High Insurance Health Plans/ HSAs and the Logic of Neoliberalism

This post could have been called, “And then they came for me.”  My employer is self-insuring and has experienced recent spikes in health care costs.  Several years ago, employees saw their premiums rise considerably and last year they rose even higher.  To respond to employee frustration with these increased costs that employees were asked to shoulder, my employer has now begun to offer high deductible health plans (HDHPs).  HDHPs offer free preventative care, but everything else for the first $6000 or so (plans vary) must be paid out of pocket, negotiated at the insurance company’s rate, by the patient.  After that, patients are responsible for 20% of costs.  Alongside the HDHP, patients can set up a Health Savings Account (HSA).  Patients can place a pre-tax portion of their paycheck into the HSA and draw on it through a card, like a flexpay account, but this account rolls over year to year.  My employer is putting some money each year in each person’s HSA who chooses to take it.  At this time, employees still have the option of taking the high premium regular insurance.

I have signed up for the HDHP and an HSA.  The HSA is managed by a third party company, Employee Benefits Corporation who is paid by my employer to manage the HSA.  Several days ago I received an email from Employee Benefits Corporation.  The first line read, “Congratulations, this is your important first step to becoming a better healthcare consumer!”

From what I have described you can see how the HDHP and the HSA are meant to encourage patients to think of their health care as consumers and not as patients.  This plan is how Republicans want to address health insurance coverage.  Such a plan supposes that patients should think of health care as consumers who have to make wise chooses about how to use their money.  I already started thinking like that in the transition to the HDHP.  In December, I had a test done that I probably would have waited on and maybe never had done if I would have had them covered in the New Year, but I knew that I wouldn’t have coverage in the New Year.  I also got a prescription filled early in order to get it filled under the previous health insurance coverage.

I have already begun calculating whether I should go to follow up appointments about various issues I have.  For example, I have a Morton’s neuroma in my toe.  Last year, I went to a podiatrist, who gave me a cortisone shot and had orthopedics made for me.  This treatment allowed me to keep running and working out and so made me healthier.  I am beginning to feel the cortisone shot wear off and find myself backing off certain workouts.  Thinking about healthcare like a consumer and considering whether to save money could likely make me less healthy.  Not only might it prevent me from dealing with something that could prevent me from certain cardio impact workouts, it could keep me from pursuing diagnoses of issues much longer than it should.  I’m already someone who doesn’t go quickly to the doctor.  I had been experiencing constant pins and needles in my right arm for two months before I went to the doctor.  Treating health like a consumer is likely to make people less healthy.

But this type of plan is typical of neoliberal approaches to social problems.  It makes individuals responsible for something that is not really in their control, like their health (and health care costs), and it transforms more vulnerable people into even more vulnerable people.  If you do not have the money to contribute to your HSA, and so cannot pay out of pocket, and you live in environments that are more conducive to disease and illness because neoliberalism has rolled back regulations (see Flint and a bunch of other cities), then you are more likely to get sick through no fault of your own and less likely to be able to get medical care.  But you are held responsible for that situation (then you are held responsible for the ways you deal with it, like alcohol or drug use).  If neoliberal thinking sees all problems as having market solutions, then human beings are taken in every way of being–as learners, as patients, as citizens–to be consumers.  Patients are not consumers, though.  As vulnerable beings, we will falter and become sick.  This sickness is generally beyond our control.  The decisions we make should be about how to get better, not how to best save money.  Getting better might mean spending lots of money.

I know what they mean about being good consumers.  Atul Guwande describes “The Cost Conundrum” as what happens when providers see health care as an opportunity to make money, describing Doctors’ Hospital in McAllen, TX (where I used to live) as making decisions to increase costs because doctors were partners in the hospital.  So at Doctors’ they order a lot of tests.  (I once went to another hospital in McAllen, and tried to resist having certain tests done, and it was really hard to get them to agree not to do tests that I thought were not necessary – is it really going to be easier when I have an HDHP?)  The thinking of the HSA seems to make patients responsible for what doctors and insurance companies have done–made health care into a profit-making ordeal.  Instead of regulating the industry, the HDHP and HSA situation makes the patients responsible for driving down costs.  This is absurd.

In the United States, whenever people begin talking about nationalized health care, opponents start yelling about freedom.  They talk about how people in national health care systems are given limited options and have long waits to see doctors.  The second point has been pretty well debunked.  But the first confuses the meaning of freedom.  First of all, insurance companies are already limiting options.  My insurance company told me when I got the recent test done that I had done, that if it were filed under one code it would be covered but under another code it would not be covered.  They wouldn’t tell me which code was which.  But second, having the possibility of paying a lot of money for a fancy doctor in order to get any treatment you want without actually having the money to get any treatment at all is not freedom.  This is the absurd conclusion of the position that freedom = more choices without concern with having the power or the means to secure those choices. Instead of the choices, let’s have the power to have basic health care.