The GREAT BIG Elephant

Perhaps the biggest elephant in the healthcare room is the cultural one.  Until we address the cultural problem in healthcare, all other problems are nothing more than a distraction.  Denial about the nature of our cultural problem is, to me, both undeniable and unbelievable.  Consider some examples:

Every 5,000 miles you change the oil in your car. Why?  Because it helps the engine last longer and ultimately reduces maintenance costs for your car.  Does your car insurance pay for it?  Of course not.  You pay for it yourself.  In fact you have absolutely no expectation that your car insurance will pay for it—perhaps because it never has.

So why does your dental insurance pay for you to have your teeth cleaned twice a year? The answer I’ve been offered by the dental insurers is that over the years they found that if they encouraged you to clean your teeth (by paying for it), it would reduce the number of cavities you get and would therefore save them money.  Perhaps that’s true.  But why then do you get your oil changed at your own expense?  I think it’s because if your engine fails, your insurance doesn’t pay for that either—you do; so you invest in avoiding it.  But if you get a cavity, your insurance does pay for the repair, so people don’t worry as much about that cavity (hard as it is to believe, it’s true).  Even at the office the cultural problem is rampant. For example, if you miss work once a week because your car keeps breaking down, that’s a problem that could ultimately lead to the loss of your job. But if you miss work too often because you’re at the dentist having things fixed because you failed to take care of your teeth, that is a legitimate medical absence and it would be improper to penalize you for it.  Why are the two situations so different?

Before you answer, ask yourself if your answer is how you really feel, or is it derived from a lifetime of biased expectations.

While from the dental insurer’s perspective, offering to pay for teeth cleaning might have been a good idea at one point; but then the law of unintended consequences clearly struck. Over time, we’ve come to EXPECT that insurance will pay for it. 

Another example:  a knee replacement.  Knee replacements average between $20,000 and $30,000 depending on where you live.  A knee replacement can lead to a remarkable improvement in your overall quality of life by eliminating pain, allowing you to participate in enjoyable activities (golf, or tennis, perhaps) and may even forestall other health issues because you’re more mobile and get more exercise later in life.  Yet while a couple might choose to borrow $30,000 on a home equity line of credit to remodel a 30 year old kitchen, the idea of borrowing $30,000 on a home equity line to remodel their knee sounds absurd.  While I agree that there are some who don’t have the $30,000 to borrow and that we need to figure out how to help them as well, the cultural expectation that insurance will pay for it cannot be denied.  So while we expect our medical insurance to replace an outdated knee, no one expects their homeowner’s insurance to replace an outdated kitchen.

I saw an interview recently where an older Medicare recipient said, “I’m going to get everything done that they’ll pay for—because I can.”  This is what happens when we start out helping those who can’t help themselves and over time allow things to turn into entitlements.  Medicare was designed to be an insurance policy.  It’s turned into a huge entitlement. The cultural ramifications become increasingly embedded in our psyche with each passing generation.

Now don’t get me wrong.  I am not suggesting that we don’t need to overhaul our healthcare system.  In fact I’m actually a proponent of universal coverage (as long as we cover the right things) and I’m happy to pay higher taxes to ensure those who need help get it.  But I’m not happy to pay for you to have your teeth cleaned. Anyone with a job can make the $150 a year for teeth cleaning a priority over spending on something else.  And I’m not happy to pay for you to have your knee replaced while you spend money refurbishing your kitchen.  I’m not happy to pay for your well-child care so you can go on a summer vacation.  And I’m not happy to pay for your prenatal care because you’re too irresponsible to take care of it yourself.  And while I’m happy to pay $2,000 for you to have your broken leg set because you don’t have it right now, I see no reason why most people can’t pay that back over the next couple of years.  You borrow money so you can have a nicer car than you need. Why can’t you borrow money to have the leg that you do need? There’s a difference between a chronic condition that costs $30,000 a year in medications and a one-time $30,000 knee replacement.  And there’s a difference between a heart attack and a broken finger.  Insurance should be there to cover catastrophic and chronic needs. It should be there to help offset the extreme cost of things that are unexpected.  But if everyone is to ultimately have their knee replaced, then we haven’t really set up a “risk sharing” model; we’ve just set up a warped loan program where we pay into an insurance fund instead of repaying a loan on our knee (or better yet, pay for it with the money we’ve saved).

Insurance certainly has a place in society.  Catastrophic coverage pays for our home when it burns down, our car when we crash into a telephone pole, and it even helps us out with a limited income when we’re out of work.  These are all terrific uses of insurance.  But when insurance starts paying for things that we can pay for ourselves, when it starts to become an entitlement versus a protection, and when we start making decisions about whether to take care of ourselves and our families based on whether insurance will pay for it, we’ve gone too far.  That’s what’s happened and it will take a generation or more to reverse the trend—assuming we acknowledge the problem and start trying to address it.

The bottom line is that until attitudes about healthcare change, the focus on competition, waste, and the role of government are of little significance. The problems as most see them today are literally unsolvable under the existing paradigm.  We need much bigger change—and despite all the rhetoric, we haven’t even begun to broach the subject in any real way.

Comments

[mike]

Do you realize cars have warantees? Some of those warantees such as BMW include free oil changes and maintanence.

A car breaking down is a poor excuse for missing a whole workday since there are alternative methods of getting from one place to another.

You have made me wonder why if a motorist hits me and damages my teeth why his car insurance pays and not his dental insurance, or why my dental insurance wouldnt pay the victims of me getting too inspired by that twilight vampire movie.

[mike]

From a public health perspective, threatening to raise one's dental insurance rates every six months if they dont get a professional cleaning and inspection is better than merely giving them the oportunities to clean and inspect them without cost.