The NEJM discusses why the government can’t do …anything?

Quite a cool editorial in this week’s New England Journal of Medicine:

The conflagration over the reauthorization of the State Children’s Health Insurance Program (SCHIP) offers a compelling example of Washington’s current inability to address even seemingly uncontroversial matters such as improved health care coverage for children.

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Why would the President veto bipartisan legislation that does precisely what he insisted on — namely, aggressively enroll the poorest children? One might blame the poisonous atmosphere that pervades Washington these days, but other important social policy reforms have managed to get through.

One answer lies in a far larger dimension of SCHIP that is basic to any health insurance legislation — namely, the legislative architecture of the reform plan, its structural and operational approach. Viewed from this vantage point, the SCHIP battle turns out not to have been about family-income assistance levels or the mechanism for financing coverage subsidies (although both the Medicare managed-care industry and the tobacco companies weighed in noisily on the latter question).

Instead, the issue became the role of government in organizing and overseeing the health care marketplace (see graphs). SCHIP uses the power of government to form insured groups, select qualified plans, oversee plan operations, and measure results. It is this architecture to which the President was referring when he said that the legislation would move the health care system in the wrong direction.

The graphs in question are quite useful:

So enrollment (the number of children being helped) is capped out and declining, while the cost is increasing. The problem? Not health insurance at all, but health care costs themselves.

So the identification that the architecture of government intervention/support, ideologically, is the sticking point, is quite correct. The real problem, in terms practical – meaning actually helping poor kids – isn’t insurance, but costs. As previously discussed, SCHIP is the wrong method by which to achieve this outcome, when it is unnecessarily cost-increasing.

Of course, this runs into the problem of letting the government manage such a thing as hospitals. Given how well they performed on something like the mere legislation towards such an end, how much do we trust them to do anything competently at all?

Post-script: a colleague and I had been discussing an interesting piece of analysis, which neither of us will ever find the time to undertake. It is this:

1. How much money/resources were employed by the US government in pursuing this legislation? This means paper, ink, admin support, debating/voting hours – costing in entirety the politics played to get this legislation up and down the monkey-bars of “government”
2. How much health-care-for-children could actually have been provided for that money?

The idea is that actually doing something was the opportunity cost of governmenting the thing into being. We believe the numbers would – very, entirely, rightly – thoroughly embarass this or any other body of politicians.

Does Preventive Care Save Money?

Yes and no. Yes, because prevention is often worth a pound of cure, and no, because often preventive care can identify problems that are expensive to fix (as opposed to not spotting them, after which the patient’s death is less expensive. Look, I’m not a dick – that’s just the way the costs work).

That’s the short version of this quite well-argued piece in the latest New England Journal of Medicine, Does Preventive Care Save Money? Health Economics and the Presidential Candidates.

With health care once again a leading issue in a presidential race, candidates have offered plans for controlling spiraling costs while enhancing the quality of care. A popular component of such plans involves greater promotion of preventive health measures. The first element in Hillary Clinton’s plan is to “focus on prevention: wellness not sickness.” John Edwards has stated that “study after study shows that primary and preventive care greatly reduces future health care costs, as well as increasing patients’ health.” Mike Huckabee has said that a focus on prevention “would save countless lives, pain and suffering by the victims of chronic conditions, and billions of dollars.” Barack Obama has argued that “too little is spent on prevention and public health.”

Indeed, some evidence does suggest that there are opportunities to save money and improve health through prevention. Preventable causes of death, such as tobacco smoking, poor diet and physical inactivity, and misuse of alcohol have been estimated to be responsible for 900,000 deaths annually — nearly 40% of total yearly mortality in the United States. Moreover, some of the measures identified by the U.S. Preventive Services Task Force, such as counseling adults to quit smoking, screening for colorectal cancer, and providing influenza vaccination, reduce mortality either at low cost or at a cost savings.

Sweeping statements about the cost-saving potential of prevention, however, are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can add to health care costs.[PDF] For example, screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures. Preventive measures that do not save money may or may not represent cost-effective care (i.e., good value for the resources expended). Whether any preventive measure saves money or is a reasonable investment despite adding to costs depends entirely on the particular intervention and the specific population in question. For example, drugs used to treat high cholesterol yield much greater value for the money if the targeted population is at high risk for coronary heart disease, and the efficiency of cancer screening can depend heavily on both the frequency of the screening and the level of cancer risk in the screened population.

