Health of Previously Uninsured Adults After Acquiring Medicare Coverage

While I work through a re-jig of my Cost-Benefit Analysis syllabus (actually it’s really Cost-Effectiveness Analysis, but the University calls it Cost-Benefit Analysis and never comes into the classroom to check, so. The differences between Cost-Benefit, Cost-Effectiveness and Cost-Utility Analysis are not problematic to navigate CEA is a better umbrella). I will take your time up with some of it.

This is going to go into a discussion that we have, early on, concerning key issues “going forward”. Methodological, social, ethical, etc. It’s a graduate class, but the students usually have not had any real exposure to things like proper analysis, research, research papers, dissemination – which is to be expected, at that level. We take the first few weeks to give them a feel for (a) what’s out there, and what’s important, and (b) the aesthetic, the structure, of applied research. It’s well-worth the time spent.

So to this paper from the Journal of the American Medical Association:

Uninsured near-elderly adults, particularly those with cardiovascular disease or diabetes, experience worse health outcomes and use more health services as Medicare beneficiaries after age 65 years than insured near-elderly adults. Because chronic diseases are prevalent and insurance coverage is often unaffordable for older uninsured adults, the impact of near-universal Medicare coverage at age 65 years on the health of previously uninsured adults may be substantial.

Most studies assessing the health consequences of lacking coverage have relied on cross-sectional data and study designs that have not allowed coverage effects to be distinguished from unobserved differences between insured and uninsured persons. A few studies have used cross-sectional data that span multiple years or ages to conduct more rigorous comparisons. For example, an assessment of the introduction of Medicare in 1965 found no discernible impact on mortality for beneficiaries,15 but subsequent medical advances may have improved the effectiveness of health care for elderly Americans.16 A recent cross-sectional analysis of age profiles found that Medicare eligibility at age 65 years was associated with modest gains in self-reported general health status for less-educated adults and minority groups, but uninsured adults and those with specific conditions could not be longitudinally followed as they became eligible for Medicare.

…

The objective of our study was to assess the effect of Medicare coverage at age 65 years on trends in self-reported health outcomes from ages 55 through 72 years for previously uninsured adults, particularly those with cardiovascular disease or diabetes. We compared cohorts of insured and uninsured near-elderly adults using a quasi-experimental design and longitudinal data on a broad array of general, physical, and mental health measures from the nationally representative Health and Retirement Study. We hypothesized that acquiring Medicare coverage would attenuate adverse health trends for previously uninsured adults relative to previously insured adults, as improved access to care, greater use of beneficial medications and procedures, and more effective management of chronic conditions helped to alleviate symptoms, maintain functioning, and prevent or postpone complications.

You will find it is familiar to a lot of what was written here, concerning SCHIP: give people insurance, and you give them access to health care. Give them access to health care, and you improve their health. This does not include the argument that it is not the absence of insurance but the high cost of care that is the problem – this, too, will be a defining issue for the our retiree Boomer self-interest.

Back with McWilliams et al, some results (click for large version):

Among 5766 adults (79.7%) who completed at least 1 survey after age 65 years, previously uninsured adults were less likely to report coverage for prescribed medications after age 65 years (62.7% vs 77.9%; P < .001). Among the study cohort, 4443 adults (61.4%) reported diagnoses of hypertension, heart disease, stroke, or diabetes before age 65 years, of whom 3103 (69.8%) were insured and 1340 (30.2%) were uninsured. Among 838 adults with diabetes in our study cohort who were also surveyed in 2003, 541 (64.6%) underwent HbA1c testing.

Before age 65 years, summary health scores worsened at a greater rate for uninsured adults than for insured adults (mean annual trend, –0.23 vs –0.15; P = .002) and were significantly worse at age 65 years (mean score, 20.75 vs 22.29; P < .001) (Table 2). After age 65 years, however, this adverse trend differentially improved for previously uninsured adults (differential change in annual trend, +0.20; P = .002) such that summary scores after age 65 years indicated near maintenance of health for previously uninsured adults but continued deterioration for previously insured adults (mean annual trend after age 65 years, –0.07 vs –0.19; P = .049 [test not shown]). In comparisons of component health trends before and after age 65 years, previously uninsured adults reported significant improvements relative to previously insured adults in change in general health, agility, and depressive symptoms (Table 2). Persistently uninsured adults reported greater declines before age 65 years than intermittently uninsured adults and worse summary health scores at age 65 years (mean difference, –0.69; P = .07 [data not shown]), but changes in health trends after age 65 years were similar for these 2 groups of previously uninsured adults (P = .81).

Which is, more or less, what one would expect. Near-elderly non-insured (since I’m sure the survey did not specifically find people, give them insurance, then take it away again) are going to be in just-plain-shit health, relative to their peers. They are more likely to have lower incomes, more likely to have avoided preventive (or even early palliative or curative) physician care, less likely to have had any sort of access to medication (particularly in the US) – you name it, they didn’t get it or didn’t do it. Meaning when the retire and hit Medicare, they do.

