Rational Arguments

A reader responds:

In your Feb. 1 post, you claim that Rep. Price’s authored bill, H.R. 3400, is “the Republican proposal” for health care reform.  It’s one of several that has been sponsored by Republicans, and most importantly isn’t the one that made headlines this fall from such a “grim” CBO review. That bill was H.R. 4038.  Your post misleads your readers and implies that: there has only been one Republican proposal, and that this is it.  Maybe you made an honest mistake, but words are important and your biases rarely hide themselves. In your words, I look forward to you correcting the record.

First of all, I always love when someone tells me my “biases rarely hide themselves” – as if they’ve caught me trying to hide my preference for a single payer health care system.  Or my disdain for rhetoric.  Or my impatience with politics over policy.

Let me say it for the zillionth time.  It’s not hidden.  I think that the available data and evidence show that such a system would be much more cost-effective.  I think that the media (and others) have done a terrible job of describing the details of proposed policy.  I think that too many people want reform to succeed or fail only because they want Democrats or Republicans to “win” or “lose”.  Even worse, I think that some people want it to succeed or fail merely because of personal feelings for politicians, which is so petty it makes me sad.

If you think I’ve got some other “bias”, please do let me know.  I’ll address it here, in the open.  I’ve got nothing to hide.

As to the idea that HR3400 is not “the Republican proposal”, it’s the one that Rep. Price was talking about when he spoke to President Obama.  It’s the one he said had more co-sponsors than any other health care reform bill in the house.  It still doesn’t.

Although it does have more co-sponsors than HR4038, which has only 23.

But if it makes this reader feel good, then I will say – again – that there has been more than one proposal.  I have talked about them in a number of posts.

None of this changes the fact that the health care reform bill with the largest number of co-sponsors is HR676 – Medicare for all.

It’s been a hard few weeks for those of us who work in health care policy.  But then, someone sent me a gift.  She didn’t mean it as such, but that’s not my problem.

A reader writes:

I’ve read your site and seen you go on and on about how malpractice isn’t the problem with health care costs.  Can I tell you how tired people are getting about your distortions?  How can you say that when there are clear examples that it’s true.  For instance, Governor Perry and Speaker Gingrich said:

Texas, for example, has adopted approaches to controlling health-care costs while improving choice, advancing quality of care and expanding coverage. Consider the successful 2003 tort reform.

Everyone knows that Texas has brought down health care costs, which is how you get more people insurance.  They’ve attracted doctors to the state.  But you deny it, even when Republicans say it over and over (and your liberal media ignores it).

When will you admit the truth?

Wow.  Where to start?

Look, I didn’t do all this work on my own.  But other people have.  I’m using their graphs (or creating some from their data) and cite them at the bottom.

Let’s start with what Texas did.  They capped non-economic damages on malpractice lawsuits at $250,000.  It’s pretty much what they Republicans want to do with health care reform as well (see their plan).  And, yes, let’s be honest and say that when you cap damages, the total cost of payments goes down.  For instance, here are the total malpractice payments made in Texas from 1997-2008 according to the National Practitioner Data Bank.

As you can see, total malpractice payments dropped by about two thirds since reform was enacted in 2003 (the line).  Is that good?  I don’t know.    That depends on the goal.  One goal is that it should result in cheaper malpractice insurance; it did.  But such insurance dropped on average by only 27% for physicians.  Where did the rest go?  Did the insurance companies keep it as profit?  Let’s push that off for another day.  Because no one is denying that capping damages will lower malpractice payments and therefore lower premiums.

The contention under dispute is that capping damages will be “health care reform”.

Did tort reform lower the costs of care?  Not according to the Dartmouth Atlas of Health Care (Selected Medicare Reimbursement Measures):

Hmmm.  It appears that Medicare costs per enrollee went up faster than the national average.  In fact, Texas reimbursement rates in 2007 were the second highest in the country.

Did tort reform lower the rates of uninsurance in Texas?  Not according to the US census:

In fact, Texas has the highest rate of uninsured people in the United States.

