Are Fat Taxes All the New Rage?

The world’s first fat tax is finally here. Well, it’s not actually here (New Jersey’s Star Ledger Newspaper took the time to say “fat chance” to such a plan working in the U.S.), but it has been officially enacted in Denmark.

The tax applies to all foods that have a saturated fat content greater than 2.3%. The tax rate is 16 Danish kroner per kilogram of saturated fat (roughly $1.29 per pound). Danish officials expect the tax to generate somewhere between 1.5  billion and 2.75 billion Danish kroner annually. According to the Danish Agriculture and Food Council, a family with two adults and two children that does not change their eating habits can expect to pay an extra 1000 kroner a year (a little less than $200).

Interestingly enough, the goal of the tax is not to target obesity. The obesity rate in Denmark is 13.4%, which is 2.1% less than the European average. The last time the U.S. had obesity rates as low as Demark was in the 1970s. Instead, the fat tax is aimed at increasing the Danish life expectancy of 79 by three years over the next decade.

This type of legislation is not new for Danes. Denmark was actually the first country to institute a ban on trans fats in 2003, and last year the country instituted a 25% tax on sugary items like ice cream, chocolate and sweets. Sin taxes for soda, alcohol and cigarettes also exist. Advocates of these taxes note the benefit to preventative health and also the advantage of filling the government’s coffers. According to the secretary general of the European Public Health Alliance, Monika Kosinska,

“Denmark will not only increase general health amongst the population but will also ease the burden on the public health care system and increase its resources at a time of recession when [European] Member States are cutting public expenditure.”

Benefits aside, the criticisms of the new tax are numerous. In an article for The Atlantic, Edward Tenner notes the rich irony that Denmark, one of the world’s foremost producers of butter, cheese and bacon, is the first country to implement a tax on fat. Critics include, of course, the numerous producers of affected foods like butter, milk, cheese, meat and oil. One CEO of a Danish meat manufacturing company called the tax a bureaucratic nightmare.

Producers are required to pay the tax, and these costs will be passed on to consumers, suggesting that more Danes will shop abroad. Denmark’s central association of margarine producers (MIFU), has already filed a complaint with the European Union (EU) Commission arguing that the tax is noncompliant with EU free trade rules.

Other critics note that the tax may not be high enough to actually change behavior.

Given the similarity to soda taxes (previously discussed on this blog), it’s worth referring to a 2009 article published in the New England Journal of Medicine by Kelly Brownell and his team. They considered the public health and economic benefits of taxing high-sugar beverages and found that the 5% soda taxes that many U.S. states have enacted are too small to affect consumption. Their team proposed that a sugar tax on beverages would have to be much higher to lower soda consumption, at around 1 cent per ounce of beverage.

A 2007 study by the Forum for Health Economics and Policy focused on the ability of a fat tax to change behavior and found that a 10% fat tax on dairy would not reduce consumption by even one percent. The authors suggest that the tax rate would have to be much higher, but even a 50% tax may only reduce fat intake by 3%.

Some critics have offered suggestions on how to better address the problem both of obesity and shortened life-spans. Dr. Mike Rayner, Director of Oxford University’s Health Promotion Research Group, argues that Danes may switch from high fat foods to other unhealthy foods. He proposes that the overall unhealthiness of food should be taxed instead, not just a single nutrient. Simultaneously lowering taxes on fruits and vegetables could promote a healthier behavior change.

Dr. Yoni Freedhoff, medical director of the Bariatric Medical Institute in Ottawa, points to the public health issue of obesity as a societal problem. He notes,

“If we want to have legislation that deals with this problem, perhaps legislation that would deal with advertisement to children and zoning laws for fast foods around school would be a better place to start than a tax that is simply going to raise money and will not, in fact, change anything.”

NYU professor Marion Nestle finds the fat tax to be troubling for a different reason. To see individual behavior change, she argues that we must change the behavior of corporations “that make and market unhealthful products, spending vast fortunes to make them available, desirable and socially acceptable.” She cites a recent Lancet article on food environment factors that sees food processing, cost and marketing as drivers of consumption. She concludes, “[G]overnments seriously concerned about reducing rates of chronic disease should also consider ways to regulate production of unhealthy products, along with the ways they are marketed.”

Despite the multitude of criticisms, several other European countries have expressed a desire to follow suit– including France, Finland, Romania, Sweden, Norway, and even Britain. Americans should also be watching this social health experiment. But given that our country’s favorite condiment is mayonnaise, maybe the Star Ledger is right– it may not be time for a U.S. fat tax just yet.

Medicaid Incentives for Healthy Behavior: Turning That Cigarette Back Into Cold Hard Cash

The Centers for Medicare and Medicaid Services (CMS) recently announced a $100 million program through which states can reward Medicaid enrollees who adopt healthy behaviors. The grant program is part of the Patient Protection and Affordable Care Act and allows states to offer incentives for tobacco cessation, controlling or reducing weight, lowering cholesterol or blood pressure, and avoiding the onset of diabetes or improving management of the condition. The goal of the program is prevention, as spending on chronic conditions is said to account for more than 75 percent of annual healthcare expenditures in the U.S.

According to CMS Administrator Dr. Donald Berwick,

With the right incentives, we believe that people can change their behaviors and stop smoking or lose weight. Not only can preventive programs help to improve individuals’ health, by keeping people healthy we can also lower the nation’s overall health care costs.

States are not limited to direct cash incentives– proposed plans could include waiving premiums, deductibles and coinsurance payments, or offering coupons or gift certificates for weight management classes or tobacco cessation counseling.

