• Why the U.S. Spends So Much More Than Other Nations on Health Care

    The following, jointly authored by Austin Frakt and Aaron Carroll, originally appeared on The Upshot (copyright 2018, The New York Times Company). It also appeared on page B1 of the January 2, 2018 print edition.

    The United States spends almost twice as much on health care, as a percentage of its economy, as other advanced industrialized countries — totaling $3.3 trillion, or 17.9 percent of gross domestic product in 2016.

    But a few decades ago American health care spending was much closer to that of peer nations.

    What happened?

    A large part of the answer can be found in the title of a 2003 paper in Health Affairs by the Princeton University health economist Uwe Reinhardt: “It’s the prices, stupid.

    The study, also written by Gerard Anderson, Peter Hussey and Varduhi Petrosyan, found that people in the United States typically use about the same amount of health care as people in other wealthy countries do, but pay a lot more for it.

    Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute, studies how health systems from various countries compare in terms of prices and health care use. “What was true in 2003 remains so today,” he said. “The U.S. just isn’t that different from other developed countries in how much health care we use. It is very different in how much we pay for it.”

    A recent study in JAMA by scholars from the Institute for Health Metrics and Evaluation in Seattle and the U.C.L.A. David Geffen School of Medicine also points to prices as a likely culprit. Their study spanned 1996 to 2013 and analyzed U.S. personal health spending by the size of the population; its age; and the amount of disease present in it.

    They also examined how much health care we use in terms of such things as doctor visits, days in the hospital and prescriptions. They looked at what happens during those visits and hospital stays (called care intensity), combined with the price of that care.

    The researchers looked at the breakdown for 155 different health conditions separately. Since their data included only personal health care spending, it did not account for spending in the health sector not directly attributed to care of patients, like hospital construction and administrative costs connected to running Medicaid and Medicaid.

    Over all, the researchers found that American personal health spending grew by about $930 billion between 1996 and 2013, from $1.2 trillion to $2.1 trillion (amounts adjusted for inflation). This was a huge increase, far outpacing overall economic growth. The health sector grew at a 4 percent annual rate, while the overall economy grew at a 2.4 percent rate.

    You’d expect some growth in health care spending over this span from the increase in population size and the aging of the population. But that explains less than half of the spending growth. After accounting for those kinds of demographic factors, which we can do very little about, health spending still grew by about $574 billion from 1996 to 2013.

    Did the increasing sickness in the American population explain much of the rest of the growth in spending? Nope. Measured by how much we spend, we’ve actually gotten a bit healthier. Change in health status was associated with a decrease in health spending — 2.4 percent — not an increase. A great deal of this decrease can be attributed to factors related to cardiovascular diseases, which were associated with about a 20 percent reduction in spending.

    This could be a result of greater use of statins for cholesterol or reduced smoking rates, though the study didn’t point to specific causes. On the other hand, increases in diabetes and low back and neck pain were associated with spending growth, but not enough to offset the decrease from cardiovascular and other diseases.

    Did we spend more time in the hospital? No, though we did have more doctor visits and used more prescription drugs. These tend to be less costly than hospital stays, so, on balance, changes in health care use were associated with a minor reduction (2.5 percent) in health care spending.

    That leaves what happens during health care visits and hospital stays (care intensity) and the price of those services and procedures.

    Did we do more for patients in each health visit or inpatient stay? Did we charge more? The JAMA study found that, together, these accounted for 63 percent of the increase in spending from 1996 to 2013. In other words, most of the explanation for American health spending growth — and why it has pulled away from health spending in other countries — is that more is done for patients during hospital stays and doctor visits, they’re charged more per service, or both.

    Though the JAMA study could not separate care intensity and price, other research blames prices more. For example, one study found that the spending growth for treating patients between 2003 and 2007 is almost entirely because of a growth in prices, with little contribution from growth in the quantity of treatment services provided. Another study found that U.S. hospital prices are 60 percent higher than those in Europe. Other studiesalso point to prices as a major factor in American health care spending growth.

    There are ways to combat high health care prices. One is an all-payer system, like that seen in Maryland. This regulates prices so that all insurers and public programs pay the same amount. A single-payer system could also regulate prices. If attempted nationally, or even in a state, either of these would be met with resistance from all those who directly benefit from high prices, including physicians, hospitals, pharmaceutical companies — and pretty much every other provider of health care in the United States.

    Higher prices aren’t all bad for consumers. They probably lead to some increased innovation, which confers benefits to patients globally. Though it’s reasonable to push back on high health care prices, there may be a limit to how far we should.

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  • The Leap to Single-Payer: What Taiwan Can Teach

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company). It is jointly authored by Aaron Carroll and Austin Frakt.

    Taiwan is proof that a country can make a swift and huge change to its health care system, even in the modern day.

    The United States, in part because of political stalemate, in part because it has been hemmed in by its history, has been unable to be as bold.

    Singapore, which we wrote about in October, tinkers with its health care system all the time. Taiwan, in contrast, revamped its top to bottom.

    Less than 25 years ago, Taiwan had a patchwork system that included insurance provided for those who worked privately or for the government, or for trade associations involving farmers or fishermen. Out-of-pocket payments were high, and physicians practiced independently. In March 1995, all that changed.

    After talking to experts from all over the world, Taiwan chose William Hsiao, a professor of economics at the Harvard T.H. Chan School of Public Health, to lead a task force to design a new system. Uwe Reinhardt, a longtime Princeton professor, also contributed significantly to the effort. (Mr. Reinhardt, who died last month, was a panelist on an Upshot article comparing international health systems in a tournament format.) The task force studied countries like the United States, Britain, France, Canada, Germany and Japan.

    In the end, Taiwan chose to adopt a single-payer system like that found in Medicare or in Canada, not a government-run system like Britain’s. At first, things did not go as well as hoped. Although the country had been planning the change for years, it occurred quite quickly after democracy was established in the early 1990s. The system, including providers and hospitals, was caught somewhat off guard, and many felt that they had not been adequately prepared. The public, however, was much happier about the change.

    Today, most hospitals in Taiwan remain privately owned, mostly nonprofit. Most physicians are still either salaried or self-employed in practices.

    The health insurance Taiwan provides is comprehensive. Both inpatient and outpatient care are covered, as well as dental care, over-the-counter drugs and traditional Chinese medicine. It’s much more thorough than Medicare is in the United States.

    Access is also quite impressive. Patients can choose from pretty much any provider or therapy. Wait times are short, and patients can go straight to specialty care without a referral.

    Premiums are paid for by the government, employers and employees. The share paid by each depends on income, with the poor paying a much smaller percentage than the wealthy.

    Taiwan’s cost of health care rose faster than inflation, as it has in other countries. In 2001, co-payments for care were increased, and in 2002, they went up again, along with premiums. In those years, the government also began to reduce reimbursement to providers after a “reasonable” number of patients was seen. It also began to pay less for drugs. Finally, it began to institute global budgets — caps on the total amount paid for all care — in the hope of squeezing providers into becoming more efficient.

    Relative to the United States and some other countries, Taiwan devotes less of its economy to health care. In the early 2000s, it was spending 5.4 percent of G.D.P., and by 2014 that number had risen to 6.2 percent. By comparison, countries in the Organization for Economic Cooperation and Development spend on average more than 9 percent of G.D.P. on health care, and the United States spends about twice that.

    After the most recent premium increase in 2010 (only the second in Taiwan’s history), the system began to run surpluses.