The focus on prevention as a key source of cost savings in health care also sidesteps the question of whether such measures are generally more promising and efficient than the treatment of existing conditions. Researchers have found that although high-technology treatments for existing conditions can be expensive, such measures may, in certain circumstances, also represent an efficient use of resources. It is important to analyze the costs and benefits of specific interventions.

I agree. I think the authors are a mite too involved with efficiency-based arguments (as opposed to equity-based arguments) and, as a result, run right past the fact that unversal health care (for example) is an intervention – possibly the intervention.

Their solution? A meta-analysis! Possibly useful, possibly not. Meta-analyses are often of little worth. The result:

Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not. Careful analysis of the costs and benefits of specific interventions, rather than broad generalizations, is critical. Such analysis could identify not only cost-saving preventive measures but also preventive measures that deliver substantial health benefits relative to their net costs; this analysis could also identify treatments that are cost-saving or highly efficient (i.e., cost-effective).

The chart is interesting. I’m not so sure this is way to go: we are interested in the cost-effectiveness of preventive care, relative to palliative (or curative). This has dis-aggregated the studies along identified cost-effectiveness thresholds, but that is not what is of policy interest, surely. Moreover I see, in this, a big risk of Simpson’s paradox. Looking at the table they provide of “selected” studies, I also see a mis-match in the conditions to which preventive vs. palliative/curative care are being sorted. Can we compare colonoscopy screening with anti-retroviral treatment for HIV? ‘Cause I have a suspicion that is what might have occurred.

This is standard for systematic reviews: one is pulling together mis-matched data for retrospective analysis for which the data was never designed. This generates value-of-information problems across the board, and we ought to remember this as we ponder the results. Ultimately, too (and more importantly), I think this piece really mis-reads the point of so-called “socialised medicine”.

That said, the authors are up-front about their motive not being to solve the problem: they are commenting upon less-informed debate by Presidential candidates. Now, one (say, me) could easily reply that this is pointless: Presidential candidates are selling us themselves, not a policy – there is a big agency problem and we really shouldn’t take them too seriously. If a candidate trotted out his/her future cabinet and invited the country to openly and knowingly elect the lot of them, then I’d pay attention.

Market failure in US Health Care

Back to the costs of the US Health Care system. From the New England Journal of Medicine:

U.S. health care expenditures rose 6.7% in 2006, the government recently reported. According to the Centers for Medicare and Medicaid Services, total health care expenditures exceeded $2.1 trillion, or more than $7,000 for every American man, woman, and child. Medicare costs jumped a record 18.7%, driven by the new privatized drug benefit. Total health care spending, now amounting to 16% of the gross domestic product, is projected to reach 20% in just 7 years.

Relentless medical inflation has been attributed to many factors — the aging population, the proliferation of new technologies, poor diet and lack of exercise, the tendency of supply (physicians, hospitals, tests, pharmaceuticals, medical devices, and novel treatments) to generate its own demand, excessive litigation and defensive medicine, and tax-favored insurance coverage.

Here is a second opinion. Changing demographics and medical technology pose a cost challenge for every nation’s system, but ours is the outlier. The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization. The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation. Profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and less appreciated syndrome is the set of perverse incentives produced by commercial dominance of the system.

Our author is correct: the US is an outlier when it comes to the cost of care:

Although the problem is – necessarily – more complex than that. Having higher expenditures on health is not surprising. The US also has more bloody money – I’m sure their expenditures on everything from vehicles to fancy soap. The key is, does the US get better health outcomes for that money? No, no it doesn’t.

This is the market failure – the US system is structured in a cost-inflating manner. Cost containment is just not adequately instituted.

The private insurance system’s main techniques for holding down costs are practicing risk selection, limiting the services covered, constraining payments to providers, and shifting costs to patients. But given the system’s fragmentation and perverse incentives, much cost-effective care is squeezed out, resources are increasingly allocated in response to profit opportunities rather than medical need, many attainable efficiencies are not achieved, unnecessary medical care is provided for profit, administrative expenses are high, and enormous sums are squandered in efforts to game the system. The result is a blend of overtreatment and undertreatment — and escalating costs. Researchers calculate that between one fifth and one third of medical outlays do nothing to improve health.

