The copay assumes the 99% treat healthcare like spiteful buffet gorgers


You know, not discouraging people from having the occasional check-up to catch problems early saves money in the long run.


If I see the doctor for a particular ailment , I’m somewhat concerned about having them order extra tests because ‘I’m that age’ and I’m also overweight. I’m not there generally for you to go on a fishing expedition if I show up with a sore knee; I’ll pass on the colonoscopy, blood tests, etc. unless there’s a solid reason. I’m also not interested in the copays for said fishing expedition.


Ah boingboing. 100% behind science, right up until it disagrees with what you already believe.

No attempt at an argument against the economics of it, no attempt to find economic arguments that oppose copays. Just dismiss the entire science of economics, because you know better.




If economics was a science you would have a good point.


If you are above a certain age (50) thats probably not a good idea.


I know this is a waste of phone charge but…

Do you personally know or have dealings with any heroin or synthetic opiate users?


People are greedy and will overuse free things.

Talk to some doctors about people who demand an MRI for every twinge and ache they come in for and talk further about why doctors over prescribe tests to protect themselves from endless massive lawsuits for malpractice if they don’t.

Or talk to ER doctors about the oddballs who wander in at four in the morning for something really minor that’s been bothering them for days and which could have been handled by a regular doctor or an urgent care clinic for a tenth the cost but they decided that late night visit was the best time to do it because, hey, they won’t be paying for it.

Same reason car insurance has deductibles; So you don’t run to them every time there’s a half inch ding in a fender.


Ironic title, Corey. Some thirty-five years ago health care economist Uwe Reinhardt wrote a great essay called “Table Manners at the Health Care Feast”. And blaming the patients was barely on the menu then.

It’s not just the austerity. Here is why copays for healthcare display neoliberalism at it’s worst (which is admittedly hard to do): Neoliberalism obliterates the distinction between private goods and public goods. There are some truly private markets where price sensitivity still sucks but isn’t intolerable. Despite the inexorable crappification of airlines, being able to score affordable tickets is not a bad thing. But …

Do I need a Beemer or a Benz? No. Will it kill me not to have one? No.

Do I need an MRI? How the hell should I know? Will it kill me not to have one? I have no idea. I just know that my doc looked alarmed when she told me to get to the Radiology Department right away.

That is the heart of the difference between health care “consumers” and many other consumer markets. (1) Consumers don’t establish the demand. Doctors do. (2) Consumers have precious little way to evaluate quality, price, or anything else because the health care industry deliberately keeps them in the dark. (3) Consumers never have to buy refrigerators while they or their children are bleeding, not breathing, or writhing in pain. Health care decisions are almost always made under duress.

The knowledge gap here is critical. Carfax, Consumer Reports, CNET, Gizmodo, and hundreds of other sites help us get on top of all sorts of mundane purchases. There is simply no equivalent in health care. Doctors, hospitals, hospices, drug companies, nursing homes, HMOs, and insurance companies all stand to make a buck off of our “decisions”. This arena will NEVER be improved by patient-centered information until squeezing the last dollar from us is no longer a blood sport.



Most of the time you can’t even know what it’s going to cost, never mind the skill of the provider or the efficacy of the treatment. I’ve had PT where they put off giving you a bill for weeks while saying you need to come 3x a week if you want to get better. So you’ve gone 10x before you see the ripoff bill where they lied to you about being in network.

High on the list for me would be dealing with end of life. Numbers vary, but

According to one study (Banarto, McClellan, Kagy and Garber, 2004), 30% of all Medicare expenditures are attributed to the 5% of beneficiaries that die each year, with 1/3 of that cost occurring in the last month of life.

We can do better for our elders, of whom many would choose not to spend their last months as bedridden cash cows for the medical/industrial complex.


As indicated in the article itself. The institution of co-pays is correlated with decreased routine care, increased hospital and emergency room visits. And thus increased costs .

So yeah you’ve got people who will over do it for various reasons. But in the end, putting up with that would cost less overall than what weve got going on now.


But it’s a math:


The last step is fallacious at best.


Yeah. “Equate indices” doesn’t hold if you’re dealing with complex numbers, which you are.


I have a non-profit health insurer and go to a non-profit medical provider. My healthcare is just as expensive as everyone else’s.