    This is not to say the system is perfect. Taiwan has a growing physician shortage, and physicians complain about being paid too little to work too hard (although doctors in nearly every system complain about that). Taiwan has an aging population and a low birthrate, which will push the total costs of care upward with a smaller base from which to collect tax revenue.

    Taiwan has done a great job at treating many communicable diseases, but more chronic conditions are on the rise. These include cancer and cardiovascular and cerebrovascular disease, all of which are expensive to treat.

    The health system’s quality could also be better. Although O.E.C.D. data aren’t available for the usual comparisons, Taiwan’s internal data show that it has a lot of room for improvement, especially relating to cancer and many aspects of primary care. Taiwan could, perhaps, fix some of this by spending more.

    As we showed in our battle of the health care systems, though, complaints can be made about every system, and the one in the United States is certainly no exception. For a country that spends relatively little on health care, Taiwan is accomplishing quite a lot.

    Comparing Taiwan and the United States may appear to be like comparing apples and aardvarks. One is geographically small, with only 23 million citizens, while the other is vast and home to well above 300 million. But Taiwan is larger than most states, and a number of states — including Vermont, Colorado and California — have made pushes for single-payer systems in the last few years. These have not succeeded, however, perhaps because there is less tolerance for disruption in the United States than the Taiwanese were willing to accept.

    Regardless of which health system you might prefer, Taiwan’s ambition showed what’s possible. It took five years of planning and two years of legislative efforts to accomplish its transformation. That’s less time than the United States has spent fighting over the Affordable Care Act, with much less to show for it.

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  • Why Advertising Is a Poor Choice to Tackle the Opioid Crisis

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and is jointly authored by Austin Frakt and Keith Humphreys. Keith is the Esther Ting Memorial Professor at Stanford University School of Medicine. He has advised several government bodies, including the White House Commission on Drug Free Communities. This also appeared on page A11 of the November 2, 2017 print edition.

    In declaring the opioid epidemic a public health emergency last week, President Trump promised that the federal government would start “a massive advertising campaign to get people, especially children, not to want to take drugs in the first place.” But past efforts to prevent substance abuse through advertising have often been ineffective or even harmful.

    Perhaps the most famous American antidrug advertisement featured a sizzling egg in a frying pan to the sound of ominous music and a stern voice-over warning, “This is your brain on drugs.” A sequel to this ad featured Rachael Leigh Cook smashing an egg and the better part of a kitchen to dramatize the impact of heroin.

    Many other ads denouncing drugs and emphasizing their destructive effects — as in the “Just Say No” campaign — appeared regularly on television and in print beginning in the 1980s. Most of them were funded by the White House Office of National Drug Control Policy, which received hundreds of millions of dollars a year from Congress for such campaigns.

    Visually dramatic though the ads were, evaluations of them were deeply discouraging. The billions spent from the late 1980s through the mid-2000s at best had no effect on drug use, research shows. At worst, exposure to the campaign might have actually increased the likelihood of adolescent marijuana use. A study of over 20,000 youths 9 to 18 found that those who had been exposed to more antidrug ads expressed weaker intentions to avoid marijuana and more doubts that marijuana was harmful.

    Why was the original campaign such a failure? In part it suffered from perverse incentives. Congress provided substantial money for the ads and was intensely interested in them at the height of the so-called war on drugs, creating internal pressure to make the ads appealing to members of Congress. But while ads that lectured or scared people about drugs might have seemed compelling to the modal member of Congress (a 60-year-old white male), they did not necessarily dissuade drug use by adolescents. In some cases, this kind of approach may make drugs more attractive as a sign of rebellion.

    Other reasons that campaigns backfire is that they make adolescents aware of a drug that they might not have heard of, sparking curiosity in some to try it. Campaigns against drugs can also create a false sense that drug use is more common than it is, making those who don’t use drugs feel socially abnormal.

    After the failure of the government’s initial antidrug media campaign, which was highlighted in the press and congressional hearings, it was significantly redesigned. The new approach, named Above the Influence, moved more toward the message that not using drugs exemplified and maximized youth freedom.

    The retooled campaign had stronger results, with one study of over 4,000 adolescents showing that it reduced teenage marijuana use.

    In switching tack, antidrug campaigns were taking a page from antismoking campaigns like the “truth.”This campaign, which research has estimated has deterred hundreds of thousands of adolescents from beginning to smoke, turns youthful rebellion to its advantage. Refraining from smoking was not about pleasing a parental authority figure; the “truth” pointed out to adolescents that people their parents’ age ran the tobacco companies and took them for saps (not cool). To be free thus meant to snub their seduction (cool).

    Still, the positive results for Above the Influence and the “truth” are not the norm. A recent Cochrane review of rigorous studies collectively examining over 180,000 people reported that the average effect of mass media campaigns on drug use in randomized studies was essentially zero. Why is it so hard for media to change young people’s drug use?

    By the time they reach adulthood, Americans are typically exposed to tens of thousands of advertisements promoting substance use, be it beer, cigarettes or more recently cannabis in some locations. Although opioids are not directly advertised to the public, seeking relief through pills certainly is (“Ask your doctor about …”).

    Given this environment, it is not surprising that the comparatively small number of ads promoting the opposite message do not make much difference. In fact, it would probably be more consequential as a media strategy to stop the promotion of addictive products, but American courts are almost alone in the developed world in treating commercial speech comparably to the protection given free speech.

    Media campaigns against drug use by young people thus can at most make a modest contribution to turning around the opioid epidemic, with some risk of making it worse if the lessons of past failed antidrug campaigns are not heeded. But the safest bet is that the results will be between those two end points: zero. To fight the opioid crisis, public money is probably best spent elsewhere.

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  • Can the U.S. Repair Its Health Care While Keeping Its Innovation Edge?

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company). It was jointly authored by Aaron Carroll and Austin Frakt and also appeared on page B2 of the October 10, 2017 print edition.

    The United States health care system has many problems, but it also promotes more innovation than its counterparts in other nations. That’s why discussions of remaking American health care often raise concerns about threats to innovation.

    But this fear is frequently misapplied and misunderstood.

    First, let’s acknowledge that the United States is home to an outsize share of global innovation within the health care sector and more broadly. It has more clinical trials than any other country. It has the most Nobel laureates in physiology or medicine. It has won more patentsAt least one publication ranks it No. 1 in overall scientific innovation.

    Strong promotion of innovation in health care is one reason the United States got as far as it did in our recent bracket tournament on the best health system in the world. Though the United States lost to France, 3-2, in the semifinals, it picked up its two votes in part because of its influence on innovation, which can save lives in the United States and throughout the world.

    Now we shouldn’t delude ourselves into thinking Americans are inherently more innovative than people in other countries. In fact, many American innovators are immigrants who may or may not be citizens. Many technological and procedural breakthroughs in medicine have occurred in other countries.

    Rather, the nation’s innovation advantage arises from a first-class research university system, along with robust intellectual property laws and significant public and private investment in research and development.

    Perhaps most important, this country offers a large market in which patients, organizations and government spend a lot on health and companies are able to profit greatly from health care innovation.

    The United States health care market, through which over one-sixth of the economy flows, offers investors substantial opportunities. Rational investors will invest in an area if it is more profitable than the next best opportunity.

    “The relationship between profits and innovation is clearest in the biopharmaceutical and medical device sectors,” said Craig Garthwaite, a health economist with Northwestern University’s Kellogg School of Management, and one of the judges in our tournament. “In these sectors, firms are able to patent innovations, and we have a good sense of how additional research funds lead to new products.”