CMS has based the program on data suggesting a short-term change in behavior when people are offered monetary incentives. Current research shows that while people may be internally motivated to make healthier decisions because of future consequences, they don’t often weigh those delayed outcomes with the immediate reward of engaging in the behavior. For example, knowing that smoking increases lung cancer risk 20 years from now isn’t always going to stop someone from smoking a cigarette. The benefit of monetary incentives is therefore their immediacy– they replace one unhealthy reward with another less harmful one. In short, CMS is betting that someone would put down that cigarette right now if you just paid them to.

But the experience of making healthy decisions seems to align more with what Mark Twain opined in Following the Equator,

He had had much experience of physicians, and said “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.

Though an individual may make a healthy choice now because they would prefer a cash incentive, that doesn’t automatically change their instinctual behavior. Someone could theoretically be convinced to take a grocery store gift card instead of buying a fast food dinner, but that does not change how much they enjoy the taste of a cheeseburger. In many circumstances, people engage in certain behaviors simply because they like to. For this very reason, critics are quick to point out that monetary incentives are unlikely to spur long-term changes in unhealthy habits. Critics also note that there is little research on whether these incentives will be successful in the Medicaid beneficiary population.

What may redeem the initiative from these criticisms is that CMS is candidly calling it a  ”demonstration program,” designed to figure out which strategies produce long-term behavioral changes. By allowing states to develop their own programs and keep data on the experience, CMS seems to be hedging its bets, wagering that at least one program will provide a successful model. Further, CMS can use the data to evaluate other factors such as the administrative costs incurred by states in rendering the programs.

Could $100 million federal grant dollars be used to support preventative health in a different way? Of course. But as long as this money is being set aside to incentivize healthy behavior, we may get an answer to whether external motivators spur long term behavior change. I, for one, would love to know just how much money it costs to convince someone to stop smoking, or to consistently trade in that Big Mac for some broccoli. It almost has to be cheaper than what we’re doing right now.

Time To Tighten That Belt….

Keep an eye out for the April edition of the American Journal of Medicine.  In it, the Los Angeles Times and U.S. News Health Blog report that you will find a new study from the Centers for Disease Control and Prevention (CDC) which identifies the “diabetes belt.”  Almost 26 million Americans - that’s 8% of the population - have type-2 diabetes, the most common form of diabetes (as opposed to type-1) often connected with weight and physical activity.  In a county-by-county census, the CDC  identifies 644 counties in 15 states where the type-2 diabetes rates are higher (11%) than the national average (8.5%).  Ethnicity, age, weight, and a sedentary lifestyle were found to be key factors.

The Los Angeles Times describes the “belt” as stretching “down the southeastern seaboard, ’round the silty Mississippi Delta and following the Appalachian Mountains north across Tennessee, Kentucky and West Virginia” and including parts of Pennsylvania (but stopping short of New Jersey).  Dr. Lawrence Phillips, who studies diabetes at Emory University, told Reuters that

[s]ince diabetes is one of what we call the silent killer diseases … it’s important for the public to be aware that this is a problem….  What this does is to give health care providers ammunition. A provider can say, ‘We’re in the diabetes belt. All of these things are increased in part because of the way we live, and all of these things can be improved to a certain extent. Our risks can be decreased … by eating healthier and to the extent that we can, being less sedentary.’”

The “diabetes belt” appears to overlap with the decades-old “stroke belt” and the recently identified “heart failure belt.” Be sure to check out whether your home state falls within one of these belts.  And then remember to tighten yours.

New Year’s Resolution #1: Preventive Care and Negotiated Costs

Happy 2011, folks!  It’s a new year of reformed eating, exercising, spending, and no-smoking habits.  It’s a new Congress with promises or threats (depending on your view) of healthcare repeal.  And with the help of U.S. Preventive Medicine, Inc., it’s a new year for Sam’s Club shoppers to reach their health goals with the “The Prevention Plan.”  Or is it?

For $99 a year, Sam’s Club shoppers can access:

a personalized, step-by-step health management program designed to help people take control of their individual health.  Via an online health assessment and at-home blood test [measuring cholesterol, blood glucose, and Hemoglobin A1c levels]… members can take the first steps in identifying potential individual health issues.  From there, a personalized plan is created to address risks.  Personal health coaching, ongoing support, a variety of tools and a plan-wide health challenge are provided through The Prevention Plan to keep members motivated to maintain a healthy lifestyle.

Although the Plan includes a 24/7 nurse line, 20 online education programs, recommended prevention screenings, and a detailed member report, it isn’t a substitute for regular health insurance… or for a primary care physician.  In a CNNMoney report, U.S. Preventive Medicine CEO Christoper Fey suggested that shoppers “[t]hink of it as what a financial planner does.   He takes all the information you provide, assesses the risk and gives you a plan on how to improve your financial health.  The prevention plan does a similar thing, but for your health.”  In the same report, a director of health policy at Families USA, a consumer advocacy group, said that she “worr[ied] about people thinking of this prevention plan as a substitute for an annual checkup at a doctor’s office.”

Participating in preventive care and services makes a lot of (dollars and) sense.  Okay, a little lame joke.  Seriously, though, why sit around when you can take measures to try to maintain your health and to prevent certain diseases from occurring?  The Patient Protection and Affordable Care Act recognizes the benefit of preventive care and services — remember, there’s that provision concerning free access to important screenings, tests, vaccinations, and the like.

