Does Health Insurance Improve Health?

An old question has gotten some new evidence. Does health insurance coverage improve health? This is a simple (and important) question that is complicated to answer definitively due to methodological reasons, but the evidence base has grown by two important papers in peer review journals in the past few weeks:

  • Ben Sommers has a recently accepted paper in the American Journal of Health Economics that is available online as an eprint. He finds that Medicaid expansions in the early 2000s in 3 states saved lives, and he documents the costs of doing so. The point of the paper is better methods of determining if Medicaid expansions did in fact save lives and looking at the cost of coverage. His top level findings:
    • 1 life saved for every 239-316 persons newly covered by Medicaid (the range represents the uncertainty in the estimate–could be as high as 316 lives saved, or as low as 239, for each newly covered person).
    • The cost per life saved was $327,000-$867,000
    • He discusses the other things that could be done with this amount of money and notes these amounts are less than often paid per life saved for many interventions
  • Ben Sommers, Atul Gawande and Kate Baicker have a paper in the most recent NEJM that looks more comprehensively (not only mortality as an outcome, and at different types of insurance, public and private) and reviews the recent peer reviewed work on the broad topic of does health insurance improve health. This is a nuanced paper that focuses on the current health reform discussions that our nation is having and goes directly to how important losses in recent coverage expansions could be to public health. On the most basic question at hand they conclude

    There remain many unanswered questions
    about U.S. health insurance policy, including
    how to best structure coverage to maximize
    health and value and how much public spending
    we want to devote to subsidizing coverage for
    people who cannot afford it. But whether enrollees
    benefit from that coverage is not one of the
    unanswered questions. Insurance coverage increases
    access to care and improves a wide range
    of health outcomes. Arguing that health insurance
    coverage doesn’t improve health is simply
    inconsistent with the evidence.

The evidence base changes weekly. These two important papers need to make their way into the ongoing policy debates.

Time & Motion Study of Community Based Palliative Care

We have a new paper (open access) in the Journal of Palliative Medicine, providing a Time and Motion study overview of the care delivery model at the heart of our CMMI HCIA-2 innovation award with Four Seasons Hospice in Western, North Carolina (Janet Bull, who is also President of the American Academy of Hospice and Palliative Medicine and I are the co-PIs of the project).

This figure provides an overview of the palliative care model that we are providing across setting (~5,000 patients will enrolled by the end of Summer, 2017, and we just received Medicare claims records for the first 2+ years of the project, so should have preliminary cost findings in the Fall).

TimeandMotion.6.6.17jpm.2016

 

House Republicans Pass AHCA

House Republicans passed AHCA, their version of repeal and replace of Obamacare, 217-213. The Republican controlled Senate declared it dead on arrival and set about to write their own bill. Here is past blogging on earlier versions of AHCA; they did not wait for a CBO score before voting, but the prior score estimated that 24 Million people would lose coverage as compared to the ACA baseline, and the most important policy points of AHCA 1.0 and zombie AHCA remain

  • Tax cut for persons with AGI greater than $200,000
  • $890 Billion (~25% cut) in Medicaid that existed prior to ACA
  • Ending of Medicaid expansion in the ACA

The new parts of AHCA related to the individual insurance market, devolving waiver responsibility to the states related to pre-existing conditions, under funded high risk pools, etc. They are mostly incoherent as a policy whole and won’t survive the Senate.

A few thoughts on all this.

  • Its shocking that after 6 or 7 years of ‘repeal and replace’ as the unifying theme of a party that this is the best they can do, both in policy and process terms. Health Policy is just not the Republican Party’s thing–sorta like the 1980s Oklahoma football team trying to throw the ball. But they spilled so many words they had to do something.
  • The Medicaid changes are by far the most consequential part of the bill. I have written lots about changing the state-federal relationship on Medicaid and think it is a big part of an eventual (inevitable) deal on health reform. But AHCA’s Medicaid provisions are just “tag, you’re it” flexibility to the States.
  • The rage of progressives/left/supporters of the ACA shows the asymmetry of health policy for the two sides. It is our ‘main thing’ and Rs in the House were willing to pass anything, just to say they had passed something. And the clarity of the ACAs ending of pre-existing conditions and lifetime limit provisions gives way to long, complicated answers under AHCA that end with, ‘well, its complicated and really depends upon that state in which you live.’ Here are two examples addressing the question of whether rape would be a pre-existing condition under AHCA (probably not; and more of same–there is some info in the length of the analysis required to answer the question).
  • After the football spike is over, I think if Rs actually pass a health reform law, it ends exactly like the ACA did–with the Senate jamming the House. Whatever passes the Senate, if anything, will define Trumpcare if there is to be such a thing.