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Many U.S. insurers do reward physicians for following standard clinical practices, but these incentives do not aggregate to an efficient national system of care. After more than three decades of managed care — and the same three decades of studies by Wennberg and colleagues identifying wide variations in practice patterns — consistent practices are still far from the norm. Commercial incentives are not fixing what’s broken.

Instead, cost-containment efforts have fallen heavily on primary care physicians, who have seen caseloads increase and net earnings stagnate or decline. A popular strategy among cost-containment consultants relies on the psychology of income targeting. The idea is that physicians have a mental picture of expected earnings — an income target. If the insurance plan squeezes their income by reducing payments per visit, doctors compensate by increasing their caseload and spending less time with each patient.

This is among the reasons why nationalised/socialised/universal (call it what you will) Health Care/Insurance makes so much sense: only a government is big enough to achieve national agency on behalf of consumers of health care. The problem, then, isn’t market failure per se – it’s that we have a tonne of markets, haphazardly stitched together nation-wide, when what is required is a national market. Whether a national market with monopsony purchasing power or not is another issue.

Here’s a third opinion. Back up in the figure/tables, the Rest of the World is getting equivalent or better health outcomes, for far less money. How are they able to keep their technology costs so low, relative to the US? Because the US spends all the money on technological change. The rest of the world can keep its costs down by relying upon the US system to reward new technologies, which we then use. In effect, US patients are subsidising patients in pretty much every other country on earth.

I’m not suggesting this is either “right” or “wrong”, nor am I suggesting that this phenomenon somehow makes the US structure for cost-containment “good” – because it certainly is not, nor is it efficient, nor is it in any way contributing positively to US patient safety. It’s a perspective to bear in mind, though. Every/anytime you suffer a non-American giving you shit about the expense of health care in the US, remind them that it is thanks to that expense that they can enjoy less-costly care.

Just remember that your system is still wildly inefficient and overly costly, though, and that you’re being thoroughly ripped off with respect to your health outcomes.

Coping with health-care costs: implications for the measurement of catastrophic expenditures and poverty

A new paper came down the Health Economics RSS feed (what of it? I’m a Health Economist. It’s perfectly normal), by Gabriela Flores (not that one), Jaya Krishnakumar, Owen O’Donnell and Eddy van Doorslaer.

Abstract:

In the absence of formal health insurance, we argue that the strategies households adopt to finance health care have important implications for the measurement and interpretation of how health payments impact on consumption and poverty. Given data on source of finance, we propose to (a) approximate the relative impact of health payments on current consumption with a coping-adjusted health expenditure ratio, (b) uncover poverty that is hidden because total household expenditure is inflated by financial coping strategies and (c) identify poverty that is transient because necessary consumption is temporarily sacrificed to pay for health care.

Measures that ignore coping strategies not only overstate the risk to current consumption and exaggerate the scale of catastrophic payments but also overlook the long-run burden of health payments. Nationally representative data from India reveal that coping strategies finance as much as three-quarters of the cost of inpatient care. Payments for inpatient care exceed 10% of total household expenditure for around 30% of hospitalized households but less than 4% sacrifice more than 10% of current consumption to accommodate this spending.

Ignoring health payments leads to underestimate poverty by 7-8% points among hospitalized households; 80% of this adjustment is hidden poverty due to coping.

They present an argument in favour of distinguishing the different impacts of catastrophic health expenditures, defined thus (and using a rural household as exemplar):

“Coping” consist of non-income financing of health care: savings, borrowings, selling assets. Specifically such expenditures can generate transient poverty, for households that finance such costs using household income, as well as identifying hidden poverty, for households that finance such costs with coping strategies:

“Hidden poverty” is defined thus:

Households that are poor on the basis of their sustainable level of consumption are not recognized as poor by conventional measures because their use of savings, assets or borrowing to pay for large healthcare costs temporarily raises their total spending above the poverty threshold.

It is more of a welfare measure of the loss of household utility/welfare, created by having to finance catastrophic care using short-term sacrifices of wealth that leave the household vulnerable to future shocks.

