This blog often deals with some heady and unpleasant stuff, but for today I’ll keep it on the lighter side with a clip from Conan on TBS that addresses some of our most pressing public health problems: diabetes, texting while driving and mental health issues.
We’re moving from non-standard silos to standards-based silos. No wonder they’re not reporting to us. — ANNA Orlova, Ph.D., Executive Director, Public Health Data Standards Consortium #2014phi
Family planning is an important part of women’s health. And reproductive health includes access to abortion that I believe should be safe, legal, and rare. I’ve spent a lot of my time trying to bring down the rate of abortions. And it has been my experience that good family planning and good medical care brings down the rate of abortion. Keeping women and men in ignorance and denied the access to services actually increases the rate of abortion. — Secretary of State Hillary Clinton, Testimony before House Foreign Affairs Committee, 2009
It wasn’t too long ago that I stumbled upon an anti-abortion protest outside of a Planned Parenthood clinic that was across the street from my shopping destination. Even though I adamantly disagree with the protesters and doubt that they understand all of the non-abortion services that Planned Parenthood provides, I think their hearts were in the right place. They want to protect fetuses that they consider to be babies.
To further their efforts, pro-life groups have fought to pass anti-abortion laws (which are frequently overturned in court as unconstitutional, most famously in Planned Parenthood v. Casey) and opened crisis pregnancy centers that show ultrasound images to pregnant women (a tactic proven to be ineffective at reducing induced abortions).
I’d like to suggest that if their real goal is to save the lives of babies in the USA — both born and unborn — they might want to focus their energies elsewhere.
First, the good news from the USA. In 2011, induced abortion rates in the United States fell to their lowest since the landmark Roe v. Wade decision. Another good sign is a declining infant mortality rate…reported at 6.05 deaths before the first birthday per 1,000 live births in 2011, which was a 12 percent drop from 2005. So we’re getting a little better at this. The bad news is that better is still not very good by international standards.
In 2008, the United States ranked 27th in infant mortality rate among Organization for Economic Cooperation and Development countries, and a previous report linked the United States’ relatively unfavorable infant mortality ranking to its higher percentage of preterm births. Despite the recent infant mortality decline, comparing the 2011 U.S. infant mortality rate with the 2008 international rankings would still have the United States ranked 27th. — U.S. Centers for Disease Control and prevention, NCHS Data Brief, April 2013 (emphasis added)
Despite spending more than any other nation on earth for health care per capita, the United States (depicted on the far righthand side of the chart) still lags behind many other countries in terms of infant mortality and abortion rates. Although the United States is not the worst performer on the list in terms of abortion and infant mortality, countries like Mexico and Estonia spend far less on health care per person. Please note that lower numbers for all variables always indicate better performance in this chart.
But is more health spending the answer? A quick glance at the data would suggest not, since the United States has the highest health care spending on earth, both in real dollars and as a percentage of gross domestic product.
In terms of the unborn, even though the U.S. abortion rate is dropping, it’s still too high. In 2008, the United States reported a rate of 20 induced abortions per 1,000 women ages 15-44. Germany, the top performing country, reported only 7.
What’s interesting is the inverse correlation between restrictive abortion laws and the number of abortions…especially the number of unsafe abortions. That is, the more restrictive a country’s abortion laws are, the more abortions occur. And they are of the unsafe, back-alley variety that endangers women’s lives.
Although the legal status of abortion and risk associated with the procedure are not perfectly correlated, it is well documented that morbidity and mortality resulting from abortion tend to be high in countries and regions characterized by restrictive abortion laws, and is very low when these are liberal…We found that the proportion of women living under liberal abortion laws is inversely associated with the abortion rate in the subregions of the world. — Sedgh, G. et al. “Induced abortion: incidence and trends worldwide from 1995 to 2008,” from The Lancet, 2012
It’s worth pointing out that the study classifies the U.S. as having liberal abortion laws, but obviously the people picketing outside of Planned Parenthood are hoping to change that.
Just because the United States spends more on health care by far than any other nation in the world doesn’t mean we’ve been spending the money very wisely. Indeed 31 percent of U.S. healthcare spending is on administrative costs.
But Sedgh, G. and colleagues offer an idea.
