A better Obamacare conversation

May 14, 2014

Obamacare is the Obama administration's singular legislative achievement, a major win squeezed out of a tough fight with an opposition Congress. Years later, the fight continues. The president's political opponents disparage the health-insurance reform law; his allies defend it. If your understanding of Obamacare comes from politicians, you mostly hear either that it's great and should be built on or that it's a travesty and should be scrapped.

What if we listened to medical experts instead? Gilbert Welch, who wrote Overdiagnosed, recently highlighted a problem with the law: insurers now pay in full for screening tests, as part of Obamacare's emphasis on preventive care. But diagnostic tests—those motivated by actual symptoms—tend to go in the deductible and co-payment columns. So, this happens:

A woman over 40 can have a free screening mammogram. But if she notices a breast lump and goes to her doctor to have it evaluated, she’ll pay for a diagnostic mammogram. That could cost $300. So the woman at lower risk for cancer — the one with no signs or symptoms of the disease — has an incentive to be tested, while the woman at higher risk — the one with the lump — faces a disincentive.

Does that make any sense? No. But it could encourage women with breast lumps not to report their symptoms.

Welch proposes making both types of tests subject to the same sort of cost sharing. Single-payer supporters Don McCanne and Ida Hellander echo Welch's diagnosis but flip his prescription: screening and diagnostic tests alike should be free to the patient. At issue is the relative importance of two different problems in health care: some people use too much care; others don't use enough.

What emerges is an interesting question about how best to improve Obamacare—which is more than we've been getting from most elected officials. Welch's article simply identifies a shortcoming in the law and proposes a way to fix it. The fact that this alone makes it a refreshing read says a lot about how low the politicians have set the bar on this subject.

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