In defense of football

I don’t write to defend domestic violence, drug abuse, denigration of women, or the many other ways in which professional football players misbehave. I don’t write to defend what I consider to be the unjust withholding of money from college players. And I don’t write to defend lack of transparency and not paying for the health needs of players injured while playing.

I do write to defend the game of football, as it was played yesterday in a middle school game in Durham, N.C. I loved playing middle school and high school football, and I now have the privilege of being a volunteer assistant coach with my son’s team, who won the game 14-12. The other team easily could have won and both played well and hard. No parents misbehaved. The refs did a good job. And no one got seriously hurt.

I realize that none of the good outcomes listed above was inevitable.And there are long term worries about head injuries in football, and the finding of a JAMA study in May, 2014 is the most worrying that I have seen–that exposure to football (years playing among college players) is associated with cognitive impairment independent of head injury. If that finding holds up, then it really could be a game changer.

Several people have asked me how I could let my 14 year old son play football given the risks. The simplest answer is that there are obvious risks of playing. However, the counter factual of him not playing football also carries risks, just of a different type. For example, he tends to do better in school during football season. The motivation of “I have to do my work because if my teachers don’t sign off I can’t play and it will hurt my team” is a better school motivator for him than anything else I have found as a dad.

There are also some benefits of football that may not be clear from  afar. My son’s football team is far more integrated racially and on an income basis than is our church or neighborhood. It is good for kids to learn that they can work together toward common goals with people who are different. And football is the consummate team game. Players have to depend upon one another. On one play yesterday that was set up perfectly, one kid missed a block. 10 guys did their job and 1 did not and the play failed terribly. This is a strong life lesson of inter-dependence and also accountability (the film doesn’t lie). Finally, some of the most practical examples of redemption I have experienced have come via football.  I’ll tell you just one.

There is a kid who last year could not run 1 lap around the track because he was so out of shape. He had lots of anger issues and couldn’t be trusted to keep his head in games. This year, he ran extra after practice the first few weeks to try and get in better shape. His improvement in fitness in 1 year is hard to imagine. Yesterday, he played both offense and defense and almost never came out of the game, and I watched him help a younger kid get in the correct position on a few plays. He did not correct with a harsh anger, but as a leader who knew it was in everyone’s best interest for him to help the other kid understand.

None of these good outcomes is inevitable. However, they are possible if football is done in the correct way.

More on working towards a deal

Harold Pollack has an interesting give and take with Avik Roy about Avik’s health reform plan. There have been legitimate criticisms about the details or lack of them and how the gaps would likely have to be filled in, and that is how it goes and why it is so hard to pass any sort of health reform proposal. Many folks thought that I went too easy on Avik’s plan, but they missed my main point. It is not the details of his plan that were the most important, but his frame of acknowledging that the overall structure of the ACA is here to stay, and that continued policy nihilism is a bad strategy. It is inevitable that the ACA will be changed and tweaked over time, and it is better to start the process sooner, rather than later.

These sorts of details noted in the various pieces won’t be “snuck through” a revision of the ACA. The country is paying far more attention to health insurance and health policy than ever before. These issues will be banged out in the open, and both political sides have a stake.

One key issue that needs to be resolved:

  • what is an acceptable out of pocket spending amount from both a policy and cultural perspective?

As Adriana Macintyre noted today on on twitter, deductibles over $1,000 have often been considered to be relatively high, and the presence of deductibles above this level has been trending up for some time.

ScreenHunter_01 Sep. 10 10.47

However, many ACA exchange plans have deductibles much larger than that. There is a lot more “skin in the game” than many think. Is that good? Bad? Acceptable? What is the maximum that should be allowed?

These are the types of questions that will have to be banged out in the next step on health reform.

Stance on Medicaid could cost N.C. $10 Billion

So says a Charlotte Observer/McClatchy analysis that was done in conjunction with Kaiser Family Foundation, the best source of non partisan health policy information around (update: it is actually done with Kaiser Health News, and independent, editorial arm of KFF). They quote me in the story, and here is the plan I put out in January, 2014 to which they refer. Here is a post from last year about the fiscal impacts of States sitting out the Medicaid expansion.

After the 2014 election, the political incentives will begin to align in a way that makes possible a reform plan that will likely include some sort of modified Medicaid expansion in North Carolina.

United to sell ACA plans in North Carolina

There has been word of this for awhile, but this is the most public statement I have seen confirming that United will sell ACA plans in North Carolina next year. Historically, Blue Cross Blue Shield N.C. had over 90% of the individual purchase market in the state. Coventry was the only company that offered plans in addition to BCBS NC in 2014 (and only in around 35 of the 100 counties), but United says they will offer plans this coming year in nearly all 100 counties. 

North Carolina had one of their higher private insurance uptake rates in year one of the ACA. United says they are coming for a share of this (stronger than expected) market.

One of the key questions for any state’s ACA marketplace is how many insurers are going to offer their plans? The plain reality is that a year ago–and for the previous 20–there was really only one game in town for the individual purchase market. At the next ACA open enrollment in November, there will be three choices in at least some N.C. counties, and two is almost all of them.

If you think competition in insurance is good, this is an incremental, positive step.

CBO: 1974, 2014 & 2024

CBO has released a long term budget outlook update. It has more detailed than average discussion of their assumptions about economic growth–an interesting read. They also reduced again their 10 year Medicare spending projections. The continuing deceleration of Medicare spending is the most important policy story that does not get much attention. Still plenty of uncertainty about its etiology and how long it will last, but it is good news (which doesn’t travel fast), that is cooked into the cake so to speak, whatever comes next.