Other studies have found that abortion incidence is inversely associated with the level of contraceptive use, especially where fertility rates are holding steady, and there is a positive correlation between unmet need for contraception and abortion levels. — Sedgh, G. et al. “Induced abortion: incidence and trends worldwide from 1995 to 2008,” from The Lancet, 2012
And if you don’t believe that, there’s this:
The United Nations Population Fund (UNFPA) has calculated that funding which provides modern contraceptive services in developing countries ($7.1 billion in 2003) prevents 187 million unintended pregnancies, 60 million unplanned births, 105 million induced abortions, 22 million spontaneous abortions, and 215,000 pregnancy-related deaths each year. — John Lomoy, Organization for Economic Cooperation and Development
Fortunately, the Patient Protection and Affordable Care Act (that is, Obamacare) goes a long way in improving access to contraception and other women’s preventive health programs that can also reduce infant mortality rates.
Unfortunately for a lot of born and unborn babies, the pro-life crowd has spread a lot of misinformation about the impact of the Affordable Care Act’s women’s preventive health provisions.
To be clear, Obamacare does not provide any funding for abortions, nor does any other federal program due to the Hyde Amendment. Even the Medicaid funds that Planned Parenthood receives are specifically for the non-abortion services it provides…just like any other health provider that provides these services.
The Supreme Court recently heard arguments in the Sebelius v. Hobby Lobby Inc. case in which Hobby Lobby argued that the law’s required coverage of emergency contraception (Plan B and Ella) violated their religious beliefs, and they should not be required to include it in their employees’ insurance plans. Pro-life groups have inaccurately referred to Plan B and Ella as abortifacients, probably for political reasons. In reality, even traditional birth control pills can prevent implantation in the uterus (not just conception), so the distinction is totally made up.
It is hard to say precisely what is prompting the pro-life movement to back policies that are so counterproductive to reducing the number of abortions, infant mortality and deaths among pregnant women. I have a few hypotheses:
Don’t fall for it. The data shows overwhelmingly the pro-life crowd is (perhaps unintentionally) harming the babies they claim to cherish.
With only a few days left to go before the March 31 deadline, there was real cause for concern that enrollment on the health insurance exchanges would not come anywhere close to the goal of 7 million enrollees. After all, between October 1 and March 21, fewer than 6 million Americans had enrolled. Some had revised the goals down to 6 million…a major blow. But more than 1 million Americans jumped on, as they often do, at the last minute, enabling the exchanges to exceed the original goal of 7 million. It just goes to show that it’s human nature to procrastinate.
Earlier I wrote about how the Obamacare exchanges have failed to attract many young, healthy people — and how the early technical glitches have made the problem worse.
Of course, the older and sicker people who really needed health insurance coverage would have enrolled by hook or by crook — but in order to make all of this work economically, we need as many young, healthy adults as possible in order to prevent the adverse selection death spiral from making the exchanges unworkable.
In order to explain the problem of adverse selection in health insurance, it may be useful to use a different, simpler kind of insurance: homeowner’s insurance.
Suppose you haven’t had homeowner’s insurance for a number of years. Then all of a sudden your house catches on fire, and you have $100,000 in damage. If you walk into an insurance agent’s office the day after the fire and try to buy a policy that will pay for the repairs to your property after they have already occurred the agent will probably have a good laugh and explain why the insurance company would never, ever want to do that.
If there were a law, however, that said homeowner’s insurance companies have to accept all new applications, regardless of the condition of the home at the time of the application, restore the home to its original condition and charge these people the same premiums as everyone else, what do you suppose people might do?
Well, first of all, people whose homes were in good condition would naturally drop their insurance coverage since there would be no incentive whatsoever to keep paying premiums. If the insurer were required by law to accept any application, then people would wait until their houses caught on fire and then apply right after calling the fire department. Why not? And, of course, in order for the homeowner’s insurance company to stay afloat, the premiums would go up — dramatically.
Even if this were somehow workable, which it isn’t, if the fire damage were too extensive, the homeowner’s insurance company could declare the house a total loss and write the policyholder a check to buy a new house.
We sort of inherently understand and accept this in homeowner’s insurance because our home (or our car, boat, motorcycle, etc.) is a piece of property that has a dollar value on it and can be replaced. Plus, a fire at your home is largely an unpredictable event — the kind of event where an insurance market can function well. (Of course, there are some cases where people try to turn unpredictable events like fires into predictable events by deliberately causing them in order to cash in on a claim payout, but this can land them in prison for insurance fraud.)
