• 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.

    “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.

    FIRST ROUND

    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.

    FIRST ROUND

    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.

    FIRST ROUND

    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.

    FIRST ROUND

    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.

    SEMIFINALS

    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.

    SEMIFINALS

    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.

    FINAL

    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.

    Conclusion

    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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  • Healthcare Triage: Shrooms, LSD, and Legit Uses of Psychedelics in Treatments

    With all the recent studies of medical marijuana and its benefits, some researchers have become interested in researching the use of psychedelics like psilocybin, LSD, and MDMA for treating mental illness. It’s hard to research though, because of the drugs’ legal status as Schedule I drugs. This makes them very hard for researchers to obtain, it makes it hard to get research approved, and it make it difficult to find funding for these studies. We’ve got the details.

    This episode was adapted from a column I wrote for The Upshot. Links to sources and further reading can be found there.

    @aaronecarroll

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  • The Economic Case for Letting Teenagers Sleep a Little Later

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company)

    Many high-school-aged children across the United States now find themselves waking up much earlier than they’d prefer as they return to school. They set their alarms, and their parents force them out of bed in the morning, convinced that this is a necessary part of youth and good preparation for the rest of their lives.

    It’s not. It’s arbitrary, forced on them against their nature, and a poor economic decision as well.

    The National Heart, Lung and Blood Institute recommends that teenagers get between nine and 10 hours of sleep. Most in the United States don’t. It’s not their fault.

    My oldest child, Jacob, is in 10th grade. He plays on the junior varsity tennis team, but his life isn’t consumed by too many extracurricular activities. He’s a hard worker, and he spends a fair amount of time each evening doing homework. I think most nights he’s probably asleep by 10 or 10:30.

    His school bus picks him up at 6:40 a.m. To catch it, he needs to wake up not long after 6. Nine hours of sleep is a pipe dream, let alone 10.

    There’s an argument to be made that we should cut back on his activities or make him go to bed earlier so that he gets more sleep. Teens aren’t wired for that, though. They want to go to bed later and sleep later. It’s not the activities that prevent them from getting enough sleep — it’s the school start times that require them to wake up so early. More than 90 percent of high schools and more than 80 percent of middle schools start before 8:30 a.m.

    Some argue that delaying school start times would just cause teenagers to stay up later. Research doesn’t support that idea. A systematic review published a year ago examined how school start delays affect students’ sleep and other outcomes. Six studies, two of which were randomized controlled trials, showed that delaying the start of school from 25 to 60 minutes corresponded with increased sleep time of 25 to 77 minutes per week night. In other words, when students were allowed to sleep later in the morning, they still went to bed at the same time, and got more sleep.

    There are costs to pushing back the start times of schools, of course. Our local school system, like many others, uses the same buses for elementary, middle and high school. Not wanting to start elementary school too early, it starts high school earlier to save money on transportation. Other costs to delaying start times come after school, when later school end times result in later after-school activities. These can interfere with parents’ work schedules and run into evening hours, when it gets dark and additional lighting might be necessary.

    A Brookings Institution policy brief investigated the trade-offs between costs and benefits of pushing back the start times of high school in 2011. It estimated that increased transportation costs would most likely be about $150 per student per year. But more sleep has been shown to lead to higher academic achievement. They found that the added academic benefit of later start times would be equivalent to about two additional months of schooling, which they calculated would add about $17,500 to a student’s earnings over the course of a lifetime. Thus, the benefits outweighed the costs.

    This was a reasonably simple analysis, though, and did not persuade many schools to change. A recent analysis by the RAND Corporation goes much further.

    Marco Hafner, Martin Stepanek and Wendy Troxel conducted analyses to determine the economic implication of a universal shift of middle and high school start times to 8:30 a.m. at the earliest. This study was stronger than the Brookings one in a number of ways. It examined each state individually, because moving to 8:30 would be a bigger change for some than for others. It also looked at changes year by year to see how costs and benefits accrued over time. It examined downstream effects, like car accidents, which can affect lifetime productivity. And it considered multiplier effects, as changes to the lives of individual students might affect others over time.

