• It’s time to reform the 340B program

    Boston University policy analyst Elsa Pearson and I have a new piece up at STAT about the unintended and undesirable consequences of the 340B drug discount program. That program requires drug manufacturers to sell drugs to some hospitals and clinics at a discount. However, those organizations can get reimbursed from payers at higher prices, pocketing the difference.

    That could be sensible, depending on what use that net revenue is put. Research suggests that in many cases it isn’t used to benefit the high cost/high risk populations the program is intended to help. We cover that research.

    There are bills in Congress to reform the program. Our piece explains what they are and what they’d do. Go read it!

    Research for this piece was supported by the Laura and John Arnold Foundation.


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  • Traditional Medicare Doesn’t Cover Dental Care. That Can Be a Big Problem.

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company). It also appeared on page 4 of the Sunday Business section on April 8, 2018.

    Many people view Medicare as the gold standard of United States health coverage, and any attempt to cut it incurs the wrath of older Americans, a politically powerful group.

    But there are substantial coverage gaps in traditional Medicare. One of them is care for your teeth.

    Almost one in five adults of Medicare eligibility age (65 years old and older) have untreated cavities. The same proportion have lost all their teeth. Half of Medicare beneficiaries have some periodontal disease, or infection of structures around teeth, including the gums.

    Bacteria from such infections can circulate elsewhere in the body, contributing to other health problems such as heart disease and strokes.

    And yet traditional Medicare does not cover routine dental care, like checkups, cleanings, fillings, dentures and tooth extraction.

    After I wrote a recent article about the lack of coverage for dental care in many state Medicaid programs, I received a lot of feedback from readers saying Medicare was no better.

    I have not had dental coverage since I retired 25 years ago. Any problems and I have to go to a foreign country to get treatment that I can afford. It is incredible that there is no coverage available in America for one of the most important aspects of health and wellness care for seniors. — Tom, La Jolla

    Several of my elderly relatives have just let teeth fall out without being cared for or replaced because of expense. This is no way to care for our senior citizens. — Bronxbee, Bronx

    Paying for dental care out of pocket is hard for many Medicare beneficiaries. Half have annual incomes below $23,000 per year. Those who have the means, but are looking for a deal, might travel abroad for cheaper dental care. Tens of thousands of Americans go to Mexico every year for dental work at lower prices. Many others travel the globe for care.

    Although low-income Medicare beneficiaries can also qualify for Medicaid, that’s of little help for those living in states with gaps in Medicaid dental coverage.

    According to a study published in Health Affairs, in a given year, three-quarters of low-income Medicare beneficiaries do not receive any dental care at all. Among higher-income beneficiaries, the figure is about one-quarter.

    “The separation of coverage for dental care from the rest of our health care has had dramatic effects on both,” said Amber Willink, the lead author of the study and a researcher at Johns Hopkins Bloomberg School of Public Health. “As a consequence of avoidable dental problems, the Medicare program bears the cost of expensive emergency department visits and avoidable hospitalizations. It’s lose-lose.”

    Traditional Medicare will cover dental procedures that are integral to other covered services. So if your Medicare-covered hospital procedure involved dental structures in some way, important related dental care would be covered. But paying for any other care is up to the patient.

    Lack of dental coverage by Medicare is among the top concerns of beneficiaries. The program also lacks coverage for hearing, vision or long-term care services. However, many Medicare Advantage plans — private alternatives to the traditional program — cover these services.

    For example, 58 percent of Medicare Advantage enrollees have coverage for dental exams. In receiving these benefits through private plans, enrollees are also subject to plans’ efforts to limit use by, for example, requiring prior authorization or offering narrow networks of providers. These restrictions can be problematic for some beneficiaries, and about two-thirds of Medicare beneficiaries opt for the traditional program, not a private plan.

    Adding a dental benefit to Medicare is popular. A Families USA survey of likely voters found that the vast majority (86 percent) of likely voters support doing so. The survey also found that when people do not see a dentist, the top reason is cost.

    Ms. Willink’s study estimated that a Medicare dental benefit that covered three-quarters of the cost of care would increase Medicare premiums by $7 per month, or about 5 percent. The rest would need to be financed by taxes.

    The cost of such a benefit might be offset — or partly offset — by reductions in other health care spending, reflecting the fact that poor oral health contributes to other health problems.