But now let’s adapt that analogy back to health insurance. (Disclaimer: I’ve said for a long time that insurance is a really inappropriate paradigm for financing health care…but it’s the one we have in the United States.)
In health care, there are certainly unpredictable events like an accidental injury from playing basketball, but there are also a lot of predictable events. And these are the ones that can really add up like the house fire. If you’re recently diagnosed with cancer, you know in advance that you’re going to need a lot of expensive treatment in the near future. And if you’ve gone without insurance for a while, you might suddenly start to rethink that decision.
But for the insurance company, they don’t want anything to do with you at that point just like the homeowner’s insurance company doesn’t want anything to do with you after you’ve had a massive fire that needs to be repaired. So, just like the homeowner’s insurance agent denying the applicant whose house caught fire, the health insurer would deny that application on the basis of pre-existing conditions.
I wrote earlier that we understand and accept this in terms of homeowner’s insurance, but we feel quite differently when it comes to our health. Obviously for the person with cancer, financing their treatment could be a matter of life and death — and there’s no way to declare a person to be a total loss and just cash out their bodies. (At least not yet.)
On the surface, it may seem like the health insurer is just being greedy by denying this person’s application, but in reality the health insurer is trying to keep its premium rates down for all of the healthy people it has in the pool. If health insurers no longer had this option, then you would see the same kind of dramatic premium increases that you would see if homeowner’s insurance companies had to accept everyone who applied, even if their house had burned.
And yet, we still don’t accept this from an ethical point of view. I know I don’t.
So if we require health insurers to accept everyone at the same premium rate regardless of health status — even someone just diagnosed with cancer — then we need a counterweight to make sure people don’t game the system and buy insurance even when they don’t need it. Along with the requirements for guaranteed issue (no denials for pre-existing conditions) and community rating (no rate increases based on pre-existing conditions), the Affordable Care Act has three counterweights.
First is the individual mandate. This is the part of the law that everybody hates because it’s basically the part of the law where we pay the price for all of the things we want — there is no free lunch. The second, and related counterweight, is an open enrollment deadline — the deadline for this year to avoid the tax penalty is March 31. Finally, there is 3:1 age banding that allows insurers to charge older people up to three times as much for premiums as younger people. (Insurers might prefer something closer to 10:1 age banding, but 3:1 is a lot less of a market distortion than no age banding at all.)
Check HealthCare.gov or your state exchange (where applicable) for yourself. If you compare the price of an unsubsidized health insurance policy with the tax penalty — especially this year — you will see that the penalty is much cheaper. Of course the price of a health insurance policy offered on the exchanges could be reduced dramatically if you qualify for income-based subsidies, but even then the penalty amount for not buying insurance is still relatively small. So many young, healthy people will opt to take their chances and pay the penalty instead of purchasing a policy…if they even realize that they have to make this decision.
If enrollment in the exchanges continues to skew older and sicker, then next year the premiums will inevitably rise higher…maybe much higher whereas the penalties are prescribed in the law without accounting for these actuarial changes. This may even accelerate the death spiral and render the law totally unworkable.
How this all plays out still remains to be seen, but if you’re a young, healthy adult without insurance, I’d like to ask you to at least shop around and see what you qualify for. You may be pleasantly surprised.
An underwhelming five million Americans have signed up for coverage in the new health insurance exchanges so far. That’s far short of the Obama administration’s goal of seven million enrollments by the March 31 deadline. It’s human nature to wait until the last possible minute, so there’s a good chance that the number will rise significantly in the remaining 10 days. In fact, the Congressional Budget Office projects another one million enrollments before the deadline.
But six million is still one million short of the goal. That gap is disappointing, and Republicans are almost certain to pounce on it as another failure of the Affordable Care Act.
When the exchanges first opened on October 1, 2013, the federal exchange site (www.healthcare.gov) was beseeched with glitches that made it nearly impossible for anyone to sign up. To make matters worse, these hassles disproportionately dissuaded younger, healthier people from enrolling. After all, younger adults tend to be more technically savvy as a group than older adults and have less patience for more traditional forms of enrollment like paper or telephone.
For all of the SNAFUs with the website and all of the delayed mandates, one thing that the Department of Health and Human Services has gotten right is the advertising.
New HealthCare.gov ads include retired basketball stars Earvin “Magic” Johnson and Alonzo Mourning as spokespeople to encourage young, healthy people to sign up for health coverage in the marketplace.
