by Jule Klotter
It’s no surprise that health care affordability is still a hot topic for the Democrats seeking the 2020 nomination for president. Health care costs for pharmaceuticals and services continue to rise, straining the budgets of many. Single payer and optional Medicare-for-all are some of the ideas proposed by the candidates. But will it make a difference? After all, the Affordable Care Act was supposed to solve this problem.
The US—unlike other countries—shies away from using cost-effectiveness data to make decisions about health coverage. As physician Aaron E. Carroll explains in his December 2014 editorial, one way to assess cost-effectiveness is to divide an intervention’s cost by the number of quality-adjusted life years (QALYs) it typically produces.1 Countries such as Britain consider QALYS and cost-effectiveness along with benefits and risks when recommending an intervention’s coverage by the National Health Service.
The Affordable Care Act mandates that insurers must cover all services rated A or B by the US Preventive Services Task Force (USPSTF) without any cost sharing by consumers and cover all vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP). In their analysis of effectiveness, these two agencies very rarely consider a preventive service’s cost-effectiveness. “That means that we are all paying for these therapies [in the form of insurance premiums], even if they are incredibly inefficient.” Says Carroll.
US legislators refused to include cost-effectiveness in the affordable care legislation because of fears about health care rationing. I remember articles, at the time, in which citizens voiced worry about “care rationing” and not being able to get the treatments they wanted. The legislation did, however, authorize the Patient Centered Outcomes Research Institute (PCORI), a nongovernmental organization, to perform comparable-effectiveness research.2 Oddly, PCORI states on its website that it will not fund any proposed research that includes a formal cost-effectiveness analysis or directly compares the costs of alternative treatment approaches. The organization will fund studies that look at the effect of a treatment’s direct cost to patients, such as out-of-pocket, hardship, or barriers to care access. Apparently, insurers’ costs that get passed onto consumers via higher premiums are not an issue.
I was recently part of a conversation about single-payer health care. A resident of Washington, DC, was all for single-payer idea. A retired Air Force nurse and I were far more cautious. If medical industry lobbyists write the plan—any plan—cost-effectiveness will never enter into coverage. The real entities worried about “care rationing,” in my opinion, are the medical, drug, and insurance industries. Can we fix this? What do you think?
- Carroll AE. Forbidden topic in health policy debate: cost-effectiveness. New York Times. December 15, 2014.
- Klotter J. Shorts: Cost-Effectiveness. Townsend Letter. January 2016;25.
