Along with all the other horrors a person endures while attempting to navigate America’s healthcare system—surprise medical bills, incomprehensible insurance claims, administrative misunderstandings, inadequate care—the last decade has thrown a new one onto the pile: a consumer choice model that pushes patients to price shop in order to meet their medical needs. You could say that it’s doubly cruel to subject people to an obtuse and expensive system, and then implicitly blame them for not finding the best bargain when they die. You would probably be right.
Despite the current political popularity of this model, two recent studies in the journal Health Affairs reiterate what others have have anecdotally shown: the consumer-focused model of cutting costs in healthcare doesn’t make much of a difference when it comes to how often or easily Americans see doctors, and in some circumstances it may be preventing them from seeking care at all.
For all the changes the consumer-driven model has brought over the last decades, the effectiveness of treating medical care like an opportunity to bargain shop is still very much in dispute. In this month’s issue of the journal Health Affairs, a study confirms what a reasonable person might have already surmised: Consumer choice in health care isn’t the same as a trip to Costco, and it could actively be preventing Americans from receiving care. The survey, which looked at a sample of people with high deductible health plans, found that fewer than 15 percent of patients reported comparison shopping at different facilities or compared “quality metrics” when seeking care. A mere 7 percent had tried to negotiate the price of a doctor’s visit—still a truly incomprehensible idea for anyone without a medical background and extensive experience with the healthcare system. As the study noted, most people think haggling is insane, or that trying to bargain with a healthcare professional won’t work. This is, after all, an industry of providers, paper-pushers, and administrators who have created an entire $3.5 trillion dollar-a-year market based on the idea that they know best. As the article succinctly noted: “perceptions of futility were common impediments.”
As Axios added when it wrote up the study rather dryly, a previous study published in the same journal found the only real impact among medical bargain shoppers affected women cancer patients. Either too broke or too overwhelmed by that “perception of futility,” patients of that type with high deductibles would simply delay care for MRIs and other imaging procedures. As lovely as it might be to imagine that a terrified person with a life-changing illness would find solace in the American tradition of voting with their dollars, that isn’t the case. So instead, people in the United States go without necessary care, go into debilitating levels of debt in service of treatment, or die. Sometimes they do all three.
America wastes an estimated $765 billion a year on medical care, and often the lavish expenses are shown to be the result of a systemic failure: medications and supplies are trashed though they’re still useful, hospitals charge flat fees for tests or routine procedures that vary widely between institutions and have little bearing in objective reality, pharmaceutical companies jack up prices to increase profit margins. But one strain of reformist policy sees a simple solution in the dogma of the free market and individual choice. It is certainly easier, from a regulatory standpoint, to believe individual spending is the problem.
The “consumer choice” model has had a resurgence under the Trump administration, but it isn’t new: you saw the same thing in 2003, when the Bush administration introduced the health savings account (HSA), a tax-advantaged program in which an individual, their employer, or a combination of each could dump money to save for a future medical emergency. More than a decade later, the Trump administration proposed legislation that would expand the same program, using the logic that watching a bank account shrink or expand would make a person who needs care more conscious of what staying alive in this country costs. And you scan see it today, as this ideology has been embraced as the solution to our very messy set of problems: “Health care bills are too complex, choices are too restrained,” wrote the Department of Health and Human Services in December, proposing “we remove and revise certain federal and state regulations ... that inhibit choice and competition.”
In practice, these directives ask sick and often terrified Americans to spend more time on their own administrative management. Hospitals, for example, are now required to post nearly incomprehensible spreadsheets detailing what an individual procedure costs, as if a person in pain would be indexing the price for a “menstrual & other female reproductive system disorder” across different medical providers before they decide to get help.
Health savings accounts have become so popular that one-fifth of Americans with employer-sponsored health plans have one. Concurrently the data in the 2018 Kaiser Employer Health Benefits Survey shows that over the last decade the percentage of employees with individual deductibles of $2,000 has grown strikingly every year. Programs like HSAs have skyrocketed parallel to the high deductible model, a development that simultaneously places more of the responsibility for healthcare costs on patients and reduces the incentive for insurance companies to offer comprehensive plans.
Essentially, it’s gotten more expensive for Americans across the economic spectrum to see a doctor. Instead of treating this as a genuine fucking crisis, the problem has been politically conceptualized as an opportunity for people to seize their own destiny with their own wages. Even Utah’s legislature approved a measure recently incentivizing its public employees to fly to Mexico and use their savings for prescription drugs there. They called the bill, perversely, the Health Insurance Right to Shop.