Yet I’m somewhat skeptical about the benefits of paying $99 to enroll in this Sam’s Club Plan.  For starters, it sounds like the same kind of educational information and health tips can be found on other sites such as WebMD… and at no cost to the consumer/patient.  Okay, well, maybe WebMD doesn’t come with a 24/7 nurse line.  Yet after you take the at-home blood test, upload the results, and figure out your health summary, you’ll still need to consult a doctor to figure out whether any additional screenings are required.  So take that $99 and add to it the cost of your co-pay… or whatever you might pay out-of-pocket if you don’t have insurance.

Speaking of which, be sure to check out a recent New York Times article which reminds us how (most of) everything in life is negotiable, including healthcare and prescription costs.  Similarly, a NPR blog post discusses how some drug manufacturers offer coupons or subsidy cards to reduce prescription costs–but as Kate Matos mentioned the other day here at HRW, that too comes with a cost.

Reform Rodeo

1. Useful Tools:  The Commonwealth Fund has released a nice tool that provides a timeline of ACA, as well as a means by which to filter the provisions based on a number of criteria.

2. Misinformation: Maggie Mahar describes some of the misinformation that is coming out of the state of Texas regarding health care reform.

3. Exchange Obstacle: Timothy Jost provides a fantastic overview of the obstacles that states and federal governments will face in the process of implementing the exchanges under the ACA.

4. Preventive Care: Somewhat out of character, the Los Angeles Times runs a piece about the irrationality that has surrounded the Preventive Services Task Force and evidence-based medicine in general.

5. Pharma Initiatives: The New England Journal of Medicine provides an overview of the policy initiatives and incentive programs that govern market exclusivity of pharmaceuticals.

The Hum of Healthcare Reform

Shhhh.  Can you hear it?  Among all of that partisan pre-midterm election cheering and jeering? There’s a faint hum.  The cogs of healthcare reform have started to turn.

Thursday marked the six-month anniversary of the Patient Protection and Affordable Care Act (PPACA) and the implementation of several consumer protection provisions.  Can you believe it?  We now live in a society where:

• Children under 19 years old can no longer be excluded because of pre-existing health conditions;
• “Young adults” (19-25 years old “dependents”) can stay on their parent’s plan until they turn 26 years old;
• Insurers can no longer impose lifetime limits on benefits;
• Insurers can no longer deny payment for services once a consumer gets sick nor search for errors on a consumer’s application in order to deny payment for services once that consumers gets sick (a practice called “rescission”);
• Depending on your age, all new plans must provide certain preventive health services — such as colonoscopies, mammograms, routine vaccinations, and diabetes tests — without co-payments or deductibles;
• Annual limits on insurance coverage will be restricted; and
• Consumers are ensured the right to appeal coverage determinations.  If the insurer upholds its own decision, consumers can  appeal to an external review process.

Granted, these protections aren’t perfect.  For instance, “grandfathered” group plans do not have to offer coverage to young adults who qualify for group coverage at work nor do they have to offer the free preventive health services.  Mary Agnes Carey of the Kaiser Health Network points out that most consumers won’t benefit from these protections anyway until their new health year plan begins after January 1, 2011.  (Carey provides a basic Q&A on the provisions here.)

The greatest challenge for PPACA right now, though, seems to be the misperceptions circulating around the country.  A recent AP poll found that:

[m]ore than half of Americans mistakenly believe the overhaul will raise taxes for most people this year….

Many who wanted the health care system to be overhauled don’t realize that some provisions they cared about actually did make it in. And about a quarter of supporters don’t understand that something hardly anyone wanted didn’t make it: They mistakenly say the law will set up panels of bureaucrats to make decisions about people’s care — what critics labeled “death panels.”

The uncertainty and confusion amount to a dismal verdict for the Obama administration’s campaign to win over public opinion….

Yet, folks, PPACA provides long overdue protections that will have a tremendous positive effect.  The White House predicts that around 72,000 uninsured children with pre-existing conditions will gain coverage.  Getting Covered, a campaign dedicated to helping parents and young adults benefit from the healthcare reform, estimates that New Jersey has 209,000 uninsured young adults, but next year that number will have been reduced by almost 28,000.

These protections come in the nick of time, too.  Sabriya Rice of CNN reports that the impact of the bad economy has taken its toll on healthcare as:

[a] recent population report from the U.S. Census Bureau says there has been a dramatic increase in the number of people without health insurance in the United States. Between 2008 and 2009, the number of uninsured people increased by 16.7 percent, to nearly 51 million. An estimated 6.5 million people were no longer covered by private health insurance and equally as many had lost employment-based health benefits.

Patient advocates say Thursday’s changes are only the beginning. “The big resolutions will come in 2014 when you will start to see tens of millions of people getting coverage,” says Avram Goldstein, communication director for the Health Care for America Now, a liberal grass roots health advocacy organization.

Rice highlights a young man named Joshua Armstrong who took a break from school, lost his mom’s health insurance coverage and became one of the approximately 118,000 uninsured young adults in Alabama, and ran up a $10,000 emergency room bill after a car accident.  According to Getting Covered:

Alabama is actually one of ten states that have not required employers to expand dependent coverage at all. As a result, most family plans in Alabama currently only offer coverage to young adults up to age 19 or after college graduation. With the new law, young adults in Alabama will now be able to join their parent’s plan for longer even if they are financially independent, out of school, married, or live far away.

The new protection provision won’t help Armstrong with that emergency room bill — he’s worked out a repayment plan with the hospital — but it will help him secure insurance for the future.

AP reporter Carla Johnson similarly highlights three families affected by the PPACA protections: one whose son is uninsurable because he’s a cancer survivor, one whose son lost coverage when he maxed out the $1 million lifetime limit, and a man whose insurer retroactively canceled his coverage after he had a stroke.  The father of the latter summed up the situation quite nicely: “It’s despicable to leave a man who’s recovering from a stroke with no insurance.”  Yes.  Yes it is.  Keep on humming, PPACA.