    High brand-name drug prices, along with generous drug coverage for much of the population, fuel an expectation that large biopharmaceutical research and development investments will pay off. Were American drug prices to fall, or coverage of prescription drugs to retrench, the drug market would shrink and some of those investments would not be made. That’s a potential innovation loss.

    This is not mere theory, economists have shown. Daron Acemoglu and Joshua Linnfound that as the potential market for a type of drug grows, so do the number of new drugs entering that market. Amy Finkelstein showed that policies that made the market for vaccines more favorable in the late 1980s encouraged 2.5 times more new vaccine clinical trials per year for each affected disease. And Meg Blume-Kohout and Neeraj Sood found that Medicare’s introduction of a drug benefit in 2006 was associated with increases in preclinical testing and clinical trials for drug classes most likely affected by the policy.

    Health care innovation can have direct benefits for health, well-being and longevity. A study led by a Harvard economist, David Cutler, showed that life expectancy grew by almost seven years in the second half of the 20th century at a cost of only about $20,000 per year of life gained. The vast majority of gains were because of innovations in the care for high-risk, premature infants and for cardiovascular disease. These technologies are expensive, but other innovation can be cost-reducing. For instance, in the mid-1970s, new dialysis equipment halved treatment time, saving labor costs.

    Even with those undeniable improvements, there are questions about the nature of American innovation. Work by Mr. Garthwaite, along with David Dranove and Manuel Hermosilla, showed that although Medicare’s drug benefit spurred drug innovation, there was little evidence that it led to “breakthrough” treatments.

    And although high prices do serve as incentive for innovation, other work by Mr. Garthwaite and colleagues suggests that under certain circumstances drug makers can charge more than the value of the innovation.

    The high cost of health care, an enormous burden on American consumers, isn’t necessarily a unique feature of our mix of private health insurance and public programs. In principle, we could spend just as much, or more, under any other configuration of health care coverage, including a single-payer program. We spend a great deal right now through the Medicare program — often held out as a model for universal single-payer.

    Despite the fact that traditional Medicare is an entirely public insurance program, there’s an enormous market for innovative types of care for older Americans. That’s because we are willing to spend a lot for it, not because of what kind of entity is doing the spending (government vs. private insurers).

    In fact, some question whether the innovation incentive offered by the health care market is too strong. Spending less and skipping the marginal innovation is a rational choice. Spending differently to encourage different forms of innovation is another approach.

    “We have a health care system with all sorts of perverse incentives, many of which do little good for patients,” said Dr. Ashish Jha, director of the Harvard Global Health Institute and the other expert panelist who favored the U.S. over France, along with Mr. Garthwaite. “If we could orient the system toward measuring and incentivizing meaningfully better health outcomes, we would have more innovations that are worth paying for.”

    Naturally, the innovation rewarded by the American health care system doesn’t stay in the U.S. It’s enjoyed worldwide, even though other countries pay a lot less for it. So it’s also reasonable to debate whether it’s fair for the United States to be the world’s subsidizer of health care innovation. This is a different debate than whether and how the country’s health care system should be redesigned. We can stifle or stimulate innovation regardless of how we obtain insurance and deliver care.

    “We have confused the issue of how we pay for care — market-based, Medicare for all, or something else — with how we spur innovation,” Dr. Jha said. “In doing so, we have made it harder to engage in the far more important debate: how we develop new tests and treatments for our neediest patients in ways that improve lives and don’t bankrupt our nation.”

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  • What Makes Singapore’s Health Care So Cheap?

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and is jointly authored by Aaron Carroll and Austin Frakt.

    Singapore’s health care system is distinctive, and not just because of the improbability that it’s admired by many on both the American left and the right.

    It spends less of its economy on health care than any country that was included in our recent tournament on best health systems in the world.

    And it spends far, far less than the United States does. Yet it achieves some outcomes Americans would find remarkable. Life expectancy at birth is two to three years longer than in Britain or the United States. Its infant mortality rate is among the lowest in the world, about half that of the United States, and just over half that of Britain, Australia, Canada and France. General mortality rates are impressive compared with pretty much all other countries as well.

    When the World Health Organization ranked health care systems in 2000, it placed the United States 37th in quality; Singapore ranked sixth.

    Americans tend to think that they have a highly privatized health system, but Singapore is arguably much more so. There, about two-thirds of health care spending is private, and about one-third is public. It’s just about the opposite in the United States.

    Singapore’s health system also has a mix of public and private health care delivery organizations. There are private and public hospitals, as well as a number of tiers of care. There are five classes: A, B1, B2+, B2 and C. “A” gets you a private room, your own bathroom, air-conditioning and your choice of doctor. “C” gets you an open ward with seven or eight other patients, a shared bathroom and whatever doctor is assigned to you.

    But choosing “A” means you pay for it all. Choosing “C” means the government pays up to 80 percent of the costs.

    What also sets Singapore apart, and what makes it beloved among many conservative policy analysts, is its reliance on health savings accounts. All workers are mandated to put a decent percentage of their earnings into savings for the future. Workers up to age 55 have to put 20 percent of their wages into these accounts, matched by an additional 17 percent of wages from their employer. After age 55, these percentages go down.

    The money is divided among three types of accounts. There’s an Ordinary Account, to be used for housing, insurance against death and disability, or for investment or education. There’s a Special Account, for old age and investment in retirement-related financial products. And there’s a Medisave Account, to be used for health care expenses and approved medical insurance.

    The contribution to Medisave is about 8 percent to 10.5 percent of wages, depending on your age. It earns interest, set by the government. And it has a maximum cap, around $52,000, at which point you’d divert the mandatory savings into some other account.

    A second health care program is Medishield Life. This is for catastrophic illness, and while it’s not mandatory, almost all of the population is covered by it. It’s really cheap, from $16 a month for a 29-year-old in 2019 to $68 a month for a 69-year-old, without subsidies.

    Medishield Life kicks in when you’ve paid the deductibles for the year, and after you’ve paid your coinsurance. Deductibles vary by your age and the class of care you choose, and range from $1,500 to $3,000. Coinsuranceranges from 3 percent to 20 percent, varying by the size of the medical bill. Medishield Life has an annual limit of $100,000 but no lifetime limit.

    Medishield Life is managed so that it covers most of a hospitalization in a Class B2 or C ward. Patients would cover the rest out of their Medisave accounts. Patients also have the option to pay for additional insurance, which would cover a higher class of care. Some plans are offered by the government, and people can use Medisave money to pay for those. Other plans are purely private, and sometimes offered by employers as benefits.

    A third health care program is Medifund, which is Singapore’s safety net program. Only citizens are eligible; it covers only the lowest class of wards; and it’s available only after people have depleted their Medisave account and Medishield Life coverage. The amount of help someone could get from Medifund depends on a patient’s and family’s income, condition, expenses and social circumstances. Decisions are made at a very local level.

    A number of people hold up Singapore as an example of how conservative ideas of competition and consumer-directed spending work. Unfortunately, the story isn’t so clean when you look at the data. In a 1995 paper in Health Affairs, William Hsiao looked at how health spending fared in Singapore before and after the introduction of Medisave. He found that health care spending increased after the introduction of increased cost-sharing, which is not what most proponents of such changes would expect. Michael Barr had similar thoughts in his “critical inquiry” into Singapore’s medical savings account, published in The Journal of Health Politics, Policy and Law in 2001.

    But why is Singapore so cheap? Some think that it’s the strong use of health savings accounts and cost-sharing. People who have to use their own money usually spend less. But that’s not the whole story here. There’s a lot of government regulation as well.