This means two things: first, as this article shows, we observe health-gains from people having this access – indicating similar gains, probably greater gains, exist if they had such access all along. Meaning expanded health care/insurance, one way or the other.

Second, as per the SCHIP plaint, an ounce of prevention, etc. – particularly now, as Boomers retire. Every individual will invest in their health, to the extent that they believe they can afford to do so (this is also why insurance, coupled with rapidly appreciating care costs, is a recipe for serious problems). As this enormous lump of people retire, the burden that they place upon Medicare is going to be substantial. Couple that with moves by companies to get people off their books and onto government books, and the problem only becomes worse.

The issue for us will be pretty much this: the increasing importance of access to care, as more people retire. Of follow-up importance is the cost: as more people retire, will price-rationing hold, as an ideal? If not, how will the US system expand their use of non-price rationing? Will America soon need a US NICE or PBS, to hold back the tide? At what point (at what age, and what severity, at what condition) do we decide that it is “worth it” to help people? We cannot just help everyone via Medicare: put more people on it, and – in the US – it will be able to do less. With limited health care resources, how do we decide who gets the resources when an increasing bulk of the electorate transition to fixed-income retirees?

I don’t yet know the make-up of my students for CBA. I’m considering brining in some climate change/Bjorn Lomberg stuff, too. As well as agricultural problems.

City Hall to Reduce Parking Placards 20% and Centralize Control

That’s the title of the post to which I’m referring (hence the “z”). Another story involving the reconciliation of incentive structures and control, from Streetsblog.

Acknowledging the dissonance between his congestion mitigation efforts and City employees’ flagrant parking abuse, Mayor Bloomberg today announced a reduction in the number of city government parking permits and new, more centralized procedures for the issuance of placards.

The problem:

That’s quite near the site of my recent experience with UPS, by the by. How is a city that can’t govern how it parks supposed to administer to how private corporations do so? Uncivilservants.org, the makers of that image, also do a good turn in USPS officials:

Bicycles Only, a Flickr site, added to the complaint (his being that this won’t affect cyclists), citing things like actual uniform cars breaking traffic laws. In front of City Hall:

Streetsblog points to the site NYPD Rant (which does exactly what it says on the box), whereat the following was among the responses:

if the city yanks our plaques, then the war is on. the pba can have some printed for its members, active and retired, and i will bang out every car with official plates that is illegally parked or runs a light (the offenders can explain themselves in front of an administrative judge at AAB or parking violations bureau)….JUST WAIT AND SEE

It is a message board, yes. The grammar and orthography are just atrocious. As long as they know not to shoot me, I won’t complain. They also tear up the NY Times, so. This response is, while hypocritical (since they will, in all likelihood, not enforce it against their comrades – see above image of uniformed cars parked illegally) basically correct. Most parking restrictions are based either upon revenue (meters) or safety (everything else). Having a permit inside your windscreen that says you belong somewhere in the civil service hardly makes one’s car not a safety hazard.

From the Mayor’s press release

… the NYPD will create a new enforcement unit to ensure compliance and agencies will develop enforcement procedures to prevent the abuse of placards. A multi-agency working group will implement and coordinate the various measures being taken and take additional actions, including a review of existing agency parking-space allocations and on-street parking regulations.

This is a standard regulation problem (don’t get me wrong – a 20% reduction in parking permits can only be a good thing, especially in very urban areas. Much of the problem is people who work very near a subway station anyway, and should be driving or parking in the city at all). People will speed, so long as they believe they may not be caught. People will also park wherever they please, so long as they believe that a plaque on their car will prevent them being ticketed, clamped or towed.

In this instance, there really isn’t a mechanism for incentives to be brought to bear. From what I read at NYPD Rant, putting parking permits into contracts would not work (this would be where the “war” stuff in the post above comes in), so the idea of offering incentives based upon not taking a plaque for one’s car probably won’t work, because it’s too much like making the others pay for their parking. Centralised issuing is certainly a good idea (although we shall see how equitably the new 80% of permits are allocated, with one service at the centre).

I don’t believe the City is asking for my advice (and I doubt they read this blog), but the key is administration of the system – something Bloomberg probably already understands, since it’s a technocrat’s problem (and his press release specifically mentions “smart placards”). If you’re given a plaque for a specific reason, a simple barcode-scanner should be able to tell a parking official that you’re mis-using it, parking illegally on the other side of town. And away we go. It really should not be that difficult to administer or maintain. Even the cops would like the idea, as far as I can tell.

LFA Sonar, round next

Last time I was making fun of this line:

“The safety of the whales must be weighed, and so must the safety of our warriors. And of our country.”

from the 9th Circuit Court of Appeals (I never did find out how the average “warrior” felt about whales needing their brains blown up to keep them safe. There’s just something emasculating about it).

Now we’re on to a hold ‘nother frequency (no, seriously):

A federal judge forbade the Navy on Thursday from using a powerful form of sonar within 12 miles of the California coast and slapped other restrictions on naval war exercises in a ruling that could have repercussions in the Pacific Northwest.