    Making a case for this in the political arena would not be easy, though. The initial cost would be an inviting target for politicians who express concern about fiscal prudence, regardless of any potential long-term gain. But expanding Medicare has been done before.

    In 2006, a prescription drug benefit was added to the program. The law for that program was enacted in 2003, and in that same year, the surgeon general released a report calling for dental care to be treated and covered like other health care. Whether by Medicaid or Medicare, that wish is still unfulfilled.


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  • Overshadowed by the Opioid Crisis: A Comeback by Cocaine

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    The opioid epidemic just keeps getting worse, presenting challenges discussed at length at a White House summit last week. But opioids are not America’s only significant drug problem. Among illicit drugs, cocaine is the No. 2 killer and claims the lives of more African-Americans than heroin does.

    In a recent study published in the Annals of Internal Medicine, researchers from the National Cancer Institute and the National Institute on Drug Abuse found that drug-related deaths have grown across all racial groups and among both men and women. The analysis found that between 1999 and 2015, overdose deaths of any kind of drug for Americans 20 to 64 years old increased 5.5 percent per year.

    For the most recent years of analysis (2012-15), the study found that deaths of men from heroin exceeded those from any other type of opioid, such as those found in pain medications. For women, deaths related to opioid medications were the most common.

    But among non-Hispanic black Americans, cocaine has been a larger problem than heroin for nearly 20 years. For example, over 2012-15, cocaine overdoses claimed 7.6 per 100,000 black men. In contrast, heroin overdoses claimed 5.45 per 100,000 black men. Black women use both drugs at lower rates than men, but cocaine overdoses exceed those from heroin for them as well.

    “We have multiple drug problems in the U.S.,” said Keith Humphreys, a professor at Stanford University School of Medicine who advises governments on drug prevention and treatment policies. “We need to focus on more than one drug at a time.”

    That doesn’t mean opioids aren’t also a problem in the black population. They are. When you combine all types of opioids — including heroin, prescribed opioids and fentanyl — they claim more lives than any other drug from every racial group.

    For a time, it appeared cocaine didn’t require as much attention. A study by RAND found that cocaine consumption fell 50 percent between 2006 and 2010. But in the past few years, the cocaine supply from Colombia has climbed to a record high in part because of a peace settlement that includes payments to farmers who stop growing coca. To be in a position to qualify for those payments in the future, many farmers started growing it. As a result, Mr. Humphreys said, cocaine prices have fallen, leading to an increase in cocaine use in the United States and some European countries.

    Mr. Humphreys said one pathway to cocaine use is encountering the illegal drug market through an opioid addiction and then adding cocaine.

    The surge in cocaine deaths has received relatively little attention. The trouble is, there’s a lot less we can do for cocaine than opioids. In contrast with addiction to opioids, there is no medication to treat addiction to cocaine. Though substantial investments have been made in search of drugs to treat cocaine addiction — including a vaccine — none are yet available.

    Harm-reduction approaches — like syringe exchanges — focus mainly on injectable drugs. But injecting cocaine is uncommon.

    Having fewer solutions doesn’t mean we can’t do anything about cocaine. Cognitive behavioral therapy can be effective in treating cocaine addiction, as well as other substance-use disorders. The defining feature of this therapy is learning to recognize patterns of thought that lead to problematic behavior and redirect them toward more positive behavior. Contingency management is also effective in treating cocaine addiction. In this approach, patients receive small rewards contingent on positive behavior (a cocaine-free urine test, for example).

    Kicking cocaine with these treatment methods works only if access and staffing are adequate. Multiple federal laws, most notably the Affordable Care Act, made major strides by extending coverage and including substance-use disorder treatment as an essential benefit that health insurance plans had to cover.

    But the new tax law undermines the A.C.A. by repealing the individual mandate. And changes to Medicaid being considered in many states — like adding work requirements or increasing premiums and other cost sharing — would also erode coverage. If insurance support is withdrawn, some addiction treatment agencies will lose staff or close, and some desperately needy addicted people will be cut off from care.

    At the White House opioid summit, President Trump said his administration would be “rolling out policy over the next three weeks, and it will be very, very strong.”

    But, as the evidence shows, even if we do respond to the opioid epidemic, it isn’t the only drug problem worthy of attention.


