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The Agenda

NRO’s domestic-policy blog, by Reihan Salam.

Misconceptions About Consumer-Driven Health Care



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Consumer-driven health plans, or CDHPs, are a relatively new concept. In the United States, they were basically nonexistent until 2003, when the Medicare Modernization Act—the one that added the prescription drug benefit to Medicare—legalized them (with significant constraints).

Since 2003, the growth of CDHPs has been explosive. Prior to the passage of the Medicare Modernization Act, several hundred thousand people were on such plans. In 2009, over 10 million people were enrolled in consumer-driven health plans. Barring a PPACA-driven regulatory strangle, the rising cost of health care will continue to drive both employers and individuals into these popular, cost-effective plans.

The novelty of CDHPs has led to many misconceptions about their qualities and flaws. One is that CDHPs place a greater burden on individuals for the cost of their medical care (i.e., increased cost-sharing). Here’s Austin Frakt on the topic:

Many suggest that the solution to our health care system’s problems is to be found in a more market-based approach. Consumer-directed health plans are at the center of this concept. If you make people spend more of their own money, they’ll be more prudent users of care and seek better value at lower prices…About now you’re thinking I disagree with the notions I just expressed. Actually I don’t. They have merit, which I recognize, accept, and support. Where I take issue is that they are not solutions to all the problems in our system.

Certainly Austin is right that CDHPs are no cure-all. And it is true that many free-market types, myself included, advocate more cost-sharing, especially in situations where the government is subsidizing health care (e.g., Medicare and Medicaid).

But it is important to understand that CDHPs do not increase the cost burden to the individual. Rather, they increase the degree to which individuals control their own health care spending.

Take your plain-vanilla, everyday, traditional employer-sponsored health insurance plan. Such a plan might be designed so that of every $100 that the insurer spends on the beneficiary’s health care, the beneficiary has to spend $18, through a combination of deductibles (i.e., dollars spent before the insurance kicks in), co-payments (dollars spent on an individual service before the insurance kicks in), and co-insurance (dollars spent, on a percentage basis, for a particular claim).

What CDHPs do is transfer control of much of that $100 to the beneficiary. Instead of the individual paying $18 and the insurer paying $82, in a CDHP, the individual (by way of lower premiums) or his employer (by way of a direct contribution) puts a portion of that $82—say $30—in a tax-free health savings account. The degree of actual cost-sharing, at $18, can remain the same. So in a CDHP that is actuarially identical to our traditional plan, there might be $18 of cost-sharing, $30 in a health-savings account, and $52 paid out directly by the insurer.

There are three critical differences, in our example, between a traditional plan and the consumer-driven one. First, that $30 is controlled by the individual, giving him an incentive to shop for high-value, low-cost care. Second, if the beneficiary remains healthy over the course of the year, he gets to keep that $30 and roll it over to the next year. (In traditional insurance, those savings are simply handed to the insurance company.) Third, individuals can invest the savings they accumulate in their health savings accounts, harnessing the power of compound interest.

A plan that seeks to increase cost-sharing, whether a traditional plan or a new-age CDHP one, would increase that $18 to a higher amount, say $25. But there is nothing inherent in CDHPs that requires increased cost-sharing. Indeed, because CDHPs save money even with equivalent cost-sharing to traditional plans, one could in theory offer more generous insurance through the CDHP approach for the same expense.

There are other misconceptions about CDHPs, e.g., they will motivate people to forego necessary care in order to save money. The actual experience of insurers who administer CDHPs rebuts these fears. What we see instead is substantial increases in preventive care (by 4 to 23 percent), increased prescription drug use (especially of generic drugs), and better compliance with evidence-based medicine (i.e., medicine’s best practices as established by the largest, best-run clinical trials).

My praise for CDHPs should not be taken to mean that such plans are perfect. As with any innovation, technical issues have arisen with some plans (read these blog posts by John Graham and the gentlemen at InsureBlog for more detail). The market, if allowed to function, can help shake these issues out over time. More problematic is the fact that the Medicare Modernization Act, the very law that legalized CDHPs, places significant restrictions on the way these plans can be designed, constraining the degree to which insurers can tweak plans and increase their efficiency. By law, a consumer-driven plan must have a deductible floor ($1,200 for an individual in 2010), a cap on annual out-of-pocket expenditures ($5,950), and a limit on HSA contributions per year ($3,050). In effect, these rules constrain the degree to which health savings accounts can drive value-oriented health care consumption.

Congress should lighten these constraints; instead, Obamacare added further ones. Worse still, the fracas about medical loss ratios under PPACA is critical to the future of consumer-driven health plans. The Department of Health and Human Services has yet to rule on whether or not health savings accounts will be counted toward the law’s MLR targets. If they are not, consumer-driven health plans will become de facto illegal. We can only hope that Secretary Sebelius takes a sensible approach.



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