    Through the tiered care system and its public hospitals, the government has a great deal of control over inpatient care. It allows a private system to challenge the public one, but the public system plays the dominant role in providing services.

    Initially, Singapore let hospitals compete more, believing that the free market would bring down costs. But when hospitals competed, they did so by buying new technology, offering expensive services, paying more for doctors, decreasing services to lower-class wards, and focusing more on A-class wards. This led to increased spending.

    In other words, Singapore discovered that, as we’ve seen many times before, the market sometimes fails in health care. When that happened in Singapore, government officials got more involved. They established the proportion of each type of ward hospitals had to provide, they kept them from focusing too much on profits, and they required approval to buy new, expensive technology.

    Singapore heavily regulates the number of physicians, and it has some control over salaries as well. The country uses bulk purchasing power to spend less on drugs.

    The most frustrating part about Singapore is that, as an example, it’s easily misused by those who want to see their own health care systems change. Conservatives will point to the Medisave accounts and the emphasis on individual contributions, but ignore the heavy government involvement and regulation. Liberals will point to the public’s ability to hold down costs and achieve quality, but ignore the class system or the system’s reliance on individual decision-making.

    Singapore is also very small, and the population may be healthier in general than in some other countries. It’s a little easier to run a health care system like that. It also makes the system easier to change. We should also note that some question the outcomes on quality, or feel that the government isn’t as honest about the system’s functioning.

    There is a big doctor shortage, as well as a shortage of hospital beds. As Mr. Barr noted in a longer discussion of Singapore’s system, “It seems to be highly likely that if one could examine the Singapore health system from the inside, one would find a fairly ordinary health system with some strong points and many weaknesses — much like health systems all over the developed world.” This concern about how much we can really know about Singapore’s true outcomes is one of the reasons it didn’t fare so well in our contest.

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  • Which Country Has the Best Health Care System? Readers Respond

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and was jointly authored by Aaron Carroll and Austin Frakt. In this post we respond to readers’ questions about the bracket tournament on the best health system in the world.


    I have both French and American passports. Americans should understand the tranquillity of spirit that truly universal health care brings to a population. People have worries … but not about losing everything because of an illness. — Bob Nelson, Calais, France

    I’m British. For me the idea that “Can I afford to accept treatment?” is bizarre. And harsh. If you’ll forgive me for saying so, the U.S. system has a sense of selfishness to it. Your country seems to have lost your sense of “together.” Rather, it looks like “everyone for themselves.” — Arthur, Glasgow

    Austin and Aaron respond: You are certainly not the only people to feel that way, but it seems many Americans value choice over security. This includes plentiful options for health insurance, including the “choice” to be uninsured. This freedom comes with at least three kinds of costs. First, it’s more than just a headache to choose a health plan. Studies show people — even experts — are terrible at doing so, routinely picking plans that aren’t the best for them. Second, the vast array of health plans with varying requirements and protocols impose administrative costs on physicians and hospitals. By one estimate, the administrative complexity of the U.S. health care system adds nearly $300 billion per year in avoidable costs. Third, strong results from the Oregon Medicaid study (a randomized trial of access to Medicaid coverage) include that the program significantly reduced the financial risk of poor health and improved mental health. It’s safe to say that the U.S. health care system may be many things, but tranquil isn’t one of them.


    I have practiced medicine for nearly 40 years, mostly in a large academic health center. The frictional administrative costs of multiple insurers, each with its own forms, rules, payment, denials and appeals apparatus, highly paid C-suites, shareholders, etc., and the counterpart to this required by all providers in order to get paid — billers, coders, compliance folks, etc. — is a colossal waste and does nothing to enhance access or quality of care. — Concerned MD, Pennsylvania

    I chose France, for many reasons, but primarily because their system is well organized and administered, which results in better and more efficient care for patients. Check out their “card of life,” which contains timely, accessible and secure health care/financial info and speeds payment to doctors and hospitals. Far less paper and insurance hassles and denials. — Scott, Port St. Lucie

    Austin and Aaron respond:

    In a comparison of the U.S. and Canadian health systems, scholars at Harvard concluded that the commercial health care market in the United States imposes inefficiently high administrative costs. One reason they’re not lower is that no single insurer can move the system toward efficiency — it’s a collective action problem. But some of the high cost imposed on doctors and hospitals may benefit insurers, since they lead to delayed payments and denial of claims.

    Patients are caught in the middle when health care providers and insurers bicker over claims and care. That kind of tussle seems to be reduced when the provider is the insurer — as when a hospital system offers a health plan. This is more evidence that the organization of health systems and coverage can make a difference in consumers’ experience, just as the commenters suggest.

    However, we should be careful not to think there are too many savings to be had by removing just any kind of administrative waste. A number of advocates have argued that by removing medical underwriting and individual rating, insurers would be much more efficient and save money. After the Affordable Care Act imposed guaranteed issue and community ratings, huge savings did not result. Further, one person’s waste is another person’s job. The trade-offs can’t be ignored.


    Based on personal experience with the German health care system and my sister’s personal experience with the Swiss system: Both systems use competing nonprofit private companies (that is the key) that are heavily regulated. A highly regulated nonprofit company is an efficient compromise construction between a government single-payer system (not exposed to competition) and between a free market of competing, unregulated, for-profit health insurance companies. — Gerhard, NY

    Austin and Aaron respond:

    This may be entirely correct. Let’s remember that Switzerland won the battle, and most people in that country do have insurance from a regulated market of guaranteed-issue, community-rated nonprofit private insurance companies. Many components of the United States health care system are nonprofit, too, and there’s a robust literature on how nonprofit and for-profit entities fare relative to each other. For instance, there appears to be a relationship between the availability of nonprofit nursing homes in an area and levels of consumer welfare. A “review of systematic reviews” of profit versus nonprofit hospitals found that for certain outcomes nonprofit hospitals performed better. Overall quality and efficiency differences could not be determined, though. In general, however, it appears that for-profit entities focus on cost (pushing it lower) while nonprofits focus on quality (pushing it higher). There are always trade-offs, and we in the U.S. have generally favored the latter.


    Weird how you picked the U.K. and Germany but not the Netherlands. According to the annual Euro Health Consumer Index (E.H.C.I.), the Netherlands systematically has the best health care in Europe — yes, better than Switzerland, year on year, and with the U.K. at 14th sandwiched between Portugal (13th) and the Czech Republic (15th). — Rdeman, London

    Austin and Aaron respond: There are, of course, more countries than we had space to discuss. We tried to pick countries that varied across the spectrum from socialized to privatized. Though we welcome delving more deeply into some of these other countries, aspects of them are close to those of the ones we’ve already discussed. The Netherlands, like many other countries, has a health care system along what the Princeton professor Uwe Reinhardt calls the “Bismarckian model,” in which health insurance is mandated from one of a small number of tightly regulated nonprofits.

    People also can buy voluntary insurance above that, which covers things not covered by statutory insurance. The country spends about 12 percent of gross domestic product on health care, and out-of-pocket payments are quite low. How it would have compared in this battle isn’t clear, but we think it would have done pretty well.


    We received many, many testimonials from American readers who received good treatment at reasonable prices (and no payment troubles) while living abroad or traveling. By contrast, one reader from Australia advised that all visitors to the United States “carry travel insurance,” and a Canadian expressed surprise (below) at what awaited him after he broke his neck on a visit to the U.S.

