Why America doesn't love HMOs as much as I do

WASHINGTON — Last week, I went to the eye doctor. An unremarkable event, hardly something to write about, except that it inspired me to reflect on how I learned to stop worrying and love my HMO.

Older readers will probably recall the managed-care revolution of the 1990s, which set out to replace the old fee-for-service model with tightly run networks of doctors. While, in theory, such networks could offer better care, the most visible effect was on costs: In the 1990s, our collective medical expenditures, after growing by double digits for three decades, rose just 6.6%.

Older readers will probably also recall that doctors and patients both hated this change. Cheapskate health maintenance organizations became Hollywood's favorite movie villain. State legislators rushed to pass patients' bills of rights that made it hard to limit access to treatment. And health care costs resumed their upward climb.

Yet those models never entirely disappeared. For the past five years, I've been covered by Kaiser Permanente, an HMO that mostly requires me to see their in-house, salaried doctors — and to get permission from my primary care physician to access anything but a few routine services. Perhaps more surprisingly, I choose this over less restrictive options.

It started as an experiment. I spent some of my formative years as a journalist covering Obamacare, which meant listening to wonks rhapsodize about European health care systems that sounded a lot like HMOs — or even just rave about HMOs. When asked what the American system should look like, one of the models health care analysts pointed to was Kaiser — which, yes, restricted your choice of doctors but also offered a kind of highly coordinated care that traditional physicians couldn't match.

I spent a lot of years arguing that the United States would never have anything like that. So when I joined The Post in 2018 and discovered that Kaiser was one of my options for health insurance, I felt honor-bound to try what I had disparaged.

Five years later, I am no longer trying; I am convinced. Yes, I have given up quite a bit of freedom. In exchange, I get . . . well, consider my eye visit.

I had never seen this doctor before; I took the first available appointment at my local facility. Yet when I started to describe a massive floater I'd developed in my eye a few years ago, she stopped me and said, "I know." Of course she did. When it happened, in 2020, I'd gone to Kaiser's Advanced Urgent Care in that same building, fearing it was a retinal detachment. They'd determined it was probably just a floater and scheduled an ophthalmology follow-up the next day. My doctor had all those records in front of her.

Which is why I stay with Kaiser: I never have to find a specialist, hassle with medical records, make sure a prescription is phoned in or explain my patient history. Nor do I have to fuss with billing or worry about the cost; the co-pays are modest, predictable and, like everything else, easily handled through their app.

This is pretty much how people 10 years ago described what the health care system should look like. Yet I'm still unconvinced that the United States will ever get there as a country — though more individual Americans could, and probably should, take the HMO option.

One reason wonks got excited about models such as Kaiser was the hope they would bring costs down from stratospheric U.S. levels to something more in line with Europe's. After all, preventive care! Ending unnecessary ER visits! Paying for health, not for expensive procedures!

Unfortunately, it turns out that preventive care doesn't save money; giving people insurance coverage means they make more ER visits, not fewer. And ongoing experiments with alternative payment models for Medicare have so far failed to generate significant savings. My Kaiser premiums are actually slightly more than my employer's other options, though I do save quite a bit on co-pays and deductibles.

That's not the only reason to prefer good coordinated care, of course — better health is valuable! But the lack of visible cost savings has drained some of the energy from the project.

Another reason the United States probably won't move in a Kaiserly direction is prudential: Not every HMO can be Kaiser, which is arguably the best in the country. Its model has proved difficult to replicate, and even Kaiser might not be as good as Kaiser after systemwide reforms, because it would no longer have to compete against insurers that offer more choice.

Even if those issues could be resolved, people seem no more willing to accept limits on their options than they were 30 years ago. When I recommend Kaiser, people often recoil, even nice progressives who theoretically want the United States to have a more centralized system. Give up their favorite doctor? Sacrifice the right to see any specialist they want? No.

It's hard to explain just how pleasant a top-notch integrated system can be; it's the sort of thing you learn only by experience. And people seem unwilling to try it for even one year. I might have learned to love my HMO, but I'm skeptical that America ever will.