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  • A Substantial Gap in Many Medicaid Programs: Lack of Dental Benefits

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    Even before any proposed cuts take effect, Medicaid is already lean in one key area: Many state programs lack coverage for dental care.

    That can be bad news not only for people’s overall well-being, but also for their ability to find and keep a job.

    Not being able to see a dentist is related to a range of health problems. Periodontal disease (gum infection) is associated with an increased risk of cancer and cardiovascular diseases. In part, this reflects how people with oral health problems tend to be less healthy in other ways; diabetes and smoking, for instance, increase the chances of cardiovascular problems and endanger mouth health.

    There is also a causal explanation for how oral health issues can lead to or worsen other illnesses. Bacteria originating in oral infections can circulate elsewhere, contributing to heart disease and strokes. A similar phenomenon may be at the root of the finding that pregnant women lacking dental care or teeth cleaning are more likely to experience a preterm delivery. (Medicaid covers care related to almost half of births in the United States.)

    “I’ve seen it in my own practice,” said Sidney Whitman, a dentist who treats Medicaid patients in New Jersey and also advises that state and the American Dental Association on coverage and access issues. “Without adequate oral health care, patients are far more likely to have medical issues down the road.”

    There are also clear connections between poor oral health and pain and loss of teeth. Both affect what people can comfortably eat, which can lead to unhealthy changes in diet.

    But the problems go beyond health. People with bad teeth can be stigmatized, both in social settings and in finding employment. Studies document that we make judgments about one another — including about intelligence — according to the aesthetics of teeth and mouth.

    About one-third of adults with incomes below 138 percent of the poverty level (low enough to be eligible for Medicaid in states that adopted the Affordable Care Act Medicaid expansion) report that the appearance of their teeth and mouth affected their ability to interview for a job. By comparison, only 15 percent of adults with incomes above 400 percent of the poverty level feel that way.

    Some indirect evidence of the economic effects of poor oral health comes from a study of water fluoridation, which protects teeth from decay. It found that fluoridation increased the earnings of women by 4 percent on average, and more so for women of low socioeconomic status.

    Other evidence comes from a randomized study in Brazil. In that study, investigators showed one of two images to people responsible for hiring: pictures either of a person without dental problems or with uncorrected dental problems. Those with dental problems were more likely to be judged as less intelligent and were less likely to be considered suitable for hiring.

    The relationship between oral health and work has gained new salience in light of Kentucky’s recently approved Medicaid waiver, which permits the state to impose work requirements on some able-bodied Medicaid enrollees. It’s a step that some other states are also considering.

    Medicaid takes different forms in different states, and even within states, different populations are entitled to different benefits. Though all states must cover dental benefits for children in low-income families, they aren’t required to do so for adults.

    As of January 2018, only 17 state Medicaid programs offered comprehensive adult dental benefits, and only 14 of those did so for the population eligible for Medicaid under the Affordable Care Act. More typically, states offer only limited dental benefits or none.

    Dental coverage under most private health care plans isn’t comprehensive, either — people who want it have to buy separate dental plans. But compared with those enrolled in private coverage through an employer or on their own, the population eligible for Medicaid is much more likely to need dental care and much less likely to be able to afford it or coverage for it. People with incomes low enough to qualify for Medicaid are twice as likely to have untreated tooth decay, relative to their higher-income counterparts.

    Kentucky offers limited dental benefits to Medicaid enrollees, including those on whom work requirements would be imposed. Those benefits exclude coverage for dentures, root canals and crowns, which could challenge some enrollees’ ability to maintain good oral health and lead to greater emergency department use.

    One study found that after Kentucky’s Medicaid expansion in 2014, the rate of use of the emergency department for oral health conditions tripled. Another study found that about $1 billion in annual emergency department spending was attributed to dental conditions, and 30 percent of emergency department visits for dental problems were made by people enrolled in Medicaid.

    Other states that have proposed imposing work requirements as a condition of Medicaid eligibility include Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Of these, only North Carolina and Wisconsin offer extensive dental benefits, while Arkansas, Indiana and Kansas offer limited benefits. (The definition of “limited” varies by state, but in all such states benefits are capped at $1,000 per year and cover less than 100 of 600 recognized dental procedures.) Maine, New Hampshire and Utah offer emergency-only benefits. Arizona offers none.