    Five years ago I fell off a rock and broke my hip while vacationing in Ireland. An ambulance took me to the hospital. Needless to say, my biggest worry was how am I going to pay for this. I was distraught. I had no coverage in the USA. The staff at the hospital were very kind and assured me I would be O.K. They replaced my hip, and when it was time to leave, they asked if I could pay $600. No other bills arriving four months later, like in the USA. $600, one bill, Done! Jaw-dropping amazing. I am grateful to Ireland, thank you! — Golf Pork, Seattle

    I live in British Columbia. Some years ago I broke my neck in a motor vehicle accident in Washington State. I received excellent treatment and had the comfort of knowing that my British Columbia government health insurance would cover all expenses, even out of country. I was, however, taken aback when the first person I met in the emergency ward had a clipboard and was asking me how I would pay for all this. I had never before faced this question. — David Paterson, Vancouver

    Austin and Aaron respond: We hesitate to allow anecdotes to define a health care system. What matters is the overall experience. T.R. Reid wrote an amazing book on this subject in 2009, though, which was reviewed in The New York Times.

    Another problem with anecdotes about overseas health care excellence is that they can always be countered by people who came to the United States because they couldn’t get good care in their country. We hear all the time about how people from Canada flock to the United States when wait times are too long. Those stories are almost always exceptions, not the rule, as a great paper in Health Affairs showed.

    It’s interesting to note, though, that most of the stories in the comments are driven by the “shock” of Americans when they can receive high-quality, reasonably priced health care in other countries. We’ve been conditioned to believe that the only choices available are our system or utter chaos. This exercise was designed to show otherwise. There are lots of other choices available, many of them are good, and some that are probably better.

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  • The Best Health Care System in the World: Which One Would You Pick?

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and was jointly authored by Aaron Carroll and Austin Frakt. Click through to the original to cast your own votes in each health system face-off described below. This piece also appeared on pages A12 and A13 of the September 25, 2017 print edition.

    “Medicare for all,” or “single-payer,” is becoming a rallying cry for Democrats.

    This is often accompanied by calls to match the health care coverage of “the rest of the world.” But this overlooks a crucial fact: The “rest of the world” is not all alike.

    The commonality is universal coverage, but wealthy nations have taken varying approaches to it, some relying heavily on the government (as with single-payer); some relying more on private insurers; others in between.

    Experts don’t agree on which is best; a lot depends on perspective. But we thought it would be fun to stage a small tournament.

    We selected eight countries, representing a range of health care systems, and established a bracket by randomly assigning seeds.

    To select the winner of each matchup, we gathered a small judging panel, which includes us:

    • Aaron Carroll, a health services researcher and professor of pediatrics at Indiana University School of Medicine
    • Austin Frakt, director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health

    and three economists and physician experts in health care systems:

    • Craig Garthwaite, a health economist with Northwestern University’s Kellogg School of Management
    • Uwe Reinhardt, a health economist with Princeton University’s Woodrow Wilson School of Public and International Affairs
    • Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute

    A summary of our worldviews on health care is at bottom.

    So that you can play along at home and make your own picks, we’ll describe each system along with our choices (the experts’ selections will decide who advances). When we cite hard data, they come from the Commonwealth Fund’s International Country Comparison in 2017.

    But enough talk. Let’s play.


    Canada vs. Britain: Single-Payer Showdown

    Both have single-payer systems, but vary in the government’s role and in what is covered.

    In Canada, the government finances health insurance, and the private sector delivers care. Insurance, run at the province level, doesn’t cover drugs, dentists or optometry. Many Canadians have supplemental private insurance through their jobs to help pay for these. The government ends up paying for about 70 percent of health care spending in all.

    Britain has truly socialized medicine: The government not only finances care, but also provides it through the National Health Service. Coverage is broad, and most services are free to citizens once they’ve paid taxes, though there is a private system that runs alongside the public one. About 10 percent buy private insurance. Government spending accounts for more than 80 percent of all health care spending.

    U.S. analogues are Medicare (more like Canada) and the Veterans Health Administration (more like Britain).

    Canada and Britain are pretty similar in terms of spending — both spend just over 10 percent of G.D.P. on health care. They also have reasonably similar results on quality, although neither ranks near the top in the usual international comparisons. In terms of access, though, Britain excels, with shorter wait times and fewer access barriers due to cost.

    Our pick: Britain, 4-1

    AARON: Britain. It’s efficient. Given the rather low spending, it provides great access with acceptable outcomes.

    CRAIG: Britain. Patients in Britain have a greater ability to shop across providers (using additional private insurance). This, combined with reforms within the N.H.S., helped increase competition and quality.

    AUSTIN: Britain. While the countries are close in spending and quality, Britain has much lower cost-based barriers to access.

    ASHISH: Britain. Access problems can be profound in Canada — nearly one in five Canadians report waiting four months or more for elective surgery, which can be more than just an inconvenience.

    UWE: Canada. The Canadian system is simpler for citizens to understand and highly equitable.


    U.S. vs. Singapore: A Mix of Ideas

    The United States has a mix of clashing ideas: private insurance through employment; single-payer Medicare mainly for those 65 and older; state-managed Medicaid for many low-income people; private insurance through exchanges set up by the Affordable Care Act; as well as about 28 million people without any insurance at all. Hospitals are private, except for those run by the Veterans Health Administration.

    Singapore has a unique approach. Basic care in government-run hospital wards is cheap, sometimes free, with more deluxe care in private rooms available for those paying extra. Singapore’s workers contribute 36 percent of their wages to mandated savings accounts that may be spent on health care, as well as on housing, insurance, investment or education. The government, which helps control costs, is involved in decisions about investing in new technology. It also uses bulk purchasing power to spend less on drugs, controls the number of medical students and physicians in the country, and helps decide how much they can earn.

    Singapore’s system costs far less than America’s (4.9 percent of G.D.P. versus 17.2 percent). Singapore doesn’t release the same data as most other advanced nations, although it’s widely thought that it provides pretty good care for a small amount of spending. Others counter that access and quality vary, with wide disparities between those at the top and bottom of the socioeconomic ladder.

    Our pick: United States, 4-1

    AARON: United States. Singapore is intriguing, because it’s so different from other systems. But its huge mandatory savings requirement would be a nonstarter for many in the United States.

    CRAIG: United States. Singapore, a scrappy underdog, has become a fan favorite of conservatives. But its reliance on health savings accounts is problematic: When people are spending more of their own money on health care, they tend to forgo both effective and ineffective care in equal measure.

    AUSTIN: United States. It’s hard for me to overlook Singapore’s lack of openness with data.

    ASHISH: United States. The lack of data in Singapore is a problem, and it had higher rates of unnecessary hospitalizations and far higher heart attack and stroke mortality rates than the United States. Plus, the U.S. has a highly dynamic and innovative health care system. It is the engine for new diagnostics and treatments from which Singapore and other nations benefit.

    UWE: Singapore. It’s hard to defend the messy American health system, with its mixture of unbridled compassion and unbridled cruelty.


    France vs. Australia: Everyone Covered

    The list of services covered in France is more extensive than in Australia — perhaps more than in any other health care system. Australia has the advantage in expense.

    Australia provides free inpatient care in public hospitals, access to most medical services and prescription drugs. There is also voluntary private health insurance, giving access to private hospitals and to some services the public system does not cover.

    The government pays for at least 85 percent of outpatient services, and for 75 percent of the medical fee schedule for private patients who use public hospitals. Patients must pay out of pocket for whatever isn’t covered. Most doctors are self-employed, work in groups and are paid fee-for-service. More than half of hospitals are public.