Impact of Free Preventive Healthcare

Benjamin Franklin famously once said, “an ounce of prevention is worth a pound of cure.” The statement has that ring of truth– especially when it comes to American healthcare.  Numerous studies have shown that early detection of diseases as well as interventions for bad habits (e.g. overeating and smoking) can potentially avert thousands of deaths each year.  Additionally, reported by Reuters, these preventative cares can lead to massive health care savings because preventable diseases such as heart diseases, cancer, and diabetes account for 75% of the national health care spending.

Considering the potential of prevention, just last week, the White House laid out rules requiring health insurance companies to provide many preventative medical services at no cost to the consumer.  The NY Times reports,

The rules will eliminate co-payments, deductibles and other charges for blood pressure, diabetes and cholesterol tests; many cancer screenings; routine vaccinations; prenatal care; and regular wellness visits for infants and children.

Other services that must be offered at no charge include counseling to help people stop smoking; screening and counseling for obesity; and tests for infection with the virus that causes AIDS.

The rules stipulate that no co-payments can be charged for tests and screenings recommended by the United States Preventive Services Task Force, an independent panel of scientific experts. The rules apply to new health plans that begin coverage after Sept. 23 and to existing health plans that make significant changes after that date. The administration said the requirements could increase premiums by 1.5 percent, on average.

Currently, the government reports that Americans use preventive services at about half the rate recommended by doctors and public health experts.  The Obama Administration, including many experts and consumers groups, is hoping that these new changes will eventually have a huge impact and Americans will take advantage of the free preventative care.

But, how much impact would it really have?

While costs have deterred some consumers from preventive care, others have avoided doctors’ offices for other reasons.  For example, people with unhealthy lifestyles avoid checkups, not because of cost, but out of fear.  According to the NY Times,

Recent studies have shown that people who know they have health-endangering vices (like smoking or drinking) put off appointments because they do not want a healthy-living lecture. Others do not go because they feel doomed despite medical treatment. At the other extreme are the overly optimistic who are convinced they will get better no matter what. And then there are those who are embarrassed to discuss their symptoms, such as incontinence or impotence.

The bottom line for many people is fear: fear of bad news, fear of an uncomfortable test, fear of discussing something intimate.

And other people, namely men, do not regularly see their primary care physician because men generally tend to overestimate their health.  According to a survey by the American Academy of Family Physicians:

● Almost one in five men (18%) 55 years and older have never received the recommended screening for colon cancer.

● More than half (55%) of all men surveyed have not seen their primary care physician for a physical exam within the past year.

● Four in 10 (42%) men have been diagnosed with at least one of the following chronic conditions: high blood pressure (28%), heart disease (8%), arthritis (13%), cancer (8%) or diabetes (10%).

● More than one out of four men (29%) say they wait “as long as possible” before seeking help when they feel sick or are in pain or are concerned about their health.

● Despite this, almost 8 in 10 (79%) men describe themselves as in “Excellent,” “Very Good,” or “Good” health.

The “missing” men in these statistics would seem to be among those who would benefit, arguably most, from regular  checkups and screenings; unfortunately, it would seem that free preventive care will not drive these groups running to the doctor.  While the new rules will undoubtedly increase the number of people receiving preventive care, it is uncertain how much impact it will actually have as some groups will continue to avoid doctors regardless of costs.

Why Primary Care in Medicare Matters

Why should we care about primary care in Medicare?  Early in the reform discussions, preventive and primary care was emphasized; in addition to extending medical care to all, reform would also implement preventive measures to keep them well.  In the current reform scrum, some are back peddling pretty fast, and in the course of finding “consensus” points (often focusing on cost-savings), we might lose conceptual coherence.

Ken Thorpe’s new Health Affairs article on chronic care patients in Medicare offers sound research and helpful analysis.  Thorpe’s data point toward a subtle explanation for health inflation keyed not to the increased cost of high-tech interventions, but to a shift in the conditions for which treatment is provided:

Our results highlight important changes in the medical conditions accounting for the rise in spending among beneficiaries over time. The most notable changes were in spending on a handful of chronic conditions: diabetes, kidney disease, hyperlipidemia, hypertension, mental disorders, and arthritis.

Thorpe has long argued that our health care delivery and finance system is stuck in a 20^th Century of acute care, while our 21^st Century needs have migrated toward chronic care.  As he has argued previously, these chronic care needs call for care at a human scale, including care management and supportive community-based care.  But he also points out that many chronic conditions are at least partially preventable, and that attention and resources should not be directed only to treating these conditions, but also to forestalling their incidence.

Prevention is, then, vital to any health care system.  But haven’t studies repeatedly shown that preventive care is not cost-effective?   Sorting this out requires that we step back and assess not only what “prevention” means, but also what we value in health care.

Preventive care can usefully be separated into three categories, as Ron Goetzel  (an Emory University colleague of Thorpe’s) has described.

• Primary prevention: Health promotion measures focus on lifestyle and simple interventions such as vaccinations to keep people from developing sickness; often cost-saving.
• Secondary prevention: Targeting people with preconditions for illness, including genetic or lifestyle markers, with screening technology, maintenance drugs, in order to forestall or prevent the manifestation of the condition; rarely cost-saving, in part because it is often applied to low-risk populations. Worth it? That depends on the design of the intervention and one’s metric for assessing health care value.
• Tertiary prevention: In this context, coordinated care management for those with chronic illness.  Properly implemented, chronic car management could “flatten the curve,” but is unlikely to be “cost-saving.”