    They found that delaying school start times to 8:30 or later would contribute $83 billion to the economy within a decade. The gains were seen through decreased car crash mortality and increased student lifetime earnings.

    Since it would take at least a year for any students affected by changes in start times to enter the labor market, there would be no gains in the first year. Costs, however, would accrue immediately. These included about $150 per student per year in transportation costs and $110,000 per school costs in upfront infrastructure upgrades. Even so, by the second year, the benefits outweighed the costs. By 10 years, the benefits were almost double the costs; by 15 years, they were almost triple.

    We’d be remiss if we didn’t acknowledge other potential costs not included in this calculation, including parental difficulty in adapting to later school start times. But even in a model where the per-student, per-year cost was increased to $500, which would compensate most parents for delays, and where the upfront per school cost was increased to $330,000, the economic benefits to society would still outweigh the costs in the long run.

    Further, it’s important to understand that these benefits may actually be underestimates. The researchers were careful to model only outcomes for which they had empirical data from sleep duration, such as car crashes and academic performance. They didn’t model other real, but quantifiably unknown, benefits, like improvements in rates of depression, suicide and obesity, or the overall effects on health.

    Some schools are beginning to take this seriously, but not enough. When it comes to start times, the growing evidence shows that forcing adolescents to get up so early isn’t just a bad health decision; it’s a bad economic one, too.

    @aaronecarroll

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  • Healthcare Triage News: Senate Republicans Longshot Repeal and Replace Bill

    Senate Republicans are going to give it one more try on repealing and replacing Obamacare. This week, Senators Bill Cassidy (LA) and Lindsey Graham (SC) plan to bring forward a bill to repeal and replace the Afffordable Care Act. It’s got a lot of hurdles to clear. We’ve got the details (such as they are).

    @aaronecarroll

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  • Can the courts stop 1332 waivers from taking effect?

    Iowa has submitted a waiver proposal under section 1332 of the Affordable Care Act that, if granted, would radically reshape its individual insurance market; Oklahoma may soon do the same. Both states have been accused of relying on some magical numbers, and Iowa’s waiver appears to violate the ACA’s guardrails, which require states to assure that any new approach covers at least as many people with coverage that’s at least as comprehensive and affordable.

    But what happens if HHS approves the waivers anyhow? Could the courts block them from taking effect?

    You bet. Although neither of the two waivers that have been granted so far (Hawaii’s and Alaska’s) has attracted a court challenge, we’ve had decades of experience with challenges to waivers granted under section 1115 of the Social Security Act. Most of those challenges have failed, but back in 1994, in Beno v. Shalala, the Ninth Circuit ruled in favor of a group of welfare beneficiaries who challenged the grant of a California waiver.

    Invoking the presumption in favor of judicial review of agency action, the court rejected HHS’s argument that the courts couldn’t review its decision to grant a waiver. “The statute does not give the Secretary unlimited discretion. It allows waivers only for the period and extent necessary to implement experimental projects which are ‘likely to assist in promoting the objectives’ of the [welfare] program.”

    With that in mind, the court enjoined California’s waiver from taking effect. In the court’s view, HHS never explained how the waiver—which would have imposed work requirements on welfare recipients—was a genuine experiment or would advance the program’s objectives. In 2011, the Ninth Circuit issued a similar ruling when Arizona sought to impose copayments on Medicaid beneficiaries.

    Courts in other circuits have universally agreed that the decision to grant an 1115 waiver can be challenged in court. Their reasoning should apply with equal force to 1332 waivers. (Although the ACA precludes the courts from reviewing some agency decisions, there’s no preclusion language for 1332 waivers.) All you have to do is find a litigant who can plausibly allege that the waiver will make her life worse. For waivers like Iowa’s, that won’t be remotely difficult.

    Still, the courts tend to be very deferential to HHS. They’re not really equipped to second-guess the agency’s predictive judgments about a waiver’s on-the-ground consequences, as Judge Friendly explained more than 30 years ago. But deference only goes so far. For 1332 waivers, the courts will still ask hard questions about whether the waiver in question adheres to the guardrails.

