Subsidizing U.S. healthcare

In this month’s issue of the American Journal of Public Health, Drs. Steffie Woolhandler and David Himmelstein of Harvard Medical School describe the extent to which our healthcare costs are already largely subsidized by the government.

In fact, between the tax subsidies for employer-sponsored insurance, Medicare, Medicaid, and insurance for public employees, the government already pays for 65% of all U.S. health expenditures, amounting to $6,560 per person in 2015. For less than this countries like Canada are able to offer universal coverage without the extremely expensive premiums and deductibles we are saddled with in the United States.

Woolhandler and Himmelstein argue that the excess we pay is essentially a handout to healthcare industries. When so many Americans are struggling with stagnant wages, is it wise for us to be doling out cash to these companies?

Read their op-ed here: “Single-payer health plan wouldn’t cost U.S. more”

An insurer’s perspective on healthcare costs

Jonathan Blum of CareFirst BlueCross BlueShield gave a great talk on delivery system transformation at the Leonard Davis Institute today. As someone that has worked for the Center for Medicare and Medicaid Services (CMS) on cost-control initiatives and now does similar work for a commercial insurer, he had a unique perspective on optimal strategies for curbing the rise in healthcare spending.

Unsurprisingly, he pointed out that brand name medications are a major driver of rising costs for health insurers (and thus a major driver of rising premiums). For both personal and legal reasons, insurers have a hard time saying no when physicians and patients push for expensive treatments.

Drug companies know this and so they have a extremely strong negotiating position when choosing a price for their therapy. They rightly predict that individual consumers, pressured by glossy advertisements, will demand their expensive medications; insurers will be unable to say no for an extended period of time; and when these costs push up premiums for everyone, this consequence will be so dissociated from its cause that it will lose emotional salience to the general public.

Continue reading “An insurer’s perspective on healthcare costs”

Monitoring outcome-switching in medical journals

Outcome-switching (changing the what outcome you measure after an experiment has started) can invalidate statistical methods leading to false positives and problems with trial replication. Yet, most scientific journals have not reliably reported when this has been happened. tracks outcome-switching with public registries and then encourages journals to issue corrections, yet some major journals such asAnnals of Internal Medicine have resisted this form of transparency. Scientifically valid results require scientifically valid methods, and it is concerning when major medical journals are not holding themselves to modern standards of scientific rigor.

“Make Journals Report Clinical Trials Properly”

Early results from Mexico’s sugar tax

Mexico has one of the highest rates of soda consumption, overweight, and diabetes in the world. The average Mexican adult drinks 163 liters of soda. 72% of adult Mexicans are overweight, and 15% have diabetes.

In the fall of 2013, the Mexican federal government passed a 10% tax on sugar-sweetened drinks. The following year, purchases of these beverages decreased an average of 6% relative to the counter-factual (controlled for seasonal and pre-existing trends), indicating that this tax was an effective deterrent. Evaluating the public health benefits of this tax will require more time, but this is a promising early result.

While hard evidence for dietary interventions is difficult to gather, much of what we know already argues for a compelling public interest in curbing the consumption of refined sugar similar to the public interest in decreasing smoking or excessive alcohol consumption.

A tax on refined sugar with proceeds going to consumer-level fresh produce subsidies would be a great way for us to invest in a healthier future for ourselves.

“Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study”

The cost of innovation in healthcare

Healthcare spending has been growing at an unsustainable rate.

In 2014, we spent $9,523 per person on healthcare which is up from $4,878 per person in 2000 and $2,854 per person in 1990.1 This growth has dramatically outpaced inflation and now accounts for 17.5% of GDP.2

This translates to rising insurance premiums, deductibles, and medical debt which in turn increase financial pressure on families that are already struggling to get by.3 A recent poll by the New York Times and the Kaiser Family Foundation found that one in five people with health insurance has had problems paying their medical bills requiring them to use up their savings, sell assets, and borrow money at high interest rates.4 For those without insurance, half had similar struggles.

A major driver of these increasing costs is technological innovation which accounts for between 30% and 50% of healthcare cost growth.5 As Nicholas Bagley, Amitabh Chandra, and Austin Frakt explain in a discussion paper written for the Brookings Institute, there are few countervailing forces against endlessly rising prices in medical treatments.6

Continue reading “The cost of innovation in healthcare”

Book Review: Pathologies of Power

Paul_Farmer_Pathologies_of_Power_smPaul Farmer’s Pathologies of Power is a written protest against the structural violence suffered by the poor. The first half of the book is devoted to anecdotes from his time spent in the rural highlands of Haiti, the HIV quarantine facilities of Guantanamo, the autonomous zones of Chiapas, and the prisons of Russia. Through these anecdotes, Paul gives voice to the suffering poor in these areas in a way that neither dehumanizes nor romanticizes their suffering, a rare feat in literature about poverty.

As a physician, Paul focuses on the ways in which this suffering is experienced through degradation of health. Particularly shameful in these stories is the extent to which the poor suffer and die from curable diseases. “Li mouri bet,” Paul bemoans in Creole at the death of a young man from an infection, “what a stupid death.”

The poor live Hobbesian lives–nasty, brutish, and short–partially because of our market-based approach to medicine in which health is the exclusive privilege of those wealthy enough to afford it. Instead, Paul calls for a far different approach to medicine based on human rights, in which the benefits of medical knowledge developed collectively by the human race are made available to all as their birthright. Health, Paul argues is not a privilege of the rich man, but the right of every person.

In particular, Paul rails against the aid and development community obsessed with “cost effectiveness” who mark the price of a Haitian life shockingly low–less than the cost of a round of antibiotics necessary to treat multi-drug resistant tuberculosis. Complacent in the charity model of health care, the global heath community timidly seeks only to provide the low quality care afforded by the castoffs of the rich rather than call into question the structural violence that keeps the poor in poverty.

Drawing heavily from liberation theology, Paul argues for a reorientation of societal values toward the preferential option for the poor. From the diabetes of Americas urban slums to the HIV of sub-Saharan Africa, the poor bear the majority of the disease burden, and so Paul calls especially on physicians to lead this priority shift to the poor by focus their efforts on those that need their care, not just those that can afford it.

More than some nominal increase in the American aid budget, what is called for is the recognition of the inherent rights of every human being regardless of nationality. This entails the coordinated effort to secure those rights not merely through the charity of the rich, but through the profound alteration of those structures which deprive people of these rights in the first place.

It’s a bold challenge, to be sure, but one of the first that actually has hope to establish a just global society.

[Of note, this is a post from an old blog that I’ve moved here to try and consolidate my healthcare related writing.]

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