U.S. District Judge Florence Marie-Cooper said noise from the Navy’s midfrequency sonar far outstrips levels at which federal rules require ear protection for humans on the job. Whales’ hearing is extremely sensitive.

“The court is persuaded that the (protection) scheme proposed by the Navy is grossly inadequate to protect marine mammals from debilitating levels of sonar exposure,” Marie-Cooper wrote in her ruling.

The Navy offered to reduce the sonar’s intensity when whales approached within about 1,100 yards and power down further before shutting the sonar off when the creatures got within 200 yards. The judge ordered sonar shut off when marine mammals are within 2,200 yards.

By the Navy’s own estimate, it would harass or harm marine mammals, as prohibited by the Endangered Species Act, about 170,000 times, the judge said. The Navy said the series of 14 exercises would temporarily deafen whales 8,000 times and cause permanent injuries in more than 400 cases.

I like those numbers. The Endangered Species Act (1973 and, seriously, Nixon really did do a tonne of cool stuff), by the by (there is also the Marine Mammal Protection Act (1972), while we’re on the topic), contains passages such as

The Congress finds and declares that —

1. various species of fish, wildlife, and plants in the United States have been rendered extinct as a consequence of economic growth and development untempered by adequate concern and conservation;
2. other species of fish, wildlife, and plants have been so depleted in numbers that they are in danger of or threatened with extinction;
3. these species of fish, wildlife, and plants are of esthetic, ecological, educational, historical, recreational, and scientific value to the Nation and its people;

… the United States has pledged itself as a sovereign state in the international community to conserve to the extent practicable the various species of fish or wildlife and plants facing extinction, pursuant to —

1. migratory bird treaties with Canada and Mexico;
2. the Migratory and Endangered Bird Treaty with Japan;
3. the Convention on Nature Protection and Wildlife Preservation in the Western Hemisphere;
4. the International Convention for the Northwest Atlantic Fisheries;
5. the International Convention for the High Seas Fisheries of the North Pacific Ocean;
6. the Convention on International Trade in Endangered Species of Wild Fauna and Flora; and
7. other international agreements;

and … encouraging the States and other interested parties, through Federal financial assistance and a system of incen-tives, to develop and maintain conservation programs which meet national and international standards is a key to meeting the Nation’s international commitments and to better safe-guarding, for the benefit of all citizens, the Nation’s heritage in fish, wildlife, and plants.

… The purposes of this Act are to provide a means whereby the ecosystems upon which endangered species and threatened species depend may be conserved, to provide a program for the conservation of such endangered species and threatened species, and to take such steps as may be appropriate to achieve the purposes of the treaties and conventions set forth in subsection (a) of this section.

The Marine Mammal Protection Act is as lofty in its ideals (being, after all, an Act that protects even non-endangered species):

The Congress finds that —

1. certain species and population stocks of marine mammals are, or may be, in danger of extinction or depletion as a result of man’s activities;
2. such species and population stocks should not be permitted to diminish beyond the point at which they cease to be a significant functioning element in the ecosystem of which they are a part, and, consistent with this major objective, they should not be permitted to diminish below their optimum sustainable population.

Further measures should be immediately taken to replenish any species or population stock which has already diminished below that population. In particular, efforts should be made to protect essential habitats, including the rookeries, mating grounds, and areas of similar significance for each species of marine mammal from the adverse effect of man’s actions;

All of this, of course, means less since the military went to war against the environment (not without help, as last year’s series by the Washington Post illuminated).

This is the other problem: speaking Environmental-Economically, there isn’t a great deal on offer, in the way of options. A recalcitrant military, and complicit/compliant legislative/executive branches do not make for workable solutions to serious negative externalities. Particularly over the last 6 years – I’m sure the likes of Inhofe and Stevens (okay, possibly just Inhofe) are honest and sincere men, but to have them in charge of things like this just wasn’t helping. These are the fortunes of democracy.

More generally, though, a government cannot construct a market to solve an environmental problem, when that problem is caused by its own military (still less these days). A government can hardly tax its own military punitively for those actions. All a government can do is regulate itself. If it won’t do that, and we don’t care enough to vote our force (and, let’s face it, we don’t – we still haven’t done a damn thing to stop random mass shootings in this country. How much less do we, as an electorate, care about marine mammals?), there aren’t really any other options. No military commander is likely to turn around and announce that they think they’ve played with their billion-dollar toys long enough for the time being, and anyway dolphins are getting hurt.

Final quote:

The service said exercises off Southern California are important because they give sailors training around undersea mountain ranges like those where they might chase subs elsewhere in the world.

“Despite the care the court took in crafting its order, we do not believe it struck the right balance between national security and environmental concerns,” said Jeff Davis, a Navy spokesman at the Pentagon.

Give a person a hammer, and every problem looks like a nail. It’s the definitions of “national security” that deliberately exclude the environment that are the problem.