 

Both Sides Still Need a Deal

The Republican Party suffered a spectacular political defeat yesterday when they pulled their AHCA legislation from the House floor, after all the words they spilled the past 7 years. Speaker Ryan said the ACA is the law of the land, and President Trump said that Democrats will want a deal to improve the ACA within a year.

On December 16, 2010 I first blogged that “Both Sides Need a Deal” and laid out a set of big ideas that I claimed would emerge in a deal if the two sides negotiated in policy good faith. I even wrote a book that more fully laid out what a health reform deal would look like, and said it was the crux of a sustainable federal budget. Last Sunday, Ross Douthat, maybe sensing the outcome of yesterday, wrote that a catastrophic insurance program loosely based on Singapore would be the best way forward for Republicans. This column reminded Reihan Salam of my pitch from several years before.

reihan.bloginsert

Deal’s between Democrats and Republicans seem impossible politically, but the structure of our system of government makes them a feature, and not a bug. At some point we will have to return to that type of equilibrium. And both sides really do need a deal to achieve more of what they want. I want to re-emphasize 3 of the big ideas from my original proposal and add a fourth in the hopes of starting a conversation, perhaps only with myself.

  • Replace the individual mandate with federally-guaranteed, universal catastrophic insurance coverage and sell private “gap” insurance in state-based exchanges, with income based subsidies
  • End the Medicaid program as we know it by transitioning full responsibility for dual eligible Medicaid costs to Medicare, and moving non-elderly and disabled low income persons into subsidized private gap insurance
  • Modify the tax preference of employer paid health insurance, and replace the cadillac tax with this provision
  • Not in my original proposal, but we should provide some help in purchasing health insurance to persons in the individual market, but whose incomes are too high to qualify for tax credits under our current system; it will help the risk pool and high income persons get a subsidy via the tax treatment of Employer coverage

I am a policy guy, and the policy is crucial (I wrote in 2014 what some of the above ideas could look like for one state–North Carolina to try some of this via an ACA waiver). What I have proposed above is a bit more grand, but it seems that a big deal may paradoxically be easier to obtain than a small one, particularly around the issue of Medicaid. Precisely because there is a no “best way” to address health policy, the politics are particularly important if we are to ever develop a sustainable health care system. A quote from my 2012 book in Chapter 7 sums this up for me:

What our nation most needs is a bipartisan health reform strategy that will allow us to address the interconnected problems of the health care system: cost, coverage and quality. There is no perfect health care system and no perfect plan. However, without a deal that allows both political parties to claim some credit as well as to have some responsibility in seeking to slow health care cost inflation, we have very little chance of success.

I will do some follow up posts on the policy aspect of the imperfect ideas above. I am happy to engage in dialogue if anyone is interested.

Defending Speech and Speakers on Campus

I was recently elected to the Chair of the Academic Council at Duke (the Faculty Senate), and so have been doing a bit of thinking about issues related to how college campuses deal with issues of free speech, association, inquiry and the like. This statement is the best thing that I have read  in the way of general guiding principles (Truth Seeking, Democracy, Freedom of Thought, and Expression). These two paragraphs are especially critical:

None of us is infallible. Whether you are a person of the left, the right, or the center, there are reasonable people of goodwill who do not share your fundamental convictions. This does not mean that all opinions are equally valid or that all speakers are equally worth listening to. It certainly does not mean that there is no truth to be discovered. Nor does it mean that you are necessarily wrong. But they are not necessarily wrong either. So someone who has not fallen into the idolatry of worshiping his or her own opinions and loving them above truth itself will want to listen to people who see things differently in order to learn what considerations—evidence, reasons, arguments—led them to a place different from where one happens, at least for now, to find oneself.

All of us should be willing—even eager—to engage with anyone who is prepared to do business in the currency of truth-seeking discourse by offering reasons, marshaling evidence, and making arguments. The more important the subject under discussion, the more willing we should be to listen and engage—especially if the person with whom we are in conversation will challenge our deeply held—even our most cherished and identity-forming—beliefs.

Three things stand out as key to me here. First, humility. Second, there are facts and things that are true and false. Third, it takes (at least) two sides to have a real conversation. I like this statement as guidance to navigating the many issues related to speech, academic freedom and inquiry on college campuses.

A few more thoughts that deserve later amplification.