So, whether “prevention” can save money (a claim Thorpe’s paper doesn’t make) is a complicated question.  In addition, it is often a poorly framed one. Explicitly or implicitly, cost-based objections to prevention often suggest that preventing one illness simply means that the person will die of something else, or less simplistically, that keeping people alive longer is cost-increasing, not cost saving.  Steven Wolf has elegantly responded to both objections:

[S]keptics of prevention argue that everyone dies of something; preventing demise serves only to allow a different disease to generate illness and spending. However, the aim of health promotion and disease prevention is not to prevent the inevitable but to “compress” morbidity, maximizing health until death.

Another common criticism is that prevention rarely saves money; it costs society if people live longer. The same applies to disease treatments. Health is a good; it is not purchased to save money. Health is a good that costs too much under the current medical care system, a problem of inefficiency that calls for wiser resource use, such as spending less per health unit gained (lower cost-effectiveness ratio). Disease prevention offers a way to improve health with low cost-effectiveness ratios and to also modulate disease rates. To reject health promotion and disease prevention because they do not save money (i.e., cost-effectiveness ratios are not negative) misses the point. (citations omitted)

Advocates who would shift our systemic emphasis to prevention and management of chronic illness, then, are not naïve about cost implications.  To the contrary, they address the issue head-on, with a three-step argument:

• The purpose of our system is or should be the maintenance of or restoration to high levels of functioning consistent with a fulfilling life.
• Our needs have largely shifted from acute to chronic interventions, and our system should shift to meet those needs.
• In preventing or managing chronic illness, as with all interventions, we should carefully examine the capacity of methods to meet our needs, and to demand value for those being served.

Applying this sort of argument to primary care, Goetzel elsewhere advocates skepticism of attempts by medicine to turn prevention into a high-tech enterprise:

We have medicalized prevention and health promotion in this country so that most people believe that only doctors in clinical settings can deliver these services. Although effective in many cases, this approach is the most expensive method of delivering prevention. If we expand our arsenal of potential interventions to include environmental, ecological, and policy changes, in addition to individually focused counseling and coaching programs, we can change the cost-effectiveness equation.

Thorpe’s article has garnered much-deserved attention, although it is tempting to think of his data in only cost-benefit terms.  That is not true to Thorpe’s conclusion, which is consistent with efforts to redirect attention from the business enterprise of health care to the health needs of Americans:

The U.S. health system remains predicated on providing acute, episodic care that is inadequate to address the altered patterns of disease now facing the American public. Our results highlight the need for prevention and care outside doctors’ offices and hospitals designed to address the changing needs of patients at risk for or living with chronic disease and, often, multiple comorbidities. As [reformers] continue their efforts to reshape the U.S. health system, they must address these changed health needs through evidence-based preventive care in the community, care coordination, and support for patient self-management.

Urgency, Medicalization, and Sick Days

The US media have recently coalesced around a narrative asserting that US health care costs too much in the aggregate because citizens are demanding too much health care. But the “too much demand” narrative must be balanced by an awareness of high prices in the US, as Ezra Klein has pointed out on the provider side, and Uwe Reinhardt notes on the insurer side. Reinhardt cited a study that found that, in comparison with West Germany, “in 1990 Americans received $390 per capita less in actual health care but spent $360 more per capita on administration.”

Nevertheless, there are legitimate concerns that citizens of the developed world are demanding (or having foist upon them) “too much health care,” as Charles J. Wright argues in the Literary Review of Canada. For example, Wright observes that

The recent analysis of all the available evidence from multiple studies published in the British Medical Journal shows that if 2,000 women are screened with mammograms regularly for ten years, only one single woman’s life will be prolonged, but 500 will have at least one false positive and ten will be diagnosed with a “cancer” that would never have become a real disease if it had been left alone. . . . The diagnosis and treatment of non-disease is also popular in some areas of psychiatric practice. Among the hundreds of diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders (known as the psychiatric bible) published by the American Psychiatric Association, dozens would be considered by most people as normal variants of the human condition but for the relentless attempts by the pharmaceutical industry to have them known as common diseases treatable by drugs.

Wright examines many causes for overmedicalization, but I think he misses one very important one–health concerns as a trump card over other social needs. In the US particularly, shrinking middle class incomes, weak unions, and high unemployment make it extremely difficult for the average worker to demand much in the way of vacation time, and there is virtually no political movement to guarantee such time. But there is momentum on both the federal and the municipal level to get sick days, in part because of the public health consequences of “presenteeism“–sick workers who spread flu and other disease when economic necessity forces them to go to work. While laissez-faire business interests can smear virtually any other pro-worker law as an intolerable burden on business, it is intuitively obvious why stopping the spread of disease is in everyone’s best interest.

Whatever happens as a result of this year’s health reform debate, I believe it has done some crucial normative work. After a long campaign by advocates of “consumer-directed health care” to reframe health care as just another commodity, the reform debate has focused the nation on its uniqueness, and on the moral imperative of providing some baseline of care to all. By vigorously blocking so many other modes of achieving better work conditions, entities like the Chamber of Commerce and Club for Growth have, ironically, shifted progressives’ focus to conservatives’ bete noir, the health care system. I predict that, if other guarantees of humane working and living conditions decline, we will see ever more “medicalization” as a way of upping the urgency of demands made by an increasingly pressed middle class.

Cut money to the EPA, and the US’s toxic waterways grow, increasing the flow of carcinogens to the populace. Put workers in insecure and demoralizing environments, and don’t be surprised if there’s an upsurge in demand for anti-anxiety drugs. Decimate funds for roads and public transit, and turn a blind eye to dangerous driving, and watch the ER’s fill with accident victims. The closer we come to a “minimal state,” the more we’ll see the resulting externalities increase demand for health care. The mechanic in the old oil filter commercial speaks for the public at large: “Pay me now, or pay me later.” When we defer maintenance of the social determinants of health, we shouldn’t be surprised when demand for doctors and hospitals rises.