    Everyone in France must buy health insurance, sold by a small number of nonprofit funds, which are largely financed through taxes. Public insurance covers between 70 percent and 80 percent of costs. Voluntary health insurance can cover the rest, leaving out-of-pocket payments relatively low. About 95 percent of the population has voluntary coverage, through jobs or with the help of means-tested vouchers. The Ministry of Health sets funds and budgets; it also regulates the number of hospital beds, what equipment is purchased and how many medical students are trained. The ministry sets prices for procedures and drugs.

    The French health system is relatively expensive at 11.8 percent of G.D.P., while Australia’s is at 9 percent. Access and quality are excellent in both systems.

    Our pick: France, 4-1

    AARON: France. It provides almost everything you’d want, and it’s expensive only compared with countries other than the United States. (Compared with the U.S., it’s a bargain.)

    CRAIG: France. It has seemingly done a better job of using markets to create competition across public and private hospitals — which provides incentives for quality provision and innovation.

    AUSTIN: Australia. It was a close call. Australia achieves good outcomes (by some but not all measures better than France) with a lot less spending, making it a better value.

    ASHISH: France. Both countries cover everyone, but people in France report somewhat fewer problems getting access to care, as well as shorter waiting times.

    UWE: France. The Australian system is basically two-tiered: a public insurance-and-delivery system, and another based on private health insurance, each of which cover roughly half the population. This seems to work well in Australia, but in the U.S. the public system most likely would be badly underfunded. Therefore, France would be superior.


    Switzerland vs. Germany: Neighborly Rivalry

    Germany’s system and Switzerland’s have a lot in common. Germany has slightly better access, especially with respect to costs. Switzerland has higher levels of cost-sharing, but its outcomes are hard to beat — arguably the best in the world.

    Like every country here except the U.S., Switzerland has a universal health care system, requiring all to buy insurance. The plans resemble those in the United States under the Affordable Care Act: offered by private insurance companies, community rated and guaranteed-issue, with prices varying by things like breadth of network, size of deductible and ease of seeing a specialist. Almost 30 percent of people get subsidies offsetting the cost of premiums, on a sliding scale pegged to income. Although these plans are offered on a nonprofit basis, insurers can also offer coverage on a for-profit basis, providing additional services and more choice in hospitals. For these voluntary plans, insurance companies may vary benefits and premiums; they also can deny coverage to people with chronic conditions. Most doctors work on a national fee-for-service scale, and patients have considerable choice of doctors, unless they’ve selected a managed-care plan.

    A majority of Germans (86 percent) get their coverage primarily though the national public system, with others choosing voluntary private health insurance. Most premiums for the public system are based on income and paid for by employers and employees, with subsidies available but capped at earnings of about $65,000. Patients have a lot of choice among doctors and hospitals, and cost sharing is quite low. It’s capped for low-income people, reduced for care of those with chronic illnesses, and nonexistent for services to children. There are no subsidies for private health insurance, but the government regulates premiums, which can be higher for people with pre-existing conditions. Private insurers charge premiums on an actuarial basiswhen they first enroll a customer, and subsequently raise premiums only as a function of age — not health status. Most physicians work in a fee-for-service setting based on negotiated rates, and there are limits on what they can be paid annually.

    Both systems cost their countries about 11 percent of G.D.P.

    Our pick: Switzerland, 3-2

    AARON: Switzerland. It has superior outcomes. It’s worth noting that its system is very similar to the Obamacare exchanges.

    CRAIG: Switzerland. The Swiss system looks a lot like a better-functioning version of the Affordable Care Act. There’s heavy, but quite regulated, competition among insurers and an individual mandate.

    AUSTIN: Germany. Germany has a low level of cost-based access barriers — tied with Britain for the lowest among our competitors.

    ASHISH: Switzerland. Switzerland outperformed Germany on a number of important quality measures, including fewer unnecessary hospitalizations and lower heart attack mortality rates.

    UWE: Germany. The Swiss social insurance system — a late comer, enacted only in the 1990s, and financed by per-capita premiums — is less equitable than many other European systems, including Germany’s.


    Switzerland vs. Britain: Meaning of a Market

    How does the cost-effectiveness of Britain’s “socialized medicine” stack up against the competitive but heavily regulated private system of Switzerland?

    Our pick: Switzerland, 3-2

    AARON: Switzerland. It has better quality, and perhaps access, but those come at a higher cost. I’m willing to make that trade-off.

    CRAIG: Britain. Switzerland’s system — privately funded with private insurers — is often held up as a bastion of competition. But it is not necessarily more of a market than Britain; it just hides the heavy hand of government a bit more. In reality, the insurance and provider market is heavily regulated.

    The U.K. system is almost entirely publicly funded, but it has done a lot to try to increase the competition between facilities, which has increased the quality of service.

    AUSTIN: Britain. It systematically incorporates cost effectiveness into coverage decisions.

    ASHISH: Switzerland. These are two countries with high-performing health systems, but Switzerland has better access and quality, albeit at somewhat higher costs.

    UWE: Switzerland. Switzerland has better facilities and speed of access to care.


    France vs. U.S.: Access vs. Innovation

    France has extensive coverage, with costs that are high relative to many other nations. The U.S. system, praised as dynamic and innovative, is even more expensive, falls short of universal coverage and can be bewilderingly complex. Which do our experts prefer?

    Our pick: France, 3-2

    AARON: France. France provides an amazing level of access and quality for the cost. The U.S. is considered the driver of health care innovation, which comes at a high price. But there are other ways to incentivize innovation in the private sector besides how we pay for and deliver care.

    CRAIG: United States. The U.S. system is a bit of a mess in that it is quite expensive and doesn’t offer complete coverage to its populace. But the system really does have the strongest incentives for innovation on medical technology — which provides an amazing amount of welfare for citizens around the globe.

    AUSTIN: France. It’s hard to justify the very high level of U.S. spending based on innovation alone, particularly without mechanisms to steer innovation toward technologies that are cost-effective.

    ASHISH: United States. France has a far more equitable system, with few delays and reasonably good outcomes. However, the U.S. delivers a superior quality of care on the measures that matter most to patients, and the system is far more dynamic and innovative. It was close, but I picked the United States.

    UWE: France. The U.S. is just too expensive for what it delivers, and includes too much financial insecurity to boot. At international health care conferences, arguing that a certain proposed policy would drive some country’s system closer to the U.S. model usually is the kiss of death.


    France vs. Switzerland: Top of the Mountain (Alps Edition)

    France’s system is impressively comprehensive and in some respects simpler. Switzerland relies on a competitive yet much-regulated system of private insurers. Which has the edge and why?

    Our pick: Switzerland, 3-2

    AARON: Switzerland. This is a tough call. Switzerland does a good job of combining conservative and progressive beliefs about health care systems into a workable model providing top-notch access and quality at a reasonable cost. It doesn’t hurt that it does so through private (although heavily regulated) insurance.

    CRAIG: France. Its system has more competition among providers than Switzerland’s does.

    AUSTIN: Switzerland. The Swiss system is so close to the A.C.A.’s structure (which, to date, has survived all manner of political attacks) that something like it could work in the U.S.

    ASHISH: Switzerland Both of these countries spend a lot on health care, outpacing the average among high-income countries, and both perform comparably on measures of access to care. However, in general, the Swiss health care system delivers a higher quality of care across a range of measures and invests more in innovation that fuels new knowledge and, ultimately, better treatments that we all benefit from.