There is no single cause of the waste in healthcare, but there are some huge issues:


We waste and overuse medicine to a ridiculous degree (estimated at ~35% of healthcare costs)

  • We have no hard national standards for acceptable treatment options like other countries
  • We don’t have any enforcement mechanism except for outright fraud against doctors who habitually choose the most expensive treatment options
  • We tend to use the most expensive medical technology when cheaper alternatives exist
  • We are focused almost exclusively on keeping someone alive another day regardless of quality of life or cost

Our healthcare pricing system is stupidly inefficient

  • We use a bid/ask system where negotiations happen every single billing instead of fixed rates
  • Providers effectively have to overbill because insurance companies pay only a fraction, but providers aren’t sure what that fraction will be which leads to the price of a service billed being completely divorced from the actual cost of the service
  • Because no one knows what insurance companies will pay for and the billing prices are divorced from cost, attempts by insurance companies to try to limit overuse of medicine is doomed
  • It requires a large staff simply to manage the process

“Non-profit” doesn’t mean not making money

  • Excess money is dumped into hospital administrator’s salaries, marketing, more, often completely unnecessary, equipment, etc.

Medical education is ridiculously expensive

  • Doctors effectively need high salaries just to repay loans
  • This leads to doctors going into higher paid specialities instead of becoming GPs and fewer doctors in lower income areas
  • Also leads to small private practices, which used to be a good way to see patients with low overhead, disappearing

Healthcare isn’t a working market

  • Patients don’t care about costs, but rather perceived quality driven by marketing and positive word of mouth
  • Hospitals often have a complete monopoly in many areas
  • The patient is largely insulated from what things cost since their insurance company ends up paying for most of it

Americans get really expensive diseases

  • While we don’t top the list of every disease, we seem to have a high prevalence of chronic diseases (68% of healthcare spending) that result in a lot of hospital admissions
  • No one seems willing to tell Americans that a huge chunk of their healthcare costs are because as a whole they are too fat and don’t exercise enough


Death panels!

No in all seriousness, how we manage end-of-life care is ridiculous. We’ll happily perform open heart surgery on someone who is in the terminal stages of disease.

Of course, who wants to tell a voter no? It is one of the reasons medicare for all seems unlikely to lower costs. Well, unless it is spun out like the Fed so politicians can’t touch it.


The real question when looking at the way copays shift incentives is whether it is a stronger disincentive to bad behavior or good behavior. I’m guessing that the hypothetical hypochondriac is reasonably unlikely to be dissuaded from excess medical treatments by a copay. They’ve already shown a strong willingness to accept medical procedures which are probably more troublesome than a 30 bill. On the other hand a 30 bill is a huge disincentive for a low income patient.


Have you ever taken an economics class? No, I’m actually 100% serious. The opening line you hear in any starter economics class is “what’s economically optimal may not be what’s societally optimal”, at least in the econ classes I’ve taken. Economics also requires rules which we assume to be true but which aren’t, unless you get really deep into stuff: we assume a market where any provider is as good as any other (in healthcare it’s not), and we assume that if you don’t like the service at the price provided you can therefore find the service for cheaper but equally good (not when you’re bleeding out) or drop out of the market (not if you’re bleeding out).

Finally, we hit the big thing: making people pay for things is a disincentive to make use of those things. That’s what we’re seeing here: by requiring you to pay to access healthcare when you’re healthy, we’re disincentivizing preventative care which means that more people are pushed towards the catastrophic option wherein economics as we talk about them do not apply (there is no market to speak of) and the cost to society is far greater than it would have been if the disincentive hadn’t been in place. There is no reasonable place in healthcare where a “market” (read neolib) solution can exist because you’re either in a situation where normal economics don’t apply or you’re disincentivizing the both societally and economically optimal solution of preventative care because fuck the people who can’t afford it.


Some plans have free preventative care, but if they find something during a free checkup, then you have a copay!

I learned about the “Big Lie” of HMOs 3 decades ago when I asked a doc for a tetanus booster. I was told if I had a wound, it would be covered, but if I wanted it prophylactically, I would have to pay. Too dumb for words.


It gets even better than that… when you ask the consumer to pay for their own stuff, they will make their own cost cuts but usually for stuff that is actually medically necessary. Asthma medication for their kids, say. (there are a number of studies on the subject, from medication to preventative health care to conditions that would have been managed non-emergently but the patient waited until it was too late etc etc etc)
Personal anecdote: took care of splenectomy patient who almost died because parents didn’t want to pay for their daily penicillin. Got all the other meds, but were strapped for cash so they skipped this one since they didn’t know how important it was…