Here’s an Idea: Asking Doctors about Health Care Reform

The New York Times just published a very interesting article that ties the efforts of the medical community to bring about change in the American health care system with Congress’s attempts to reform health care through legislation.  The article, which details the research of a team of health care providers in the Intermountain Healthcare system in Utah and Idaho, offers insight into what doctors are doing on their own to effect change while waiting for our nation’s leaders to implement the means to better health care for Americans.

As can be seen by American Medical Association’s recent endorsement of the Democratic House bill, and the long time call of the National Physician’s Alliance for reform, there is a consensus among  health care providers for health care reform.

Of course, essential in that reform is delivery system reform. Part of delivery reform is likely to emphasize not only preventive care, a cornerstone of Obama’s plan, but also a careful monitoring and consideration of the outcomes of health care practices.  Although there is debate about the best way to monitor and measure such practices, and some bridle at the prospect of being “confined” to protocols derived from large studies,  the evidence-based medicine model is emerging  as a favored tool with which to analyze how health care providers themselves can produce more cost-effective, life-preserving results. Evidence-based medicine puts protocols in place (which may be overridden at a doctor’s discretion) and relies heavily on the statistical analyses of a health care system’s performance (i.e., patient outcomes from particular practices).  Such is the model executed by the Intermountain Healthcare system highlighted in the Times article.

The protocols ultimately implemented sometimes differ from the usual course of treatment offered by some doctors. The physicians at Intermountain Healthcare admit that it is often hard for doctors to hear that they are doing something wrong– or perhaps “not optimally” would be a better choice of words.  The Executive Director of Intermountain Healthcare Institute for Healthcare Delivery and Research, Brent James, relates that some doctors do not believe the results of the statistical research because doctors are reluctant to change their ways, but that oftentimes when presented with clear statistical evidence doctors change their practices.  He gives the example of obstetricians who were performing elective inductions prior to 39 weeks for pregnant women for the sake of convenience, as the inductions save hours of labor for the mothers and therefore hours of hospital time.  However, an analysis showed that babies born prior to the 39th week of gestation were far more likely to wind up in intensive care. After doctors saw the data, and protocols were put in place, James found that the rate of elective inductions fell dramatically. A similar protocol developed for the treatment of one form of pneumonia was said to have cut the rate of death for that condition by 40% over several years.

Some doctors contend, however, that the medical metrics of evidence-based models are not the best way to bring change in health care practice, both because doctors will feel pressured to follow set protocols without considering other possible treatments and because humans are not statistical data that can be remedied through calculations and formulas. The danger, of course, is in negating the healing art– in throwing the proverbial baby– independent critical thought– out with the bathwater.  Doctors of this school of thought often espouse  revamped medical education as a better way to reform health care practices; after all, the basis of how health care providers develop their practices is the way in which they were/are taught.

And one wonders if there isn’t room for both approaches. If the education of medical students can be changed to incorporate better and cost effective practices based on studied outcomes (perhaps in part culled from the Health IT initiatives), and changed to incorporate greater emphasis on preventive care (coupled of course with a pay system which rewards patient wellness), while still respecting doctor autonomy so as not to prepare a generation of medical robots. It doesn’t sound “un-doable.”

Interestingly enough, medical schools have seen an increase in students applying to their programs.  In response, four new American medical schools have opened.  With the older generation of health care practitioners on its way to retirement, the need for more doctors is imminent.  But, we need doctors that are able to help carry the new ideals and practices of a reformed health care system; reaching into the med school curriculum would seem to make a lot of sense.

Report: Uninsured Hospitalized Children Face a 6o Percent Increased Risk of Dying

Sometimes the numbers speak louder than words, and the words are just painful to hear: the New York Times’ Prescriptions reports that

Researchers analyzed data from more than 23 million children’s hospitalizations from 1988 to 2005.

Uninsured children who wind up in the hospital are much more likely to die than children covered by either private or government insurance plans, according to one of the first studies to assess the impact of insurance coverage on hospitalized children.

Researchers at Johns Hopkins Children’s Center analyzed data from more than 23 million children’s hospitalizations in 37 states from 1988 to 2005. Compared with insured children, uninsured children faced a 60 percent increased risk of dying, the researchers found.

On a regular basis writers on this blog have discussed health reform as a moral imperative: citing religious doctrine, philosophers, economists and statistics to show that health care, unlike the purchase of automobiles and designer shoes, is not correctly a conventional aspect of a market economy– that the distribution of healing and life itself should not be premised upon who is the best capitalist, or, for that matter, the child of the best capitalist. That uninsured hospitalized children face a 6o percent increased risk of dying says that in a way that I simply cannot add to. Lack of insurance kills.

The Times noted that “Although the research was not set up to identify why uninsured children were more likely to die, it found that they were more likely to gain access to care through the emergency room, suggesting they might have more advanced disease by the time they were hospitalized.”

According to the Times the study showed that “uninsured children were in the hospital, on average, for less than a day when they died.”

Which is to say that it was too late by the time they got there.

The Times noted that “Alison Buist, director of child health at the Children’s Defense Fund, a nonprofit advocacy organization,” said in response to the study’s findings:

If you wait until a child gets care at a hospital, you have missed an opportunity to get them the types of screening and preventive services that prevent them from getting to that level of severity to begin with.

