Sue Lowden needs better health policy advisors

Sue Lowden is very likely to clean Harry Reid's clock this November. [Confidential to political junkies -- yes, that link is to Rasmussen, but in this case their house bias is consistent with just about all the reliable polling out there.] Frankly, this makes me admire Harry Reid rather more, in that he went to bat for health care reform even though it probably doomed his chances of re-election. However, that's beside the point.

Being as it were that Ms. Lowden is probably headed to the Senate, I really hope someone sits her down and explains that health care policy doesn't work this way:
The feathers are flying in the political attacks over Nevada Republican Senate candidate Sue Lowden's declarations that people could control health care costs through the use of barter.

On Monday, Lowden doubled down on the barter idea. "Let's change the system and talk about what the possibilities are. I'm telling you that this works," Lowden said. "You know, before we all started having health care, in the olden days, our grandparents, they would bring a chicken to the doctor. They would say I'll paint your house."

This idea demonstrates a fundamental lack of knowledge of how the current health care system works. I know essentially nothing about Sue Lowden, and I'm willing to admit the possibility that she's a smart woman. But she should not be demonstrating such blatant ignorance.

The only kind of provider that could possibly accept chickens (or any other non-monetary form of compensation) is a private practitioner who owns his or her own office and takes no insurance. (I'm not even totally sure that it would be legal in that case, though I'm not aware of any specific law that would prohibit it.) Back when our grandparents were seeking care, that kind of provider was the norm. These days they are very much the exception.

Once you accept third-party payers of any kind, you are obligated to charge all of your patients the same fees for the same services. You cannot charge insured patients more, or accept non-monetary payments from uninsured or underinsured patients. To do so violates the contractual relationship providers have with the public and private insurance companies, in essence making them subsidize the care of patients not enrolled in their plans. To undercharge based on ability to pay is fraudulent, so I am obligated to document and code for visits uniformly, even when I know the family will have a hard time affording my fees. (Situations like this formed the foundation for my support of the health care reform package recently signed into law.)

Lowden's suggestion was just completely out of touch with how the health care system works. Someone really needs to make sure she closes this gap in her knowledge before she is sworn in.


  1. Once you accept third-party payers of any kind, you are obligated to charge all of your patients the same fees for the same services.

    AFAIK, this isn't a law, but rather an agreement between insurers and medical providers. Insurance companies want to be sure they have the best price, and providers want to attract large pools of insured people. Please correct me if this is wrong.

    The unfortunate result is that the uninsured pay the "rack rate" for services, while insurance companies take large discounts off the rate.[1] This is bad public policy. Here's where Insurance Reform would make sense. Make all such contract provisions illegal -- insurers could not stipulate they get the best rate and no one else be charged a lower price. Make it illegal to require medical providers to charge fixed prices (of course, this will apply to Medicare and Medicaid as well). That is the sort of reform Congress ought to consider.

  2. I am not so sure she will win, this might make her a laughingstock, people will be coming to her campaign rallies with chickens or even bigger farm animals. It really was a truly stupid thing she said.


  3. GJ, I'm not sure exactly what the legal entanglements are. I know that documentation and coding are standardized based on Medicare regulations, so the billing level of each visit is somewhat regimented. As far as uniform billing is concerned, it is largely a matter of contract, but violation of those contracts is a Very Big Deal.

  4. Excellent! So we get Congress to pass a law stating that contract forcing medical providers to charge minimum amounts are illegal on their face, and all such provision are unenforceable as of Jan 1, 2011. Then you can use your judgment as to how much you must charge Little Billy's Single and Poor Mom for that test. What's not to love?

    It really is outrageous that Big Insurance and medical providers collude to make the uninsured pay the absolute highest prices, but the icing on the cake is claiming this behavior keeps insurance companies from subsidizing the uninsured. If anything, the uninsured, if they try to pay, are subsidizing the insurance providers.

  5. please gj, that is just wishful thinking on your part. Doctors have their own nut to crack, once one Doctor has split rates all the local poor might flood to his office making his practice untenable. The point is not to have poor people beg for discounts to get decent care, the point is to ensure all Americans have access to health insurance worth a damn, (I would have loved for there to be a public option)

    So there is a lot not to love in your scheme of relying on the goodness of a local doctor to give away practically free care.