Cadillac or Prius healthcare?

Reuters' Maggie Fox has filed a report today called "No 'Cadillacs' in US healthcare reform proposals". She gives an example of a BCBS plan that is considered by most a "Cadillac" of healthcare coverage, but, alas, upon closer scrutiny leaves many gaps in the high-end disease coverage. She also describes the familiar rhetoric employed by the American Cancer Society's Cancer Action Network, the political action arm of the ACS. ACSCAN President Daniel Smith is quoted as saying that "too many cancer patients are delaying or forgoing lifesaving screenings and treatments because of access problems". This is interesting use of the word "access". We are used to equating coverage with access, but in this case the CAN statement refers to coverage limits set by the insurer, and advocates for swift healthcare reform to remedy this.

But should the intent of healthcare reform be to bring us closer to "Cadillac" coverage? I do not think so: we need to aim for the efficiency of a Prius. The amount of unnecessary and even harmful interventions is staggering and increasing every day. Because currently healthcare is a business that relies on traditional market forces, its implicit purpose is to generate revenue. And while there is tension between purveyors of gadgets and procedures and the payor, a critical approach to coverage is viewed with suspicion by the consumer. Take, for example, screening mammography for low-risk women between the ages of 40 and 50 years: although experts admit that there is little evidence for its value, it is political suicide for the payor not to cover it. The PSA story is similar, as is cholesterol screening, and many other tests and treatments we undertake with blind acceptance.

So, if Mr. Smith is truly worried about access, he and his organization need to take a step back and support evidence-based, rather than politics-based, decision making in healthcare. Universal access should never mean that all of us can get every test or treatment on the market, no matter how marginally effective or ineffective it is. Universal access means using critical thinking to make rational choices.

Bioethicists' litmus test for recognizing rationing is the question "would you do it if it were free?" I would guess that if all of us were well informed about the seamy side of doing "everything", we would refuse many an "evidence-based" recommendation that medicalizes our lives in favor of healthy and happy living. The result? Fewer worried well, less preoccupation with transient ailments, and yes, a lower overall healthcare bill with money left over to cover everyone for what they truly need. And, Maggie, Cadillacs are so 20th century!