The Times further noted that

The most common reasons for children being hospitalized were complications from birth, pneumonia and asthma. The study found that the reasons did not differ depending on insurance status.

Read the full NY Times article here.
Read the Report here.

Principles for the Homestretch

House and Senate leaders will soon have to reconcile several different versions of health reform bills. The bills are complex, but some simple principles should guide the process of integrating them into a final product. As the press reports on a whirlwind of proposed laws, we need to ask of any particular proposal: Does it . . .

1) Increase productive competition in health care? Everyone talks about “increasing competition” among insurers and providers, but there are many ways to compete. Hospitals and doctors can game the reimbursement system. Insurers may not directly discriminate against the sick, but can find other ways to keep high-risk patients out of their plans, as even the most market-oriented health policy experts realize:

[T]o avoid patients with costly, complicated medical conditions, health plans could include in their networks relatively few doctors who specialize in treating those conditions, said Mark V. Pauly, professor of health-care management at the University of Pennsylvania’s Wharton School.

Both the Netherlands and Switzerland have already experienced problems in this area, even though the Netherlands has implemented risk-adjustment methods (which attempt to deter such “cherrypicking” and “lemondropping”) far more serious than anything proposed in current bills in the US. As Karen Pollitz has repeatedly argued, we’re going to need a much greater investment in insurance regulation to make any reform bill work.

2) Make it easier for uninsured or underinsured individuals to buy coverage? Many of the proposals for allocating and awarding subsidies for coverage sound exceedingly complex. We’re hearing about serious limitations on access to exchanges, subexchanges, burdensome “free rider” provisions, etc. Any particular provision may sound good in the abstract, but taken as a whole they could become an obstacle course that makes obtaining insurance coverage a miserable and exasperating experience for those supposedly aided by reform. During the second Bush administration, hundreds of thousands of children eligible for subsidized health insurance were not enrolled because states failed to make enrollment convenient enough for time- and cash-strapped parents. As Liebman and Zeckhauser remind us, “we must design systems for mere mortals, not the people who inhabit the models of traditional economists.” What seems easy to one of DC’s privileged elite can be very hard for an overworked mom or minimum wage-earning service worker.

I believe that the main reason a solid 2/3 to 3/4 of the country supports a public option is because it is a straightforward, transparent way to provide a backstop of health insurance for everyone. If Congress both rejects a public option and makes subsidies for private insurance as complex as the tax code, health reform risks becoming a model case of government failure. Last week’s negative votes on Rockefeller’s strong and Schumer’s weak public options could easily become a “you broke it, you bought it” moment for centrist Democrats and Republicans on the Senate Finance Committee.

3) Fairly distribute the burdens of reforming the health care system? This is the tax and finance question, and it promises to generate some epic battles on Capitol Hill. However the Senate Finance proposal ultimately evolves, it will be in tension with a House of Representatives that sees progressive taxation as a foundation for financing reform. The Baucus proposal to tax “high end”/Cadillac/”gold-plated” health plans may seem progressive, but it promises to gradually engulf even normal plans. While David Leonhardt offers some good economic arguments for such a tax, policymakers should be guided by Leonhardt’s observations on the propriety of taxing those at the very top of the income scale, who have disproportionately benefited from economic trends and tax cuts of the past decade.

4) Provide incentives for long-term cost-saving and preventive medicine? Comparative effectiveness research is a crucial tool for focusing pharmaceutical research on drugs that save lives. We have a shortage of primary care doctors vis a vis specialists. Reimbursement systems are too easy to game. Insurance markets are concentrated and need more competition and transparency. Any bill that ignores these problems (or fails to empower HHS or another agency to address them) can’t lead to truly sustainable universal coverage.

The health reform fight has been bruising, disappointing, and frustrating for many who care about health policy. Many unwise assumptions are already baked into leading bills. In the Senate, ostensibly Democratic lawmakers are promoting what are essentially Republican ideas and granting enormous subsidies to industries that may well betray them at the next electoral cycle. Nevertheless, there remain many opportunities for improving the final product at the beginning of the end of the legislative process.

Reform Rodeo II

1. On the Public Option Developments:

The New Republic has an optimistic assessment of the recent developments which are said to have forced the Obama administration to adopt a more centrist strategy.

2. On Exercise:

An interesting article in Time Magazine describing the counter-intuitive results that exercise–particularly strenuous exercise–may have on weight gain. However, see this article in the New York Times, describing a Finnish study which found that strenuous physical activity–and not moderate physical activity–reduced the risk of a suffering from a number of different types of cancer.

3. On Treatment Guidelines:

The New York Times also has an interesting discussion of the difficulties of implementing national treatment guidelines that aim to help health care providers utilize best practices. (Note: The article may require a free New York Times account).

4. On Payment Reform:

A recent piece in the New England Journal of Medicine explores the implementation of alternatives to the fee-for-service model.

5. On Taxing Health Benefits:

Merill Goozner frames the taxing of health benefits, arguing as others have, that taxing health benefits may in fact be regressive.

6. On the Best Health Care In the World:

Ezra Klein has a nice discussion of (and link to) an interesting post by the Urban Institute where they explore the (un)truthfulness of claiming that the U.S. has the best health care in the world.

7. In Case You Missed it:

Professor Tim Greaney  in The Health Care Blog: “Market Entry by Health Care Cooperatives: Neither Quick Nor Easy” (Originally posted here on Health Reform Watch, then picked up by THCB).

8. In Case You Missed it:

Professor Timothy S. Jost in The Health Care Blog ,”Are Cooperatives a Reasonable Alternative to a Public Plan?”  (Originally posted here on Health Reform Watch, then picked up by THCB).

