yet, Bloche as outsider can perhaps be forgiven for not knowing about the existence of charity wards (overcrowded through they are) and the fine coordinated care that goes on all the time in teaching hospitals.
The latter quickly shows up on the bills of insured and paying patients but may proceed behind the scenes without indigent patients necessarily knowing about it.  For this is, in essence, the most humane of professions.  This is also why Bloche’s fear that those at the frontlines, in emergency and outpatient services, will refuse to at least inform indigent patients about high-value tests and treatments is refuted in daily practice.
One can rely on the innate high empathy of medical practitioners to discern when patients decline care due to cost, and hence to counsel patients that certain “savings” may put them at risk (White, 2006).  In fact, access to high-value preventive care (for e.g., diabetics, the hypertensive, those at risk for stroke) has been addressed by HCA rules that explicitly mandate “first-dollar coverage” for preventive care.  This includes those needed for control of chronic disease (Baicker, Dow & Wolfson, 2007).
That said, talent does go where the money is and paying or well-covered patients have readier access to diagnostic tests and therapies.  Until the government can budget the sums necessary to transform the healthcare system to a welfare state like the British NHS or the Nordic nation models, both White and minority citizens must earn their keep with the kind of hard work, business acumen and economic rewards needed to purchase adequate coverage.
References
Baicker, K., Dow, W. H. & Wolfson, J. (2007). Lowering the barriers to consumer-directed health care: Responding to concerns. Health Affairs, 26(5), 1328-32.
Census Bureau (2006) 2005 census: Household incomes by race. Retrieved March 14, 2008 from
Greene, J., Hibbard, J.H., Dixon, A. & Tusler, M. (2006). Which consumers are ready for consumer-directed health plans? Journal of Consumer Policy, 29(3), 247-262.
Gordon, C.G. & Kelly, S.K. (1999) Public relations expertise and organizational effectiveness: a study of U.S. hospitals. Journal of Public Relations Research 11, 143.
Office of Minority Health (2007) Asian-American profile. U.S. Dept. of Health and Human Services. Retrieved March 14, 2008
White, B. (2006). How consumer-driven health plans will affect your practice. Family Practice Management, 13(3), 71-8.

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