    Though emergency-only coverage is less than ideal, it is better than nothing, as documented in a recent study based on Oregon’s Medicaid experiment. The study used a random lottery to offer some low-income adult residents eligibility for Medicaid. At the time of the study, Oregon offered dental coverage only for emergencies..

    The study found that one year after the lottery, Medicaid coverage meant more people got dental care (largely through emergency department use), and the percentage of people reporting unmet dental needs fell to 47 percent from 61 percent. It also doubled the use of anti-infectives, which are used to reduce gum infections. Another study, published in the Journal of Health Economics, found that Medicaid dental coverage increased the chances that Medicaid-eligible people had a dental visits by as much as 22 percent.

    It’s an accident of history that oral care has been divided from care for the rest of our bodies. But it seems less of an accident that the current system hurts those who need it most.


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  • Point and counterpoint on the recent NEJM 340B study

    Last week, the American Hospital Association (AHA) posted a critique of a recent, NEJM-published study by Sunita Desai and Michael McWilliams examining the effects of the 340B Drug Pricing Program, which has the goal of enhancing care for low-income patients. That AHA critique links to a methodological review by economist Partha Deb of the study’s methods. (Partha Deb was kind enough to speak with me and disclosed that he was compensated by the AHA for his time to prepare his review. At the time we spoke, that financial relationship was not disclosed in his online review, something he said he would try to correct.)

    The study used a regression discontinuity design, exploiting a threshold in the program’s eligibility rules for general acute hospitals — hospitals with disproportionate share hospital (DSH) adjustment percentages greater than 11.75% are eligible for the program. The study findings suggest that the 340B Program has increased hospital-physician consolidation and hospital outpatient administration of intravenous and injectable drugs in oncology and ophthalmology, without clear evidence of benefits for low-income patients.

    As Desai and McWilliams note in their paper, the study had several limitations. One that holds for all regression discontinuity studies is that the estimates pertain to hospitals close to the threshold. Another is that the study relies on data from Medicare and the Healthcare Cost Report Information System. The AHA claims that these limitations and other issues raised by Deb constitute “major methodological flaws” that “negate” the study’s findings.

    In a subsequent post, the AHA suggests that the study was unnecessary because the authors could have just asked hospitals how they were using resources generated from the 340B Program.

    The authors’ sent me a response to these critiques, which I have agreed to host here at TIE. I will let that response speak for itself. Read it.

    But I do want to make two additional comments. First, the notion that we should only learn how a program works by “just asking” those that participate in it or benefit from it is absurd. To be sure, much insight can be gained from such qualitative work. But independent, objective, quantitative work is also essential to unbiased assessment of programs. I reject the AHA’s dismissal of research on these grounds.

    Second, there is something troubling to me about advocacy organizations hiring top academics to critique specific studies. The potential for conflicts of interest is obvious. That is not to say there is anything wrong with Deb’s critique, but it is hard to know, in general, what role the financial relationship plays in these kinds of situations. At a minimum, that financial relationship should be disclosed.


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  • A new study finds cost shifting, but I’m skeptical

    A new NBER working paper by Michael Darden, Ian McCarthy, and Eric Barrette claims to have found evidence of hospital cost shifting. I’m not so sure.

    I will skip the throat clearing about what hospital cost shifting is, why or when we should or should not expect it to occur in theory, and what the prior literature says in some detail about whether it occurs in practice. Go read this Upshot post and all it links to for that. I will only say that based on the prior literature, we should begin consideration of the new paper with some skepticism about claims of cost shifting — it is reasonable to believe it doesn’t happen.

    Therefore, even to find, with credible methods, a modest degree of cost shifting — like $0.10 per dollar of public payer shortfall is shifted to private payers — would be a big deal.

    What Darden et al. found isn’t modest. It’s huge. They estimated that more than half of Medicare payment shortfalls are recouped by jacking up prices charged to private insurers — 56 cents on the dollar, to be precise. Yow! (Right here you should wonder why hospitals would stop at 56 cents on the dollar. If your answer is, “that’s the limit of their market power,” you’re on the right track. That also means they’ve exhausted their market power and, unless they acquire more, cost shifting should halt. And right there is why more than rare claims of cost shifting aren’t credible.)

    But, without even looking at methods, we should be careful about taking this figure to mean that there really is cost shifting at a rate of 56 cents on the dollar. Given prior work, a Bayesian might, at most, update his/her thinking from “there is no cost shifting” to “there could be a little cost shifting.” However, the methods might not even warrant that.

