This may not shock anybody, but a new paper from Health Affairs finds that consumer-driven care -- also known as the Republican Party's answer to universal health care -- "would probably widen socioeconomic disparities in care and redistribute wealth in 'reverse Robin Hood' fashion, from the working poor and middle classes to the well-off. Racial and ethnic disparities in care would also probably worsen."
The reasons for this are largely issues we've talked through in the past. Health Savings Accounts and their ilk are attractive to the healthy, unattractive to the sick, and thus worsen "risk segmentation" in the market. Without healthy individuals subsidizing sick folks, more sick folks will be priced out of care. It's possible that attracting health individuals would actually lead to a net increase in those with something called "coverage." But the losses would be concentrated among those who most need health insurance.
The paper also brings up a finding from the RAND health care experiment. Cost-sharing didn't affect the health outcomes of most participants. But among the poor, higher cost sharing resulted in "elevated death rates, worse control of hypertension, and other inferior health outcomes." We now know, though, that a large number of participants in the cost sharing plans dropped out when their health took a turn for the worse. Going by the rules of the experiment, upon dropping out, their insurance reverted back to its pre-RAND state. So those who dropped out, we can infer, had pretty good insurance, which probably means they were high-income. Low-income folks don't generally have good insurance, and so they stayed in -- and showed worse health outcomes. So we can both say, with some certainty, that consumer-driven care will result in worse outcomes for the low income, and suggest, with good reason, that that result is generalizable up the income scale.
I also want to highlight this argument about consumer-driven care and coordinated care, which I'll quote in full:
