Coverage and Care: Two Very Different Things

Monday provided us with a wonderful opinion piece in The Philadelphia Enquirer. It was written by a physician and lawyer who is also a visiting scholar at the Georgetown University Law Center named Caroline Poplin.

Have you noticed that presidential candidates assume that universal health insurance means universal health care? They use the terms interchangeably. They assume that once the law enables or requires everyone to buy health insurance, everyone will have adequate health care.

But anyone who has been seriously ill or cared for a sick relative knows that while health insurance may be the solution, too often it is part of the problem.

In fact, health insurance and health care are two different products for two different markets. Health insurance is for healthy people. Health care is for the sick. What we need to lead full, productive lives is good health care.

Dr. Poplin goes on to address the oft invoked example of auto insurance. While it has come up repeatedly in debate, I am not aware of a more concise comparison than the one presented here.

There was a time when health was like driving. Illness or injury was sudden, unpredictable and brief. You either recovered, or you died. Medical care was not expensive, and (surgery apart) not terribly effective. Insurance did not cover doctor visits for minor problems or for physicals, any more than car insurance covered routine repairs.

Since then, medicine has been transformed. Many people no longer die from heart attacks, pneumonia, cancer, even HIV/AIDS; they may live many years if they are treated promptly, aggressively and often long-term.

These patients are no longer average drivers. They have "pre-existing conditions" and are thus at high risk for predictable, serious, expensive, often chronic complications. A diabetic patient is at high risk for heart attacks and kidney failure. Many cancer patients are at high risk for pneumonia. Even someone with uncomplicated high blood pressure is at increased risk for heart attack and stroke.

Commercial insurance was never designed for situations like this. No one sells flood insurance for a house that regularly floods.

So insurers routinely exclude pre-existing conditions from coverage. Most commercial health insurance, like car insurance, is intended for one-time, unpredictable expenses.

But people with pre-existing conditions, the chronically ill, are exactly the people who need health care the most. They can get it now only if they qualify for public programs like Medicare, or they work for large employers who can spread their expenses over a large, mostly healthy, workforce. The chronically ill are disproportionately uninsured.

Since five chronic diseases account for 75% of all health care expenditures, this should be cause for alarm. As noted in Health Care Reform Now!, management of chronic conditions is cheaper by several orders of magnitude than emergency room visits. Asthma, for instance, requires only a few hundred dollars per year to manage, but one ER visit caused by an asthma attack can skyrocket past the $20,000 mark.

SOURCE: "Health insurance and health care are not the same" 02/25/08
photo courtesy of takomabibelot, used under this Creative Commons license