    So, what’s up with the methods? Craig Garthwaite did a nice job pointing out a few issues, starting with this tweet:

    Let’s unpack a few of his concerns, which I share. First of all, the headline result of massive cost shifting is based on examining how private hospital prices change due to changes in hospitals’ Medicare penalty status. That is, Medicare financially penalizes hospitals for lower quality in several ways, which the paper examines. The study found that hospitals that change from not-penalized to penalized status increase their private prices more than hospitals that don’t. From that, they back out a cost shift rate of 56 cents on the dollar.

    But there’s another way to estimate what the cost shift rate is, not by looking at changes in penalty status, but by looking at what the penalty amount is. How much does a hospital cost shift when it is penalized an additional dollar? When estimated this way, the authors find small and statistically insignificant evidence of cost shifting, which is a highly credible finding on its face. (See footnote 17 of the paper.)

    So, one has to ask, why might hospitals that become penalized differ from those that don’t, and in ways that are associated with increases in private prices? About this, Craig made a very good point: Hospitals were aware in advance of their risk of being penalized. Those that looked like they would be may have invested more in quality improvements. For some, those improvements didn’t translate into avoiding the penalty, but they did increase the value those hospitals were delivering. Private payers may have been willing to pay more for that additional quality. It’s possible they’re even willing to pay more for investments in quality that haven’t yet translated into actual improvements.

    Separately, it’s also possible that hospitals that respond to potential penalties change their marginal costs, which would change their profit- (or revenue-) maximizing price. This could look like cost shifting, but it’s still a response to a change in quality or, more generally, cost structure. It wouldn’t be a response to Medicare reimbursement shortfalls in the sense that if Medicare just cut payments without linking them to quality, one would not expect the same change in private prices.

    The BIG IDEA here is that firms (here, hospitals) respond to incentives in ways that change their production function (their costs and the value they provide). In fact, this is the point of Medicare quality penalty programs. They should affect what hospitals do and that, itself, can affect prices, as explained above. That’s not cost shifting. Not being able to control for that in a cost shifting study is a big problem. The particular approach taken in this paper likely doesn’t address this problem, leading to estimates that should not be attributed to cost shifting.

    I will close by adding that this paper is highly useful for tracking down claims of cost shifting made by hospital executives and policymakers. See the main text as well as footnote 1.

    PS: I should make explicit what should be obvious. I would appear to have a large interest in arguing away findings of hospital cost shifting, given my prior writing on the issue. I am so aware of that apparent conflict that I had a few colleagues without that conflict look over this post before publishing. All of their input was incorporated to their satisfaction.


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  • JAMA Forum: The economy and health

    It’s important to recognize that the financial effects of a shrinking or growing economy—employment and reduced income—can accrue to different people than its health effects. This is demonstrated in an intriguing study by Ann Stevens, PhD, Douglas Miller, PhD, Marianne Page, PhD, and Mateusz Filipski, PhD. They found that increases in mortality during strong economic conditions are concentrated among the elderly, particularly older women living in nursing homes. One mechanism for this phenomenon is that employment levels in skilled nursing facilities—particularly for nursing staff—go down when the unemployment rate falls. This might occur because nurses who would otherwise work in those facilities are able to find better jobs elsewhere, or their other household members are able to gain employment. Moreover, it may be the case that during economic expansions, the nursing staff that facilities are able to retain are of lower quality. Since quality is positively correlated with nursing home staff levels, this connection between employment rates and nursing home mortality is plausible.

    That’s from my latest on the JAMA Forum. Go read the rest!


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  • The Connection Between Retiring Early and Living Longer

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    You may not need another reason to retire early, but I’ll give you one anyway: It could lengthen your life.

    That’s the thrust from various research in recent years, and also from a 2017 study in the journal Health Economics.

    In that study, Hans Bloemen, Stefan Hochguertel and Jochem Zweerink — all economists from the Netherlands — looked at what happened when, in 2005, some Dutch civil servants could temporarily qualify for early retirement.

    Only those at least 55 years old and with at least 10 years of continuous service with contributions to the public sector pension fund were eligible. Men responding to the early retirement offer were 2.6 percentage points less likely to die over the next five years than those who did not retire early. (Too few women met the early retirement eligibility criteria to be included in the study.)

    The Dutch study echoes those from other countries. An analysis in the United States found about seven years of retirement can be as good for health as reducing the chance of getting a serious disease (like diabetes or heart conditions) by 20 percent. Positive health effects of retirement have also been found by studies using data from IsraelEnglandGermany and other European countries.

    That retirement promotes health and prolongs life isn’t obvious. After all, work provides income and, for some, health insurance — both helpful for maintenance of well-being. It also can provide purpose and camaraderie. Evidence is mounting that loneliness and social isolation are linked to illness, cognitive decline and death. One study of American retirees found them less likely to be lonely or depressed.

    Some work involves physical activity, which can help keep bodies healthy, too. One study found that those accustomed to getting exercise through physically strenuous jobs — like construction or landscaping — are more likely to become obese upon retirement than those who don’t have such jobs.

    But for many people, work can be stressful, take time away from exercise, and promote bad habits like excessive alcohol consumption. The Dutch study found that half of the mortality reduction associated with retirement is attributable to cardiovascular and digestive system diseases. Obesity, smoking and alcohol consumption, as well as reduced exercise and stress, can all contribute to these. If you drive to work, that’s another life-threatening risk.

    Teasing out the causal effect of retirement on health isn’t straightforward. After all, some people retire precisely because they are in declining health. Without careful analysis, you might conclude that retirement causes poor health and an earlier death.

    Indeed, some studies find retirement associated with worse health and reduced longevity. One found that retirement raises the risk of cardiovascular disease and mortality. Another found higher risks of cardiovascular disease and cancer. But another such study found that poor health outcomes were more pronounced among retirees who were unmarried, reduced their physical activity, and had less social interaction. In other words, it isn’t retirement itself that affects health, but what you do in retirement.

    Keeping active and developing healthy habits are good ideas. Physical activity is associated with prevention of disease and reduced mortality in older people. Lack of time, perhaps due to work, is a chief reason many adults don’t exercise. Retirees are more likely to exercise, and those who do are better off for it. One study found retirees get more sleep and spend more time doing household work and gardening — both of which are more active than a desk job. Another study found that better health in retirement may be because of the reduced likelihood of smoking.

    The age for full Social Security retirement benefits has been on a schedule, increasing gradually from 65 to 67 (67 for those born in 1960 and later). Those working longer as a result are in worse health than earlier cohorts. To retire, they’d have to rely more on their own savings.

    But according to a recent national survey by the Board of Governors of the Federal Reserve System, many Americans don’t have the resources to retire. About 20 percent of Americans over 44 years old have no retirement savings. Half of Americans are at risk of being unable to maintain their standard of living in retirement. If you want to retire, whether for health benefits or otherwise, you’ll have to start preparing when you’re still young.


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  • Come work with me (job posting 1, re-up)

    Colleagues and I are still advertising for research data analysts. If that’s you, this is an opportunity to work with us at the Partnered Evidence-based Policy Resource Center (PEPReC). Though PEPReC is a center in the Veterans Health Administration, the position will be filled through Boston University.

    Apply here. (We are also looking for policy analysts.)

    PS: Yes, the job posting has a typo: “SA” should be “SAS”.


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  • Health and Financial Literacy Courses in Kentucky’s Medicaid Waiver

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company). It also appeared on page A12 of the print edition on January 23, 2018.

    If you’re on Medicaid in Kentucky and are kicked off the rolls for failing to meet the state’s new work requirements, Kentucky will be offering a novel way to reactivate your medical coverage: a health or financial literacy course you must pass.

    The precise content of the courses is not yet worked out but may include instruction on household budgeting, how to open a checking account, weight management and chronic disease management, said Kristi Putnam, a manager with Kentucky Health, the state’s new Medicaid program that includes work requirements. She said quizzes would be included that people must pass to complete the course.

    Kentucky says the courses, along with the bigger elements of the recently approved waiver it received from federal Medicaid rules, will help to “empower individuals to improve their health.”

    The courses are just one way people subject to and failing to meet work requirements could regain coverage. But some health policy experts express dismay with the approach. For one thing, many Americans, not just those who seek Medicaid, struggle with health and financial literacy. And to some, literacy quizzes — however well intentioned — evoke the tests used to impede voting registration of black Americans in the Jim Crow South.

    “Requiring people to pass a health literacy course to get care — care for conditions that might prevent them from passing — is just expensive, punitive and cruel,” said Atul Gawande, a surgeon and a health care researcher with the Harvard T.H. Chan School of Public Health.“It serves no health benefit whatsoever. You have to be concerned about requirements like literacy tests, which states have a bad history of applying selectively and arbitrarily.”

    Ms. Putnam said that the courses were “intended to be a tool/support for people to improve both health and finances, and not a barrier in any way.” Her agency, she said, is looking into ways to provide help to people who might struggle with understanding the courses.

    There is no standard definition for health literacy. Ms. Putnam said Kentucky’s “pertains to learning about healthy habits, how to manage chronic conditions, effectively utilizing health care benefits and understanding commercial market insurance concepts.”

    However defined, health literacy is related to literacy and numeracy more generally. To understand and use health-related information, you need some fluency with written or spoken language, and usually with numbers and basic math as well. People with low skills in other forms of literacy or numeracy also have lower health literacy.

    Apart from instruction aimed at specific populations with certain conditions — such as training to self-manage chronic diseases like diabetes and hypertension, or even birth training classes for pregnant women and their partners — health literacy courses are uncommon. (Say Ah! is one source for health literacy resources.)

    Financial literacy courses are more widely available but still not a routine part of general education.

    “If these topics are taught at all in primary education, they certainly aren’t addressed consistently or in an evidence-based way,” said Harold Pollack, a professor at the University of Chicago who was a co-author of a book on basic financial education. “But singling out the Medicaid population for classes as a condition for access to insurance suggests that shrinking and stigmatizing the program, not literacy, is the goal.”

    Numerous studies document the widespread need for greater health and financial literacy. By one estimate, one-third of adults have health literacy deficits. For example, most people make errors in selecting health plans and don’t know basic features of the plans they choose.

    The last large national survey of U.S. adult literacy (including health literacy) was conducted in 2003. One study found that 60 percent of Medicaid enrollees had only “basic” or “below basic” health literacy, meaning, for example, they could not recognize a medical appointment on a hospital appointment form (below basic) or would have trouble understanding why a specific test was recommended for someone with certain symptoms, even when given a clearly written and accurate explanation (basic).

    But Medicaid enrollees are not the only ones. Nearly the same proportion of Medicare enrollees also had basic or below basic health literacy. Privately insured people scored better. They are typically younger than Medicare enrollees, and they typically have higher education levels and are less likely to have cognitive impairments than those with public coverage. However, only a small minority even of the privately insured had a “proficient” level of health literacy — meaning, for example, that they could deduce the employee share of health insurance costs from a table that listed that cost as a function of income and family size.

    Another study, based on data collected in 2013, showed adults’ blood test results alongside the normal range (typical of reports many of us receive from our doctors after blood tests). Only about half of the subjects could recognize if the blood glucose level indicated on the test was outside the normal range. Of those with diabetes — to whom blood glucose measurement and levels should be familiar given the importance to their condition — only 56 percent could identify out-of-range values.

    Poor health literacy is associated with worse health care outcomes and higher health care spending. But causality could run both ways. It is likely that people in greater need of health care are also less likely to have high literacy skills in general. It’s also possible that poor health literacy contributes to worse self-management of health and lifestyle issues that could result in worsening health and increased health care use.

    Likewise, low financial literacy can contribute to insufficient or inefficient saving. One national survey found that only 14 percent of respondents got all the answers right on a five-question quiz about financial topics like interest rates, inflation, bond prices and mortgages. Only 37 percent got four out of five. (As an example of its difficulty, the true/false mortgage question was: “A 15-year mortgage typically requires higher monthly payments than a 30-year mortgage, but the total interest paid over the life of the loan will be less.”)

    Other research documents high rates of errors in financial decision making even among highly educated people, including mistakes made in 401(k) investingselection of mutual fundsuse of creditreceipt of payday loansand others.

    Addressing these issues through financial literacy education improves financial outcomes. A recent review of financial literacy research found that providing financial literacy education in school settings is effective. So is the approach of targeting education during teachable moments, as when individuals are making financial decisions: taking out a loan, establishing a saving plan, and the like. The Kentucky program would do neither.

    Though policy experts are divided on the merits of Kentucky’s health and financial literacy program, there may at least be in agreement that education in both needs improvement. That’s true not just for would-be Medicaid enrollees, but for many of the rest of us, too.


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