Health Affairs Slams CDHC

Jamie Robinson and Paul Ginsburg have paired up in Health Affairs to take another shot at consumer driven health care. This is one of the most peculiar articles I’ve read on the subject. You can tell which author wrote which part of the piece. Ginsburg (Center for Health System Change) has long been a skeptic who is willing to look at the evidence. Jamie Robinson (UC Berkeley), on the other hand, has been consistently foaming-at-the-mouth hostile. About a year and a half ago he gave a speech to the Consumer Driven Summit where he declared the death of consumer driven health care (CDHC) in favor of what he termed “managed consumerism.” He had a list of about ten particulars, but as we wrote at the time, he was wrong on every single one. He just hadn’t bothered to look at the evidence.

My biggest objection with the article is the way the authors cherry-pick and mischaracterize the available evidence. They try to make the case that high-deductible health plan (HDHP) adoption has been “anemic,” but they do so by purposefully overlooking the available data. They acknowledge that, “The HDHP represents the most important product innovation in health insurance since the point-of-service (POS) product, (but) the HDHP has been a disappointment in terms of actual sales.” To support that idea they cite the America’s Health Insurance Plan’s (AHIP’s) census of Health Savings Account (HSA)-qualified health plans. But AHIP counts only plans that are HSA-qualified. It does not count Health Reimbursement Arrangement (HRA) plans or stand-alone HDHPs. In fact, the Centers for Disease Control and Prevention’s annual National Health Insurance Survey found that over 20% of the under-65 population were enrolled in HDHPs as of the middle of 2008. Ain’t nuthin “anemic” about that. This finding was confirmed by the Kaiser Family Foundation/Health Research & Educational Trust (KFF/HRET) Employer Health Benefits Annual Survey of employers that found 18% of workers are in HDHPs. The authors had the KFF/HRET survey right in front of them and cited it in arguing that only 8% of workers are in “HDHPs with a savings option!” But they didn’t say that “savings options” are “the most important product innovation,” they said HDHPs are. As critics have rightly pointed out, there is no advantage in having a tax-favored savings account for a person who pays no taxes. But the behavioral impact of the HDHP applies with or without the savings option.

Even more astonishing is the authors’ complete disregard of behavioral changes which have been well documented by the parties best positioned to measure it. Just in the past few months reports have been released by the Mercer Company, WellPoint, CIGNA, the Blue Cross Blue Shield Association, UnitedHealthcare, Aon Consulting, and even the chronically skeptical EBRI, all showing that people in CDHPs pay more attention, seek out information, participate in wellness and prevention programs, choose lower-cost treatments, and save substantial amounts of money for themselves and their employers.

If Messrs Ginsburg and Robinson are what passes for scholarship these days, no wonder the country is in trouble.

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