    That’s going to be a problem for waivers like Iowa’s, which would divert funding for cost-sharing reductions and eliminate protections against excessive out-of-pocket spending. As David Anderson notes:

    The Iowa waiver submission will increase the number of low income residents with high percentages of their income devoted to health care costs. The hypothetical 40 year old who has an expensive chronic condition will see a dramatic change in his total out of pocket spending from 8.52% of income under the ACA to 44% of income … . There will be a number of individuals who will have significant, real and obvious harms from this waiver. I will be shocked if at least one of them does not file suit to stop the Iowa waiver for at least the 2018 plan year.

    I’ll be shocked, too. How on earth does Iowa’s waiver provide “cost sharing protections against excessive out-of-pocket spending that are at least as affordable” as the ACA, as the statute requires? It eliminates those protections!

    Deferential or not, the courts won’t stand for this. The guardrails are really restrictive. If you take them seriously—and the courts will, even if HHS doesn’t—they suggest that a state’s waiver can be approved if and only if it doesn’t make a substantial number of people worse off than they were under the ACA. Iowa’s waiver flunks that test.

    Iowa is nonetheless pressing forward—and on an expedited, emergency basis so that its waiver can take effect for 2018. If the waiver is approved, however, there’s a very good chance a court will enter a preliminary injunction to prevent it from taking effect. That’s the worst of all worlds for Iowa. Inviting a legal battle on the eve of open enrollment will not give insurers the confidence they need to participate on the exchanges.

    What’s true in Iowa is true for other red states. If they want to revamp their insurance markets, they’re going to have to ask Congress to relax the guardrails. Maybe Congress will oblige, either in Cassidy-Graham or in a bipartisan deal to include more targeted fixes. In the meantime, the courts probably won’t allow the states to radically change the ACA’s structure through waivers.

    @nicholas_bagley

     

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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 Medicare for All Act is more than just universal coverage

    Senator Sanders has released the text of his Medicare for All Act. This bill won’t be enacted in this Congress, so the point of introducing it now is to stimulate discussion, above all about the principles that should guide the design of the American health care system. Most of the discussion so far has focused on universal coverage, and the bill delivers that:

    Every individual who is a resident of the United States is entitled to benefits for health care services under this Act.

    But there’s a lot more than just universal coverage in Senator Sanders’ bill and I want to quickly highlight some of those features.

    Comprehensive benefits. The Act requires the provision of hospital, ambulatory care, preventive care, and prescription drugs. It also covers several important domains of health care that have not been adequately supported: oral health (that is, dentistry), mental health, substance abuse, and

    comprehensive reproductive, maternity, and newborn care.

    In any reasonable construal of comprehensive reproductive care, this would require providers to supply contraceptive care. This will be controversial, to say the least. Because it includes mental health, substance abuse care, and dentistry, this list is notably better than covered services required by the Canada Health Act.

    Non-discrimination. By design, the Act eliminates discrimination on the basis of pre-existing conditions. But it also bans discrimination

    on the basis of race, color, national origin, age, disability, or sex, including sex stereotyping, gender identity, sexual orientation, and pregnancy and related medical conditions (including termination of pregnancy) [emphasis added]

    Working out what the italicized words require will be, let’s say, interesting.

    Health disparities. The Act identifies health disparities associated with

    race, ethnicity, gender, geography, or socioeconomic status

    as a quality of care problem. The mention of geography is particularly interesting, in that accessibility problems associated with living in rural or remote areas are an underappreciated dimension of health disparities.

    Evidence-based policymaking. The Act requires HHS to

    develop methodological standards for evidence-based policymaking.

    This brief phrase tells us nothing about the scope of such standards, what criteria would be used to develop them, or how evidence should constrain policy-making. Nevertheless, if we could do this right…!

    National reporting. Currently, Medicare is too much about just cutting checks and policing fraud. Medicare for All would have a mandate to improve system performance on

    outcomes, costs, quality, and equity.

    The inclusion of equity in this list is important and — please correct me — a first. At the same time, the Act would require providers to supply data while balancing this with a goal to minimize

    the administrative burdens of data collection and reporting on providers.

    These goals are in tension, but that doesn’t mean that the Act is incoherent. They are in tension because that is how the world is. The legislation also includes whistleblower protections for providers who report problems in billing and quality.