“Transient poverty” is short-run household poverty that could be eliminated with insurance for catastrophic care (such that households did not need to pay Out-Of-Pocket): it is the (or a heretofore non-measured part of the) opportunity cost of not having such insurance.

Why the distinction?

In the context of low-income populations with limited formal health insurance coverage, this paper argues that the strategies households adopt to finance health care have important implications for both the measurement and the interpretation of how health payments impact on household consumption, welfare and poverty. Given the availability of cross-section data containing information on the means of financing health payments, we propose that the relative impact of those payments on consumption of other goods is best approximated by payments financed from income as a proportion of that income.

Measures based on the ratio of health payments to total household expenditure, which have been used previously, overestimate the risk to current consumption induced by health payments and so exaggerate the scale of catastrophic payments. Failure to take account of the extent to which health care is financed from running down savings, borrowing and depleting assets leads to the oversight of the long-run opportunity cost of health payments.

We show how information on the source of finance can be used to uncover poverty that is hidden by conventional measures because total household expenditure is inflated by payments for health care that are financed from coping strategies. We propose that the impact of health payments on transient poverty be approximated through assessing poverty on the basis of current income both gross and net of health payments financed from income alone.

The authors consider India. Given the nature of the appreciation in health care prices here in the US, it’d make for a great study for the opportunity cost to the US economy of not having such insurance across the board.

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.

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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.

The “healthy retiree” bias just became stronger

The “healthy retiree” bias runs thus – particularly in the US: if you’re healthy, you’re more likely to retire; if you are not healthy, you are more likely to need employer-provided medical insurance, so you are less likely to retire (Michael Moore’s Sicko had at least one such example). This is, necessarily, confounded by income (i.e. if you can afford to self-insure, the problem goes away, but health and wealth are concordant goods).

So to the news! They are discussing, over at the Wall Street Journal, the ruling, by the Equal Employment Opportunity Commission, that employer synchronisation of retiree health benefits with Medicare is not unjust discrimination according to age:

Employers who provide retiree health benefits generally “coordinate” those benefits with Medicare by supplementing the government healthcare or by offering retirees a “bridge” benefit to cover health expenses after employees retire until they become Medicare-eligible. Until the 2000 interpretation, employers believed that the ADEA permitted them to coordinate any retiree health benefits they provided with Medicare without having to ensure that the benefits received by Medicare-eligible retirees were the same as those received by younger retirees.

To correct the problem, the new regulation provides an exemption for ADEA coverage for this common and longstanding employer practice. The Commission voted to approve this regulation on April 22, 2004, but the AARP sued the EEOC in early 2005 to prevent its publication. After several years of litigation, the EEOC emerged victorious as the Third Circuit Court of Appeals found that the rule was “a reasonable, necessary and proper exercise of [EEOC’s] authority.”

EEOC Legal Counsel Reed Russell said, “Our rule makes clear that it is lawful for employers to continue to provide retirees with the health benefits they currently receive. Contrary to what some interest groups have erroneously asserted, the rule will not require any cuts to retiree benefits.”

I imagine the rule will not – it will, however, allow those cuts, as well as allowing more (or all of any new) money to flow to new retirees – read Baby Boomers. Is this age-discrimination? Yes – and the EEOC as much as admits it. Over at the WSJ:

The U.S. Court of Appeals for the Third Circuit found in favor of the federal government. But, the court added, “we recognize with some dismay that the proposed exemption may allow employers to reduce health benefits to retirees over the age of 65 while maintaining greater benefits for younger retirees.”

Although one can (and no doubt several did) make the argument that, as far as equity goes, there’s no reason why two discrete(ish) sets of retirees should receive equal compensation, when the Boomer set probably contributed more, while they worked.

So why exclude this practice from coverage of the Age Discrimination in Employment Act (ADEA)? Because if the complaint was upheld the employers would probably have dropped the whole thing for everyone, where they could. Does the Federal government want a world in which Boomers retire, with only the Federal government to pay for their care? Of course not. They’d have to put our tax dollars to some kind of practical use in terms of American human and social capital. Can’t have that.

Once again, though, we see more patchwork palliatives for the actual problem – escalating health care costs. I’m sure messing about with the COBRA laws is next.