This figure 1-5 (p. 19) comparing the federal budget in 1974, 2014 and 2024 projection from the report caught my eye. The huge growth in Major Health Care Programs is both demographic (the baby boomers) and health care inflation the past 40 years (ACA contributes, but is not the main thing going on; see p. 12, table 1-2). Even as health care inflation has moderated, the baby boomers moving into Medicare (and also Medicaid via long term care expenses) foretells continued growth of the Major Health Care programs bucket in the federal budget. And the increase in Social Security is wholly demographic.

The demographic drivers of this were inevitable in 1974.

ScreenHunter_04 Aug. 27 10.21

Did the FDA under count the benefits of smoking cessation?

This is the third post in a series on the FDA’s recent rulemaking around Graphic Warning Labels (GWLs) for cigarettes. The first two:

At the heart of the FDA’s estimate of the cost of smoking (and therefore the benefits of cessation, which in turn provide the justification for the regulation) are the cost of smoking estimates that are the essence of our book The Price of Smoking. Frank Chaloupka and colleagues note in a paper commenting on the regulations that the FDA has undercounted benefits by relying on the estimates from our book that their review wrongly states were estimated with an improper control group. This is incorrect as noted in this post, (and Frank and I have communicated and he says that they will revise their paper as it moves toward publication).

However, the FDA estimates do appear to have under-counted the benefits of cessation by not including what we termed as quasi-external costs. We specified the NPV cost per pack smoked in 2000$ as follows:

  • $33 private cost: borne by the individual, primarily through a substantially shortened lifespan
  • $5.50 quasi-external cost: borne by the smokers’ family through increased health costs, slightly lower wages and other factors
  • $1.50 external cost: borne by society, and representing the net effect of things like taxes paid, Medicaid and Medicare payments, and Social Security received

The FDA analysis appears to only count the individual mortality effect, which is roughly the same as the private cost above. The external cost could rightly be excluded because the taxes collected, on average, more than account for these purely externals costs (though there would be some state-level distributional impacts due to state tax variation). However, excluding the quasi-external costs, which would be avoided with cessation, and thus become benefits of the new regulation, the FDA likely did under count the benefits of smoking cessation.

In the next post, I will take on the issue that my friend Chris Conover is addressing here–is government intervention warranted to stop an activity that mostly imposes costs on individuals through their own actions.

Mismatch between patient preferences and what Medicare covers

I have a new paper with Duke and NIH colleagues out today (early online) in the Journal of Clinical Oncology (update full pdf:JCO-2014-Taylor) that demonstrates gaps between the stated preferences of Medicare beneficiaries with cancer and their caregivers about what Medicare should cover, and what the benefit package actually covers. The gaps we highlight show beneficiaries and caregivers allocating finite resources toward now-uncovered benefits that broadly speaking are designed to maximize quality of life:

  • unrestricted cash  (some level chosen by 46%)
  • home based long term care (52% choose a level far beyond what home health would cover)
  • concurrent palliative care (45% chose a level beyond the current hospice benefit; such care without having to unelect curative treatments)

The numbers highlighted in yellow (from Table 3 in the paper) correspond to the text just above, and show the distribution of subjects choosing benefits not now covered by Medicare at the initial assessment in the study (subjects did multiple assessments; their selection of non covered benefits was relatively stable before and after facilitated discussions).

ScreenHunter_02 Aug. 25 16.17

The kicker is that these choices were observed under the imposition of a serious resource constraint. We asked subjects, what benefits are most important to you if you couldn’t have everything? The exercise was based on actuarial estimates, so respondents choosing now-uncovered benefits were allocating resources away from expensive, curative treatments, and toward less expensive care that is focused on quality of life (including unrestricted cash that could be spent for anything). They were not just adding new benefits on top of everything else; instead they were engaging in difficult tradeoffs. Around 1 in 5 respondents picked some level of each of these 3 uncovered benefits, and allocated around 30% of their total resources toward this care that is broadly focused on improving quality of life. In exploratory analyses, the only significant predictor of choosing all three of the highlighted, non covered benefits, after controlling for other factors was African American race (around twice as likely as whites to pick all 3).

There are several limitations to this work, most notably that these were theoretical choices being expressed that did not influence actual health care coverage. However, the point of the research is to point out the gaps between what is covered by Medicare, and the preferences of some Medicare beneficiaries with cancer and caregivers (people for whom the issues underlying the discussion are not theoretical).

What might these findings this mean? First, our results suggest a possible benefit structure in Medicare in which beneficiaries could be granted flexibility in how they will receive their entitlement; our study poses the choice in cost neutral terms to Medicare. Second, our study was designed to detect Black/White differences in end of life preferences, and we did so, but we consider these findings exploratory, and they are being more fully investigated via qualitative methods. Third, patients and caregivers were able to make choices, tradeoffs and to discuss difficult topics in a reasoned fashion during this study (more background on the study).

The most difficult aspect of determining what this study means and determining how it could be used for policy making is trying to imagine how our society could have a similarly reasoned dialogue around what types of services should be covered by Medicare for persons with cancer who are near the end of life, and whether we would grant patients discretion in how they consume their benefit entitlement. Patients and family members appear to be ready for this discussion and hard decisions. I am not so sure about the rest of us.

 update: fixed a few typos and revised for clarity


*Donald H. Taylor, Jr., Marion Danis, S. Yousuf Zafar, Lynn J. Howie, Gregory P. Samsa, Steven P. Wolf, Amy P. Abernethy. There is a Mismatch Between the Medicare Benefit Package and the Preferences of Patients with Cancer and Their Caregivers. Journal of Clinical Oncology 2014; Published early online ahead of print on August 25, 2014


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