    Negotiation of prices. The government would be able to negotiate prices on prescription drugs, medical devices, and equipment (and, please God, let this allow the government to negotiate prices for information technology).

    Destruction of Employer-Sponsored Insurance. As Aaron has described,

    The single largest tax expenditure in the United States is for employer-based health insurance.

    The expenditure is wasteful and highly regressive. The Act bans employer-sponsored benefits that duplicate the comprehensive benefits offered by Medicare for All.

    Automatic enrollment. The plan to automatically enroll people into Medicare for All might seem like a detail. However, many Americans cannot exercise rights or access entitlements because they have difficulty completing burdensome enrollment procedures.

    No-balance billing. The Medicare for All Act bans co-pays. This will generate much discussion. But note that the Act also states that

    no provider may impose a charge to an enrolled individual for covered services for which benefits are provided under this Act.

    This would, among other benefits, eliminate surprise billing.

    Increased coverage of long-term care. I study kids and long-term care is beyond my remit. But I read this act as seeking to increase Medicare’s coverage of long-term care.

    When I wrote about the Canada Health Act, I noted that we have many significant gaps between the principles in the Act and its implementation. In that light, there are many points in the Medicare for All Act which require further clarification. There is also a list of points that worry me.

    Nevertheless, if the Medicare for All were passed and successfully implemented, it would have far reaching effects on US health care beyond universal coverage.


    DISCLOSURE: I provided Senator Sanders’ staff with comments and suggested language in the drafting of the bill.

    @Bill_Gardner

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  • Prescription Drug Monitoring Programs: A Helpful Tool to Combat the Opioid Crisis

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    The opioid crisis is so complex and so large — drug-related deaths now exceed those caused by cars, H.I.V. or guns — that there is no single solution. Among the partial ones: prescription drug monitoring programs, an approach highlighted in the draft report from President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis.

    The epidemic has led every state but Missouri to establish one of these programs, which allow doctors and regulators to track how many opioid medications and other controlled substances have been dispensed to patients. A new analysis shows that prescription drug monitoring programs can reduce the overuse of narcotics — but that many states have adopted relatively weak versions.

    Opioid medications, like Vicodin, Percocet or OxyContin, can be useful in treating pain. But when patients receive many prescriptions — whether from multiple doctors at the same time or from the same one for a long period of time — it can signal a problem. Patients with more pills than they need could endanger themselves or divert them to the black market. Longer-term use increases the risk of addiction and other bad outcomes.

    Data from the Centers for Disease Control and Prevention show that opioid overdoses and prescriptions grew in parallel between 1999 and 2010. Though prescriptions have fallen more recently, they have been written for longer durations. Black-market opioids — heroin and, in particular, fentanyl — also contribute to overdose deaths. But many who use these drugs also use prescription opioids and may have become dependent on them first.

    That’s where prescription drug monitoring programs come in. They collect data from pharmacies to track what prescriptions for controlled substances patients have filled. The databases can be used to assess whether patients are getting more opioids than they can safely use. In addition, they can be used to tell if patients are getting other drugs, like a benzodiazepine, that are dangerous to use in combination with an opioid.

    According to research summarized by the Leonard Davis Institute of Health Economics at the University of Pennsylvania, prescription drug monitoring programs can help reduce the amount or strength of opioids prescribed and dispensed. When physicians or dentists check the database and see a worrisome pattern of dispensed opioids, they can deny or change a prescription, screen for an opioid or other substance use disorder, and even counsel the patient to seek other forms of pain management or addiction treatment, if warranted.

    Dr. Zachary Meisel, an author of the Leonard Davis review, uses a drug database when he practices in the Hospital of the University of Pennsylvania emergency department. In related work, he found that the databases often prompt conversations about opioids between provider and patient. In other cases, he said, prescription drug monitoring programs “help dispel a suspicion that a patient is seeking additional opioids.”

