Health Reform and 20-Somethings

In my PolicyMic colleague Jacob Shmukler’s recent series, "Why Obamacare is A Bad Deal For 20-Somethings I & II" the author highlights one of the worst qualities of our generation: our myopic egotism. I say myopic because Shmukler’s articles ignore the crisis of rising cost in health care that demands 20-something pay more attention to their health coverage before they get sick, and egotism because the series highlights the fundamental—and distressingly common—misbelief that young adults can simply opt-out of the health care marketplace (Politico-esque Spoiler: We can’t).

Health care costs have continued their unchecked rise over the last decade at a rate far exceeding the one-percent rise in premiums that Shmukler claims 20-somethings may see under the Affordable Care Act (ACA). In Part I of the series, Shmukler singles out the community rating insurance system as particularly unfair because it leads to higher prices for these individuals. Unfortunately, the alternative to the “community rating” system in health insurance pricing—called “experience rating”— places the heaviest premium burden on the least healthy patients, which only shifts the high-cost burden of health care in America to focus it on older and higher-risk individuals. The scheme might sound good to a relatively healthy 25-year-old, but whatever expenses you might have avoided early in life will come back to haunt you—and your checkbook—by the time you retire.

This economic shortsightedness can be attributed somewhat to the hubris of youth. The moniker “young invincibles” was not bestowed on people our age with a nod toward the vitality and good health of being 20-something. Rather, it’s a reflection of the stupid things we do on Saturday nights and our collectively cavalier attitude toward health care. Substance abuse, questionable sexual encounters, traumatic accidents, and poor diets are the predominant health problems of people in our age bracket. Without access to reliable, insured primary health care, 20-somethings are more likely to let their chronic conditions simmer and intensify until they become acute — read: expensive — illnesses that demand medical attention.

Well-practiced preventive care is simply cheaper than curative medicine, and the benefits can minimize health care costs throughout an individual’s lifetime by obviating the need for expensive, interventional care. Shmukler claims that 20-somethings would rather pay for care out-of-pocket, a position that seems to ignore the realities of hospital pricing, where even simple visits can bill at hundreds or even thousands of dollars for the out-of-pocket patient because of the complex mathematics that hospitals use to spread costs across their patient mix. As a result, industry bean counters often refer to out-of-pocket patients as “self-no-pay” because of the resultant bad debt that clouds hospital balance sheets.

Dark humor aside, the notion that insurance for 20-somethings often covers unwanted or unnecessary care also ignores the realities of the health care marketplace. In short, no matter how much a young invincible believes in her own health, it is impossible to fully opt-out of the American health care system. Since 1986, American hospitals have been legally obligated to treat emergency patients, regardless of their citizenship or insurance status. This is a particularly relevant issue for 20-somethings, who unsurprisingly have the highest emergency room utilization rate of any age group.

Thus, when an uninsured 20-something gets into a car wreck, her unpaid emergency department bill can be shifted to every other patient in the hospital, and eventually, to the taxpayer-at-large. A decision to willfully subject the public to this cost burden seems socially irresponsible and hypocritical for a generation of people who, as this site suggests, are highly concerned with the future of our country and world.

Despite these technical points and, admittedly, more than a few ideological differences in our attitudes toward health reform, Shmukler’s articles point correctly to the need for further changes to our public safety net and entitlement programs. As I described a few weeks ago, the current fee-for-service payment model in American health care incents physicians to treat, not prevent illness, inflating costs by rewarding high volume, rather than good outcomes. To purposefully address the issue of rising health care costs and maintain access for all individuals, the entitlement reform debate that has just begun cannot simply slash benefits to cut costs. Instead, it must also include reimbursement reform and an emphasis on preventive medicine.

Even for 20-somethings.

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Andrew Wickerham

Andrew Wickerham is a medical student at the Tulane University School of Medicine in New Orleans. He completed his Master of Public Health degree at Dartmouth Medical School and his Bachelor's degree in history at Colgate University. He has worked with the New America Foundation in Washington, DC on issues including shared decision-making in medicine and definitions of value and productivity in health care. His research interests include primary care systems, reimbursement reform, and the interactions between young adults and the health care system.

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