This case rests on challenging in an aggressive and forceful way the fundamental assumption behind all parity cases: that all forms of health care should be paid for in the same way.
1. Different types of illnesses require different payment structures in order to achieve better health outcomes for lower costs. read more...
2. The problem with the current system is not that there is too little parity, but that there is too much - we need even more diversity than we now have in paying for different types of health care services. read more...
3. The affirmative approach would make the current system worse by causing eight bad outcomes. read more...
- A slippery slope for other illnesses
- A slippery slope for special interests
Basically, the case for mental health parity can be expressed lucidly and persuasively in the space of one or two minutes. A credible affirmative plan can be advanced in about the same amount of time. All the rest is window dressing. What is most appealing about this case is its simplicity and the ease with which it can be presented.
The chief weakness in any pro-parity case is that it endorses a vision of health care that is simplistic and naive. But in pointing this out, the negative faces a daunting challenge. Specifically, the negative has to overcome the resistance of ordinary listeners to three propositions:
- That deductibles and copayments and other kind of cost sharing can be desirable features of a health insurance plan.
- More cost sharing means lower premiums, and vice versa.
- Employer premium payments are a substitute for wages (or deposits to employee owned Medical Savings Accounts.)
One way of summarizing all three points is to observe that there is no such thing as a free lunch. Lower employee cost sharing --> higher premiums --> lower wages.
As an illustration, you might check out premiums charged for individual health insurance in your area. You may find that the extra premium you have to pay for a low deductible plan costs more than the increased coverage you get. Put another way, in moving from a low deductible to a high deductible, the premium savings are more than the extra exposure you incur. (Be sure to subtract the copayment.)
Just as there are gains (premium savings) from higher cost sharing for health insurance in general, there are also gains for different types of insurance, e.g., mental health and physical health. And there is no reason why the gains (premium savings) from higher cost sharing with physical health must be the same as the gains from higher cost sharing with mental health. In fact we have every reason to believe that the gains in the mental health area are higher. What the affirmative wants to do is take away people's right to take advantage of those differences.
We suggest the following strategy:
The First Negative should be devoted almost entirely to the development of a different vision of health care. The vision needs to be presented forcefully with examples and appeals to common sense.
This vision should be reinforced on cross examinations by challenging the affirmative to defend its vision.
1. Do you believe we should outlaw all deductibles, copayments and other forms of cost sharing?
- If so, refer to opportunities in some parts of the country to actually "profit" from higher deductibles.
2. Would you agree that cost-sharing affects behavior by encouraging patients not to be wasteful?
(If the affirmative doesn't agree that cost sharing affects behavior, then they are largely giving away their case. Most teams are going to argue that high cost sharing discourages access.)
3. Would you agree that cost sharing will affect patient behavior differently for different kinds of care? E.g., care for diabetes vs. setting a broken leg?
4. If you agree people don't respond in a one-size-fits-all manner, why do you want to impose a one-size-fits-all cost-sharing on all health services?
The affirmative also should be put on the defensive for outlawing mutually beneficial, voluntary exchanges:
1. If an insurance company is willing to sell me a plan with higher deductibles for mental health in return for a lower overall premium and if that is precisely the plan I want to buy what's wrong with that?
2. Are you saying people should only be able to buy insurance plans designed by the affirmative team? There can't be any room for individuality and choice?
3. Is it your position that you are a better judge of the kind of insurance people need than the people themselves?
The Second Negative should focus primarily on the negative consequences of the affirmative plan. We are suggesting quite a laundry list of complaints, and the speaker will need most of his eight minutes just to reel them off.
The First Negative Rebuttal and Cross-x should again come back to the vision thing. Examples of the enormous amount of discretion in mental health care should help reinforce the need for flexible payment systems.
Some questions that the negative team can ask in its cross examination to expose the flawed reasoning behind parity include:
- Are you aware that 28% of visits, money spent etc., are by people who have no mental health disorder?
- Would you agree that if thousands of people with only minor problems see therapists and send the bill to the insurance company, the cost of insurance will go up?
- Are you aware that patients are four times more sensitive to out-of-pocket costs of mental health care as physical health care? (Compare broken leg with depression.)
By the time the First Affirmative Rebuttal speaker rises, he should be in a position of having to defend against eight minutes of nonstop and unanswered problems in addition to being very much on the defensive on the affirmative vision of health care.