    Monitoring programs are mitigating the opioid epidemic. One study, published in Health Affairs, found they’re associated with a decline in the chance a patient with pain will receive a Schedule II opioid prescription, to 3.7 percent from 5.5 percent. The study was based on a sample of 26,275 doctor’s office visits in the 24 states that started drug monitoring operations during 2001-2010. The results of another study— of Medicare beneficiaries over 2007-12 in 10 states — suggest that such programs are associated with reductions in the strength of opioid medications dispensed and the duration of opioid prescriptions. Deaths related to oxycodone use fell 25 percent in 2012, after Florida created a monitoring program.

    But other work shows that having access to a prescription drug monitoring program is not enough. States can make the programs much more effective by mandating prescribers to engage with it. Twenty-five states require prescribers — physicians and dentists — to register with their state database. This forces prescribers to push through the first barrier to use — just signing up — and seems to make a difference.

    One study, published this year in Health Affairs, found that states that required prescriber registration saw a 10-percentage-point reduction in use of Schedule II opioids among Medicaid enrollees, relative to states that did not require registration.

    Most, but not all, states with mandatory registration also require prescribers to consult their state databases before prescribing an opioid. A study published in Health Services Research this year found that states requiring this experienced a reduction in the duration of opioid prescriptions in the Medicare population. Another study, also of the Medicare population, found that mandatory use was associated with fewer patients getting opioids from multiple doctors — so-called doctor shopping — and with patients holding a smaller supply of the drugs.

    Studies expanding beyond the Medicare population to include younger Americans find that use mandatesreduce admissions to treatment facilities for opioid use disorder. A New York study of prescriptions by dentists in an urgent care center found that when its mandatory program went into effect, opioid pills prescribed went down 78 percent.

    When states roll out monitoring programs, opioid-related overdose deaths fall, according to one study. And they decline more in states that mandate their use. Though some studies have not found that such programs reduce opioid use or opioid-related mortality, it could be because they do not distinguish between programs with such mandates and those without.

    Nevertheless, prescription drug monitoring programs have limitations. They can track only dispensed drugs, not black-market drugs (like heroin and fentanyl). And though they can be used to tell how many and what kinds of opioids are dispensed, they can’t tell who takes them or if they’re diverted to the black market. The programs could also be more effective if more prescribers used them. One study found that only about half of primary care physicians use the database. Among those who use them, many do not do so routinely.

    The data monitoring programs could be more useful if integrated with other health data and shared across states, as recommended by the opioid commission. Doing so could make it easier to combine prescription data with other data that could indicate problems — like a history of mental health or substance use disorders. These data, together, can help predict who is most likely to suffer adverse outcomes from prescribed opioids. This is an approach being adopted by the Department of Veterans Affairs, with an evaluation underway. [Disclosure: I am involved in that evaluation.]

    Prescription drug monitoring programs are not the only tool to combat the opioid crisis. Other state laws that tighten regulations of pain clinics and combat doctor shopping can help, too, reducing overdose deaths and admissions to treatment facilities. Wider distribution of naloxone, which can reverse an opioid overdose, and public education on its delivery can also help, as can greater access to safe means of disposing of unused pills.

    Prescription drug monitoring programs have shown promise, but so long as relatively inexpensive heroin and fentanyl are available on the street, they will never be a full solution on their own.

    @afrakt

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  • Healthcare Triage: Hurricanes, Floods, and Their Long-term Health Impacts

    The wind and rain and flooding and destruction that happen during a hurricane are dangerous, and have obvious impacts on the health of people who live in hurricane-prone regions. But many of the health impacts of hurricanes and floods are non-obvious, and can have long-term negative effects.

    This episode was adapted from an Upshot column written by Aaron and Austin. Links to further reading and references can be found there.

    @aaronecarroll

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  • If you have anything bad to say about kids today, just shut up

    I guess you could find something wrong with some kid, somewhere, but come on. Data are from the 2016 National Survey on Drug Use and Health. In each of these charts, kids 12-17 are the RED LINE.

    Cigarette use:

    Alcohol use:

    Pot use. And this is after legalization, when lots of you started screaming that this would HAVE to lead to increased use:

    Cocaine:

    Heroin:

    Things don’t look good for all age groups, but for adolescents – the red line – we’re pretty much at the lows. Not to mention teen pregnancy rates and teen births continue their all time lows. What more do you want from them?

    @aaronecarroll

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