9. Wild card Pick: If you haven’t heard about the astounding medical applications of a pooch’s powerful snout, this short video (with an accompanying transcript) from National Geographic is definitely worth watching.

Substance: Obama names Regina Benjamin, MD, MBA, to Surgeon General Post

In a week that has us considering personal experience as it relates to job performance as regards a seat on the Nation’s Highest Bench, I’ve found myself considering the well worn aphorism of Oliver Wendell Holmes: “The life of the law has not been logic: it has been experience….The law embodies the story of a nation’s development through many centuries, and it cannot be dealt with as if it contained only the axioms and corollaries of a book of mathematics.”

And it has occurred to me that perhaps Holmes’ rubric lends something to a consideration of health care reform and President Obama’s pick for Surgeon General, Regina Benjamin, MD, MBA.

Although much in healthcare (and healthcare reform) can be (and perhaps must be) the complex and dismal mathematics of zero sum, gored oxen and have and have not—as Holmes reminds us: the math is not all. Yesterday, in a post by Professor Kathleen M. Boozang, we looked at health reform through the lens of Catholic social doctrine: a proposition leading to the conclusion that

We must pursue a system in which each of us has access to health care, which necessarily requires that, in solidarity for our fellow being, those of greater fortune accept the responsibility for those who do not, giving the gift of an opportunity for the basic good of health.

In a recent post considering Atul Gawande’s article on McAllen, Texas, which lamented Medicine performed as a sheer business proposition (McAllen is “one of the most expensive health-care markets in the country” and suffers from what Gawande sees as an all too prevalent, treat the patient as though they were an ATM mentality), we came face to face with Immanuel Kant’s Categorical Imperative:  “Act in such a way that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end.”

We noted then that we found it “passing strange to find ourselves, in the midst of such daunting medical, technical, and financial data contained within the  proposed solutions and counter-solutions to arrive at this–a simple (but difficult) age old moral truth.”

And that it had “struck me while reading that what Gawande finds is essentially a medical culture functioning, and incentivized, contrary to Kant’s categorical imperative (see above): the simple moral admonition that one must not merely “use” others.”

And then there’s Dr. Benjamin.

She is the founder and CEO of the Bayou La Batre Rural Health Clinic in Bayou La Batre, Alabama (if the name of the town sounds vaguely familiar, think Forrest Gump, shrimping boat). Emily P. Walker, Washington Correspondent, MedPage Today reports:

A major supplier of charity care, Dr. Benjamin has provided medical care to patients in the Gulf Coast regardless of insurance status.

“I decided I would treat patients regardless of their ability to pay,” she said when she accepted the president’s nomination in the Rose Garden on Monday. “It should not be this hard for doctors and other providers to provide care for their patients.”

Dr. Benjamin’s practice was destroyed several times by hurricanes, and once by a fire, but she always rebuilt, sometimes by refinancing her home and maxing out her personal credit cards, President Obama said Monday.” (emphasis added).

She is also said to have “had to moonlight in an emergency department and nursing homes to keep her practice open.”

It is notable that while Congress argues over where the money will come from to fund health care reform, when faced with the need to rebuild the clinic she herself had started– which offers care regardless of ability to pay–Dr. Benjamin, despite the MBA which follows her name, maxed out her credit cards, mortgaged her house and took a part-time job.

Extraordinary and beyond the call. Perhaps beyond Kant, and certainly beyond the math. According to the NY Times, “Dr. Benjamin is a devout Roman Catholic.”

By no means am I advocating this degree of personal risk and sacrifice as a paradigm for health care reform. It is much too much to ask or expect–as it seems Dr. Benjamin herself well understands: “It should not be this hard for doctors and other providers to provide care for their patients.” Agreed.

As noted in the post,  “Why McAllen Texas Kant be the Answer to Health Reform,”

Pragmatically, as one looks upon the current system of health care and health care finance,  it is well worth quoting Harold Luft from today’s Washington Times: “A redesigned system must create new incentives for those entities so their self-interested behavior leads to a better societal outcome.” Gawande offers examples of systems which provide an infrastructure conducive to Mr. Kant’s imperative.

Dr. Benjamin offers an example of personal commitment despite extraordinary disincentives. The Huffington Post reports

She said she would combat preventable diseases. Her father died with diabetes and high blood pressure, her only brother of HIV. Her mother died of lung cancer because as a girl “she wanted to smoke just like her twin brother,” an uncle now on oxygen.

“I cannot change my family’s past. I can be a voice in the movement to improve our nation’s health care and our nation’s health,” Benjamin said. “I want to be sure that no one falls through the cracks as we improve our health care system.”

Sounds like the voice of experience.

Senators Harkin & Baucus Considering Enabling Employers to Punish Employees for Failure to Address Health Issues

In Self Reliance Emerson states that “Society everywhere is in conspiracy against the manhood of every one of its members. Society is a joint-stock company in which the members agree for the better securing of his bread to each shareholder, to surrender the liberty and culture of the eater.”

If Tom Harkin has his way, in addition to liberty, you may find yourself surrendering your cheeseburgers as well. The New York Times reports that Mr. Harkin and Max Baucus have proposed that in order to lower the costs of health care, employers be given the ability to reward and punish workers according to their relative health. Such rewards and punishments will be meted out in accord with measures such as cholesterol readings, blood sugar, weight, smoking, etc…

I would suggest that to reward is one thing, to punish is another. To John Stuart Mill is attributed the statement at the heart of classical liberal notions of ordered liberty: “The rights of your fist end at my nose.” I believe Mr. Harkin and Mr. Baucus have forgotten where their noses end and mine begins.

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