Nicole Sapier is a NYC physician, working in radiology. She is also a Fox News contributor, and given her statements it is not hard to imagine that she is a Trump supporter, although she does not say who she voted for. She does argue often against the ACA (Obamacare) and the health proposals of Democrat presidential candidates.

There is a question about whether it is right to even give publicity to those supporting the Trump administration, and I have my reservations. But Saphier’s book is at least clear and is being promoted in a variety of locations, so it is worth replying to its main points. 

First, one might wonder about Saphier’s background. Her training is in radiology, not health policy. She makes many claims about health economics and the solution to the problems of health in the USA, and while she gives some footnotes, her evidence is not strong. Quite often her selection of evidence seems one-sided, and her claims are implausible. She is adamant that the US provides the quickest and best health care in the world 

Often her targets are also not well chosen: for example, most people will concede that there are many problems with the ACA because it was a policy that was achieved through political compromise. The aim was to improve it over the years as its general principles became better accepted. But the Trump administration and various states have worked against it, in an effort to make it unpopular and get it repealed. If we are going to have a successful health care policy in the USA, it needs to be a policy that provides care for all and has the support of all stakeholders.

There are arguments in this book that are worth looking at. Some of the greatest health problems are caused by human behavior: people eat badly, do not get enough exercise, and get addicted to dangerous substances including those delivered by cigarettes. Health in the US would be a great deal better if people changed their behavior. These days there is a great deal of health information so everyone knows that they should eat better and get more exercise. Yet people persist in their self-defeating behavior.

Saphier’s proposal is that there should be less constraint on physician decisions, less government involvement in the provision of health care, and there should be more incentives and disincentives aiming to get people to change their behavior so they are healthier. In particular, she argues that insurance companies should be able to discriminate against people whose health problems are caused by their own behavior. 

Many people would just rule out such a proposal as unfair, on the grounds that we should not discriminate against people when it comes to illness. But not everyone has that opinion, and maybe there would be some support for the general idea, given that we have scarce resources and we need to do something to improve public health. We would still have to address which conditions people could avoid if they wanted to, because some are addictive, and people find it very hard to give them up. This may be true not just of alcohol,nicotine and hard drugs, but also of sugar. It is also often argued that people at the bottom of the socioeconomic ladder have far less opportunity to cook healthy food for themselves because the supermarkets in their neighborhoods do not stock it, and when you are working 2 or 3 minimum wage jobs, you do not have the time to cook a healthy meal. These issues may be complex and so are hard to take into account, but Saphier does not address them at all. Her zeal for small government won’t allow government policies that would address these parts of life. Indeed, one wonders where she stands on taxing alcohol and tobacco: it seems her approach would dictate that there should be no “sin taxes” at all imposed by government. 

But the central question for her proposal is whether it would work. Do people actually change their behavior when there are incentives and disincentives created by health insurance? It is true that the number of people consuming tobacco and alcohol seems to decline in response to higher taxation and education. But there is already plenty of social motivation to avoid obesity, yet the rates of obesity keep rising, so we may be skeptical that making it more expensive for individuals to get treatment will have any significant effect on their eating patterns and will work to improve their health. There is a strong chance that it will have the opposite effect, leading them to seek out less health care, and decline further in health. Then it would be basically a punitive health policy. 

The other central issue that Saphier fails to address is that her proposals would take us back to a time when many people did not have health insurance. Whatever the problems with Obamacare, it did result in millions more people having health insurance. The USA is still the only country in the west that fails to provide universal health care of some form, and any health policy has to address this major problem. Yet Saphier says nothing about it. So her approach is a non-starter as a general guide, even if there are elements in her proposals that deserve further consideration. 

© 2020 Christian Perring

Christian Perring teaches in NYC

Categories: General

Keywords: healthcare,