This is a great piece by Mike Munger that notes the role of academic freedom that flows from the 1st Amendment protection of freedom of association as the true distinctive of Universities (and not speech, which is a universal freedom of our nation). However, bad, harmful speech often has an asymmetric chilling effect on individuals from groups that have historically been excluded from full membership in the robust discussions envisioned by the statement linked above. And freedom of association is a key way that people can decide which issues to discuss and debate, as well as how and when. So, while the entire University could never rightly be a “safe space” so would it be wrong to say there can be no such “safe spaces” on campus, of a variety of ilks. This may seem to be a paradox.

Similarly, for some members of University communities the term “safe space” is viewed only as a term that applies to intellectual discussion, while for others they have in mind their physical safety. People who are physically afraid have no hope of engaging in intellectual inquiry. Living up the best that a University can be will require continued struggle on many fronts.

CBO Score of AHCA

Following up on past stuff on the blog on the House reform plan, the CBO released its score of the legislation that passed the House Energy and Commerce and Ways and Means Committees last week. This puts numbers on on the general description I provided earlier, but I was wrong–CBO scored that it will reduce the deficit.

  • $1.2 Trillion decrease in spending on health insurance (Medicaid and private subsidies)
  • $900 Billion tax cut/decline n revenue
  • Reduce the deficit by $337 Billion (all over 10 years)

This version of health reform costs so much less than the ACA because it covers so many fewer people. The project a loss of health insurance coverage of 14 Million persons by next year, and 24 Million by 2026.

Underneath all this, the most profound thing going on in this bill is a nearly $900 Billion drop in federal Medicaid spending over 10 years– a 25% decline in the federal share over 10 years. The Medicare cuts that Republicans savaged for years that are part of what Obamacare used to pay for coverage expansions are kept in place.

This is horrible policy is health insurance coverage expansions are remotely important. The politics are even worse I think, as the shift of burden to states of either paying for Medicaid or deciding who not to cover in the future will be hard, and premiums in the exchanges will decline for younger persons under the new tax credit subsidies, but they will rise for persons in the decade before Medicare eligibility (age 55-64).

I keep thinking there must be some political angle that I am missing, but I don’t see it. If you wanted to lose the House in 2018, you would push for this. Many elected Republicans are getting cold feet. Not sure what comes next, but nothing is increasing as a possible outcome. If something becomes law, expect it to come out of the Senate–in much the same way the ACA did.

 

 

Boil it down for me

A friend asked me “boil it down–how is the Republican repeal and replace different from the new status quo after the ACA?”

  • Most fundamentally, it would change the financing formula for Medicaid, and limit the federal government’s financial responsibility for same. The flexibility given to states will have to be used to decide how to cover the same number of people with less money, or increase state funding. I am not talking about expansion but the part of the Medicaid program that was untouched by the ACA–children, pregnant women, disabled, elderly.
  • It ends the Medicaid expansion that is a part of the ACA (so will increase uninsured rate).
  • It provides more people with smaller tax credits for purchasing private health insurance while making the mandate/penalty/steering mechanism to purchase health insurance weaker. Hurt are low income people who will get less, while higher income people get more. The ban on pre-existing conditions is kept, as are mandated essential health benefits. The bottom line will almost certainly be fewer more uninsured (update post), and a much more likely death spiral in the individual insurance market. There are some complicated geographical forces at work that mean the impact on uninsured rates will differ by state, but fewer will be covered as compared to the ACA. It is unclear what the changes will do to employer sponsored coverage–some say there will be lots of drops. We need to know what the CBO thinks to see by how much private insurance coverage is likely to drop.
  • The Medicare cuts that were used to partially pay for increased coverage in the ACA-and which the Republicans have viciously criticized–remain. About $700 Billion worth over the next 10 years.
  • The taxes on people making over $290,000/year in the ACA have been repealed. The exact size of the tax cut is unclear (again, we need to hear from CBO, but estimates are between $700 Billion and $1 Trillion.

In summary, this bill is a tax cut for high income folks that is funded by cuts to the Medicare program as compared to the ACA new baseline. In addition, it provides a fundamental change of the federal governments financial commitment for Medicaid which weakens the safety net we have, while wiping out coverage gains from Medicaid expansion. States get less money, but the same number of people who now qualify for coverage, leaving aside any expansion effects. And the changes to the tax credit, insurance rules, penalty structure seem likely to destabilize the individual, private insurance market, with unclear impacts on the employer sponsored health insurance system. And the bill will likely increase the deficit (update post: CBO says it reduces the deficit, because of how many more uninsured there will be), but unclear by how much.

The simplest I can do.