    UWE: France. It is cheaper, its financing is more equitable, and its system is simpler.


    Germany would have tied Switzerland had we averaged our rankings of the nations instead of using head-to-head matchups in a bracket system (Switzerland eliminated Germany in the first round). It’s an example of how close the voting was. Not one vote was unanimous among the judges, and all the semifinal and final votes were 3-2. Clearly, there is room for disagreement about the relative merits of health systems, and different experts would surely reach different conclusions.

    Some judges took a global view, giving the edge to countries, like the United States, that promoted innovation that benefited the rest of the world. In other cases, how health systems treated the poorest of society was paramount.

    To nobody’s surprise, the United States could do better at balancing health care costs with access, quality and outcomes. But there are many ways to reach that goal, and there will always be trade-offs. Learning about them from other systems and debating them honestly would probably do us a lot of good.

    We hope that readers will consider this to be merely the beginning of a discussion, not the end. We welcome your questions or comments. In fact, we look forward to writing articles in which we answer those questions and ask other experts with different views to weigh in.

    Have you experienced a health system outside the United States? Tell us its best or worst feature. And what advice would you give Americans?

    The panel:
    Craig Garthwaite is a conservative economist who believes that well-regulated markets offer the best means of providing quality and innovation. He’s a lifelong Republican but has been broadly supportive of the market-based A.C.A.

    Uwe Reinhardt, who has analyzed health care systems around the world for half a century, has been a longtime supporter of single-payer, although he has said he doesn’t believe the United States could manage that system well because it’s captured by special interests.

    Ashish Jha and Aaron Carroll believe in universal coverage. Austin Frakt is less invested in universal coverage than universal access to affordable coverage. All three pay less attention to whether a system is more government-run or more market-based because they think either approach can succeed if devised well. Aaron and Austin blog at The Incidental Economist. For more information on health care systems, you can view Aaron’s Healthcare Triage playlist of videos. Ashish blogs at an Ounce of Evidence.

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  • Blaming Medicaid for the Opioid Crisis: How the Easy Answer Can Be Wrong

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and was jointly authored by Aaron Carroll and Austin Frakt.

    The theory has gained such prominence that a United States senator is investigating it.

    “Medicaid expansion may be fueling the opioid epidemic in communities across the country,” Senator Ron Johnson, Republican of Wisconsin, wrote recently.

    Some conservative opponents of the Affordable Care Act have been passing around the same theory for months. It’s a politically explosive (and convenient) argument, but is it true? Substantial evidence suggests the answer is no, but let’s give it a fair hearing.

    Some data seems to support this connection, and the idea has a certain logic. Coverage from Medicaid — or any kind of health insurance for that matter — plays a role in access to prescription opioids, just as it does for access to many other types of health care.

    We know from earlier analyses that Medicaid enrollees tend to be prescribed opioids more frequently than people with other kinds of coverage. But that could be because of other factors also related to insurance. It’s important to remember that people who go on Medicaid are sicker than those with other forms of coverage, so they may have more pain that warrants opioids.

    It is also true that the 31 states that expanded Medicaid experienced a larger increase in drug overdoses between 2013 and 2015 than states that did not. As Mr. Johnson wrote, “These data appear to point to a larger problem.”

    But this is a weak foundation on which to base a conclusion that Medicaid is driving the opioid epidemic. Responding to these facts when they were first noted, a Department of Health and Human Services statement said, “Correlation does not necessarily prove causation, and additional research is required before any conclusions can be made.”

    In a post on the Health Affairs blog, Andrew Goodman-Bacon, an economist at Vanderbilt, and Emma Sandoe, a Ph.D. student in health policy and political analysis at Harvard, recommend that, to understand the opioid epidemic and Medicaid’s role better, we should look much further back than 2013.

    For example, OxyContin prescriptions for noncancer pain grew by a factor of almost 10 between 1997 and 2002, long before the A.C.A. was signed into law. Drug-related mortality rates doubled between 1999 and 2013, the year before most states expanded Medicaid.

    Further, while it is true that drug-related deaths have grown more rapidly in expansion states than in other states, that more rapid growth started in 2010, before the A.C.A. expansion. This suggests that causes other than Medicaid are more likely. Given the timing of these findings, “there is little evidence to support the claim that Medicaid expansion caused the increase in opioid-related deaths,” Ms. Sandoe said.

    Yes, Medicaid could still be playing a role, but as with all correlations, it’s important to consider both directions of causality. It’s possible that states experiencing larger growth in drug deaths might have been more eager to expand Medicaid programs. After all, Medicaid also provides financial support for drug abuse treatment. One study found that prescriptions for medications that treat opioid addiction increased by 43 percent in Medicaid expansion states, relative to states that did not expand their programs. When Gov. John Kasich, a Republican, talks about why he’s happy that Ohio expanded the Medicaid program, he often cites the opioid crisis in his state.

    Craig Garthwaite, a Republican labor economist of Northwestern University’s Kellogg School of Management, said: “It’s not that there isn’t a single case of an individual insured by Medicaid developing an opioid habit or illicitly obtaining drugs. But the evidence to date doesn’t suggest that this is the net effect.”

    Another way to test the Medicaid-opioid connection is to examine a dose response. States with higher levels of uninsurance saw greater coverage gains through Medicaid. If more Medicaid causes more opioid death, then states that added more Medicaid beneficiaries should see greater increases than states with smaller coverage expansions. But Mr. Goodman-Bacon and Ms. Sandoe show that the opposite holds. Counties in states with historically higher levels of uninsurance (and therefore greater subsequent growth in Medicaid) had lower growth in drug-related death rates from 2010 to 2015. This relationship holds within expansion and nonexpansion states separately.

    Or course, drug-related deaths include those from prescription opioids as well as those from black-market drugs (like heroin and fentanyl). Medicaid directly enhances access only to the former. This makes it hard to identify the role of Medicaid in the opioid crisis definitively, which is all the more reason to be cautious about suggesting the program is fueling it.

    “The really sad thing here is that these numerical arguments have the veneer of seriousness, and as a result, they can drive really bad policy,” Mr. Garthwaite said.

    Providing health care through insurance means providing access to both its benefits and harms. No one seems concerned that the increased access to health care that private insurance provides might lead more people to take opioids — only that Medicaid could. It’s also interesting to note that no one makes assertions that increased coverage, even increased Medicaid coverage, probably leads to more deaths by medical errors.

    We should not look at harms in isolation. Even if Medicaid does enhance access to prescription opioids, thereby playing a role in their misuse, that is far from the only thing the program does. Medicaid provides many other benefits, about which we’ve written, including increased access to substance use disorder treatment.

    To use a theoretical Medicaid-opioid connection (for which the evidence is weak anyway) to justify scaling back Medicaid ignores the larger picture — that it is a crucial aspect of our safety net, providing access to health care and financial protection that many low-income Americans could not otherwise obtain.

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  • The Long-Term Health Consequences of Hurricane Harvey

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and is jointly authored by Aaron Carroll and Austin Frakt.


    Long after the floodwaters recede, and even during cleanup and rebuilding, the people who lived through Hurricane Harvey will face another form of recovery — from the storm’s blows to physical and mental health.

    The short-term health effects of floods capture our attention. Harvey has already caused dozens of deaths, and in 2005 Hurricane Katrinakilled more than 1,800 people.

    Yet people endure injuries and illnesses in numbers that far exceed the death toll. When Hurricane Iniki hit Hawaii in 1992, injuries went up by a factor of six, and more than half those injuries were open wounds. Waterborne and communicable respiratory and gastrointestinal disease can spread amid the breakdown in water sanitation, contamination from industrial or hazardous waste sites, or the higher density of people crowding into shelters.

