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Consumers not the best drivers in health care

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By Froma Harrop
For years, conservatives have pushed for a health-insurance model emphasizing catastrophic coverage. It works as follows:
Consumers pay the cost of ordinary care, such as a checkup, a blood test or an eye exam. Insurance kicks in only for major crises -- a heart attack, cancer requiring extensive treatment, a kidney transplant, intensive care for a newborn.
The Affordable Care Act, also known as ObamaCare, goes in the other direction by expanding Medicaid to more lower-income Americans. Medicaid picks up the bills for the "little things."
Catastrophic coverage and other "consumer driven" approaches won't work as the basis for health reform. But before we go into the reasons why, let's put in a few good words for catastrophic coverage -- and its cousin, the health savings account. An HSA marries a high deductible (paid before insurance starts picking up the big bills) to a tax-favored savings account from which people can tap money for smaller medical expenses.
What we most fear are medical "catastrophes" leading to bankruptcy or the inability to afford appropriate care. This kind of coverage protects against financial traumas. Meanwhile, asking consumers to dig into their pockets for routine care makes them more careful about spending.
Here's the problem: You and I may nod in agreement over the merits of catastrophic coverage. We are informed, and our financial lives are organized. We make it our business to save for retirement. We budget for unforeseen expenses. We know not to rack up big balances on our credit cards.
Other, perhaps most, Americans don't do these things. Or they would if they weren't supporting families on low-paying jobs. Loss of work, death of provider or punishing education costs might leave no budgetary room for a doctor's visit. If the choice were buying textbooks for your child or skipping a physical, which would you do?
Yes, there are those who could easily afford health coverage and don't buy it, preferring to roll the dice that nothing awful will happen. If they lose, they're still let into the emergency room. The responsible ones will pay for their care.
When they're old enough, they'll have Medicare. And if conservatives have their way, forcing more means-testing into Medicare, those who didn't protect their finances by buying insurance will pay less into the program than those who did.
ObamaCare does not get into the backstory of why people don't have health coverage. What it does is make sure they get it. At the same time, it addresses the wasteful spending problem that consumer-driven health plans are supposed to solve. ObamaCare just does it in different ways.
For starters, the health care reforms promote primary care, whereby family doctors help patients avoid expensive specialists when they don't need them. And it would start changing the way medical providers are paid.
Rather than charging a fee for every service, providers would be paid a set price to cover soup-to-nuts care for a particular condition. That would take away the financial incentive to overprescribe tests and office visits. And because doctors don't earn more if their care is substandard and the patient has to return, they have an incentive to do it right the first time.
Consumer-driven health care is still fee-for-service. Patients are the ones to decide when they are being sold too much or too expensive medicine. But how many of us can second-guess our doctor on what treatment we should have?
Doing so may be wise, or it may be dangerous. Thing is, average, or even above-average, Americans probably don't know which. Consumers do participate in their health care decisions, but if they don't trust their doctors to drive properly, they need to change doctors.

Froma Harrop is a Providence Journal columnist. Her email address is

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