With new rules prohibiting insurers from discriminating on the basis of pre-existing conditions, it’s easy to get older, sicker people to sign up for health coverage because they obviously need it. But it’s harder to get young, invincible people to see the value in purchasing health insurance since they don’t use much health care. But it’s also critically important to get them into the risk pool because, without them, there is a high risk of adverse selection in the risk pools, driving up insurance premiums for everyone. That’s why the much-maligned individual mandate is so important and also entirely inadequate.
While a bunch of young men on a basketball court probably can’t relate to cancer treatment, they can often relate to sports injuries. So it’s obvious why athletes are compelling spokespeople for this cause.
But why Johnson and Mourning instead of current players who are more relevant? Without going into their stories explicitly, many basketball fans understand that these men became seriously ill during their NBA careers. Johnson famously announced his HIV diagnosis in 1991, and Mourning’s career was also cut short by a rare kidney disease that required a transplant and ended his career. Both men had an air of invincibility but were faced with life-and-death circumstances. Both are survivors, and both required expensive medical treatments that most young people don’t think about.
So these ads are a stroke of genius by HHS. Will they be enough to close the gap of young, healthy people? Probably not. But they could definitely move the needle.
If you hear the phrase “burning platform,” you probably think it has a negative connotation. Obviously it’s not particularly pleasant or comforting to envision the ground on which you’re standing catching on fire.
But in the case of health care, I think having a burning platform is a very good thing.
I first heard the phrase “burning platform” from Robert Matt, Vice President at Hancock Regional Hospital, who was teaching a graduate course I took called Lean in Healthcare. I bluntly asked him why LEAN principles which had proven to be so transformative in other industries and had even showed value in a few limited cases in health care had not really become the norm in the health industry. His response was that there had never been a “burning platform” that created a sense of urgency for the industry to change. The U.S. health industry was too comfortable (dare I say fat and happy) to change its practices.
But as plenty of research has demonstrated, things are not fine in the U.S. health care industry. We pay far too much and do not receive the requisite value in return for what we pay in terms of safety and outcomes when compared with the health systems of other nations.
Fortunately, it looks like the industry is beginning to notice some warmth under its feet as a result of the Patient Protection and Affordable Care Act, commonly known as Obamacare. In short, the decline in per-patient reimbursement expected as a result of the law is forcing hospitals and physicians to take more drastic steps toward improving efficiency, quality and safety. Indiana University Health, the largest health system in Indiana, is aiming for savings of more than $1 billion per year.
Of course, some of those savings will be the result of layoffs, and I certainly can relate to losing a job through no fault of my own. The health industry is unusually labor-intensive compared to many other industries, and so it’s impossible to cut costs significantly without cutting people.
I’m afraid that these pink slips will create skepticism toward implementing lean principles in other places, but this skepticism is unwarranted. Had it not been for the lean innovations made at IU Health to improve processes, even more people would have lost their jobs in order to reach the $1 billion goal. Lean is not about cutting people, it’s about helping people to do their jobs more efficiently and effectively. It’s about problem solving, not just (or even primarily) cost-cutting.
But think about it this way — when the industry saves, we as patients save. We save on our medical bills and even on our health insurance premiums because health insurance premiums are a function of the cost of claims. Plus, I have a feeling a lot of those people who received pink slips will land on their feet, just doing something different within the industry to accommodate the influx of new patients.
Nobody every said progress would be easy or pleasant all the time, but that doesn’t mean we shouldn’t do it. Sometimes progress forces us to light a few fires and burn a few platforms.
When people normally think of health policy, the first thing that comes to mind is health insurance reform like the Affordable Care Act.
But health status isn’t just about access to insurance, doctors, drugs and hospitals, it’s also about the environment where we all live. That means factoring in the health effects of air quality, water quality, urban planning, transportation (is it safe to walk or bicycle instead of driving?), public safety, nutrition and sanitation.
Now that’s holistic medicine.
For all the talk about people “losing their health care” (which really just meant their plans were cancelled and they would have to switch to a different plan with richer benefits) and all the technical difficulties on the exchanges, the Patient Protection and Affordable Care Act (aka Obamacare) is already working to reduce the uninsured rate to its lowest level since 2008, according to a report by the Associated Press. This should surprise no one since that was the whole point of the law. The Affordable Care Act is far from perfect, but it does represent real progress.
The Health Policy Wonk 