    A systematic review published just months ago showed how various phases of flooding and storm disasters affect health. Researchers found that wounds, poisonings and infections of the gut and skin increase soon after storms. Gastrointestinal infections increase more frequently after floods. Diabetes-related complications increase after both.

    People with chronic conditions like cardiovascular disease or respiratory illness are particularly prone to health problems immediately after a storm, and their care can be complicated by lack of necessary medications or access to medical records. After Hurricane Katrina, one study found that 14 percent of emergency visits to health care facilities were to treat chronic conditions, and almost 30 percent of those seeking care were sick enough to warrant admission, which is much higher than average for emergency departments. An additional 7 percent of emergency visits were to fill medications.

    Visits to the doctor for conditions such as asthma and heart disease also increased significantly after Hurricane Iniki. Harvey caused the shutdown of dozens of dialysis centers. Patients with kidney disease rely on dialysis several times per week, and missing even one session can have severe consequences.

    But large floods and other natural disasters have longer-term physical and mental health consequences we’re less attuned to. Well after the event has faded as a top news story, victims continue to suffer and struggle.

    A 2012 systematic review published in Environment International documented floods’ tolls on human health, also covering longer-term effects. Flood-affected areas can experience higher mortality rates for months. For example, after Hurricane Katrina, the mortality rate in the New Orleans area was 47 percent above normal for the first half of 2006, up to 10 months after the storm. After Iniki, the mortality ratefrom diabetes went up significantly in the year after. Heightened rates of chronic illnesses can persist in flooded areas for decades.

    Many studies document a surge in mental health diagnoses in populations that experience floods. These, too, can last years. Six months after floods in Mexico in 1999, a quarter of the affected population still had symptoms of trauma or depression. Increased rates of both could still be detected two years later, particularly among those among those who had experienced the worst aspects of flooding: flash floods, mudslides, the witnessing of injury or death, and displacement.

    Similarly, months after floods in Thailand and South Korea, those with more harrowing experiences were four times more likely to have symptoms of post-traumatic stress disorder or depression.

    In a post-Katrina assessment, the Centers for Disease Control and Prevention found that though a quarter of respondents lived with someone who needed mental health counseling, fewer than 2 percent received it. Another C.D.C. assessment found that one-fifth to one-quarter of New Orleans police officers had symptoms of P.T.S.D. or depression three months after the flood. Other analyses showed that suicide rates spiked in New Orleans in this period and that rates of P.T.S.D. among workers there were high.

    Floods can also have lasting effects on infants and children. With access to obstetric services challenged during and after a flood — as well as negative effects on pregnant women’s physical and mental health — researchers have found worse pregnancy outcomes in flooded areas. One study of women who became pregnant in the six months after Hurricane Katrina found that exposure to the hurricane was associated with earlier delivery and delivery of a lower-weight infant. Another study of pregnant women exposed to flooding in North Dakota in 1997 had similar findings, but also found increased risks to the mother, including anemia, eclampsia and uterine bleeding.

    Research tells us how we might respond to natural disasters like Harvey. Recommendations include public education about health effects and precautions, and improved surveillance programs to detect diseases or complications that usually increase after a disaster. They also include monitoring communities for mental health problems, then providing the services needed to care for them, and paying special attention to pregnant women. If you or those you know have been directly affected by Harvey, the C.D.C. has many helpful links on how to cope with a disaster or traumatic event.

    Everyone is understandably focused on the immediate dangers from flooding. But analysis of previous natural disasters shows that Harvey’s survivors will need attention and care far into the future.

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  • Network adequacy standards

    This post is jointly authored by Austin Frakt and Yevgeniy Feyman.

    Like everything in health care, network adequacy is complicated, with numerous measures and differing regulations by program. This post offers a flavor and a bit of organization of that complexity, based on some of our recent reading.

    Medicare Advantage

    When is network adequacy assessed? CMS is only certain to assess a plan’s network upon application for a new contract or expansion of a contract’s service area. At its discretion, CMS may review networks at other times, for instance when a plan terminates a contract with a provider, when it changes ownership, or when there are network access complaints or plan-identified network deficiencies.

    What types of entities are assessed for adequacy? There are different network adequacy standards for each of 27 practitioner specialty types (e.g., primary care, cardiology, urology) and 23 facility types (e.g., acute inpatient hospitals, outpatient dialysis, mammography).

    Are all markets treated equivalently? No. CMS places each county into one of five categories: Large Metro, Metro, Micro, Rural, or CEAC (Counties with Extreme Access Considerations). Within each practitioner and facility type, there are different network adequacy standards by county type. These can change from year-to-year as well.

    How is network adequacy measured? The gist is that each plan must contract with a specified number of providers of each type. Moreover, 90% of beneficiaries in the county must live within specified travel distance and travel time from at least one provider of each type. To calculate the minimum number of providers, each county receives a population of beneficiaries (termed “beneficiaries required to cover” in the table below) that is equal to the 95th percentile of penetration in all plans in its county type, multiplied by the total number of beneficiaries in the county. That’s a mouthful, but roughly speaking it means that CMS makes sure that each plan can serve a number of beneficiaries larger than it is ever likely to enroll.

    This is rather abstract. How about a concrete example? Sure! The following tables should help. The first illustrates the calculation of the number of primary care providers a plan in Baldwin, AL must contract with (10) for 5,857 beneficiaries.

    The next table shows that in Baldwin, AL, at least one primary care provider must be within 10 miles and 15 minutes of travel time for 90% of beneficiaries in the county. Additionally, a PCP who is not within the time and distance requirements of at least one beneficiary, will not count towards the minimum number of providers required. Moreover, because at least 90% of beneficiaries must be within the time and distance requirements, a plan may have to contract with more than the minimum number of providers required to meet these requirements.

    Where can I learn more? Here are some potentially helpful links:

    • Most of the foregoing can be found in this CMS guidance document.
    • Additional details on how time and distance to providers are calculated can be found in this memo.
    • Here is the most recent file that specifies year-specialty-county type network adequacy regulations.


    The following is for federally facilitated marketplaces, but concludes with a comment about state facilitated ones.

    When is network adequacy assessed? As best we can tell, network adequacy is assessed for each plan every year.

    What types of entities are assessed for adequacy? CMS focuses on a subset of specialist areas and facility types that have been associated with network adequacy problems in the past: hospital systems, dental providers (if applicable), endocrinology, infectious disease, mental health, oncology, outpatient dialysis, primary care, and rheumatology. That other specialists and facility types are not necessarily scrutinized is one limitation of the approach.

    Are all markets treated equivalently? No. CMS places each county into the same categories used for MA plans’ network adequacy: Large Metro, Metro, Micro, Rural, or CEAC (Counties with Extreme Access Considerations). Within each practitioner and facility type, there are different network adequacy standards by county type. Presumably, these can change from year-to-year as well.

    How is network adequacy measured? The approach is similar to that for MA plans: 90% of enrollees must have access to at least one provider/facility type within specified travel distances and travel times. A key difference is that there does not appear to be a minimum number of each provider type every plan must contract with. It’s reasonable to hypothesize, therefore, that marketplace plans would have much more narrow networks than MA plans, but no direct comparison exists, to our knowledge.

    This is rather abstract. How about a concrete example? The table below lists the time and distance standards by county and provider type.

    Where can I learn more? Here are some potentially helpful links:


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