Did tort reform result in health insurance costs going down?  Not according to the Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey:

Did tort reform result in doctors flocking to Texas to practice? Not according to the Texas Department of State Health Services:

So let’s recap.  If you believe that tort reform will work than you must believe that (1) it makes doctors want to practice there and (2) lowers medical costs which will then (3) lower the cost of insurance and (4) result in fewer people being uninsured.  And, it seems, many of you believe Texas proves this to be true.

You couldn’t be more wrong.  Since tort reform, the number of doctors remains stable, health care costs have gone up (along with insurance costs), and the number of uninsured remains the worst in the nation.

The are probably some examples that can support the cause of tort reform, but Texas sure ain’t one of them.  Please stop using it.

If you want to get even more detail, read Liability Limits in Texas Fail to Curb Medical Costs (where I brazenly copied a lot of this from) and Defensive Medicine and Disappearing Doctors.  And, if you are really engaged in this topic, read Tom Baker’s The Medical Malpractice Myth.

A reader points me to a study out in the New England Journal of Medicine this week.  The abstract:

Background When copayments for ambulatory care are increased, elderly patients may forgo important outpatient care, leading to increased use of hospital care.

Methods We compared longitudinal changes in the use of outpatient and inpatient care between enrollees in Medicare plans that increased copayments for ambulatory care and enrollees in matched control plans — similar plans that made no changes in these copayments. The study population included 899,060 beneficiaries enrolled in 36 Medicare plans during the period from 2001 through 2006.

Results In plans that increased copayments for ambulatory care, mean copayments nearly doubled for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05). In control plans, mean copayments for primary care and specialty care remained unchanged at $8.33 and $11.38, respectively. In the year after the rise in copayments, plans that increased cost sharing had 19.8 fewer annual outpatient visits per 100 enrollees (95% confidence interval [CI], 16.6 to 23.1), 2.2 additional annual hospital admissions per 100 enrollees (95% CI, 1.8 to 2.6), 13.4 more annual inpatient days per 100 enrollees (95% CI, 10.2 to 16.6), and an increase of 0.7 percentage points in the proportion of enrollees who were hospitalized (95% CI, 0.51 to 0.95), as compared with concurrent trends in control plans. These estimates were consistent among a cohort of continuously enrolled beneficiaries. The effects of increases in copayments for ambulatory care were magnified among enrollees living in areas of lower income and education and among enrollees who had hypertension, diabetes, or a history of myocardial infarction.

Conclusions Raising cost sharing for ambulatory care among elderly patients may have adverse health consequences and may increase total spending on health care.

Here’s the recap.  Some researchers wanted to see what happened to seniors if you increased their Medicare co-pays a bit for primary care and ambulatory care visits.  This is all based on the moral hazard argument.  It goes something like this: People use too much care if it’s free.  So the more you make them pay for it out of pocket the less they will use.  People who need the care the most will pay for it, but people who don’t need it will avoid it.  We become more efficient shoppers, spend less on needless care, and everyone wins.

Right?

No.

What happened here is that just by increasing the co-pay from $7 to $14 and $13 to $22, about 20 fewer outpatient visits occurred per 100 people.  That’s a huge reduction for just a few dollars increase.  Imagine the reduction you would have seen for a significant increase.  And that reduction wasn’t harmless.  There were an additional 2 hospitalizations per 100 people and an average of more than 13 additional days in the hospital.

This minor additional cost-sharing not only resulted in worse health outcomes, but it might also cost more.

Here’s where it gets worse: The most effects were seen in those who were poor or sick.  That’s exactly what we’re trying to avoid.

You will hear some people say this contradicts the findings of the RAND Health Insurance Experiment, which basically “justifies” the whole co-pay thing.  They will say that the RAND HIE showed you can increase co-pays without negative health consequences.  But that’s because many have always misinterpreted the results.  As I’ve argued before about the HIE:

[H]ere’s the gist of that they found: People in the high deductible plans – those most exposed to health care costs – did spend significantly less and consumed less health care.  And, yes, much of that care was unnecessary, as healthy people did not suffer negative consequences  from forgoing care.  BUT, and this is important, poorer participants with hypertension avoided necessary care, and saw their mortality rates rise significantly.

Removing the moral hazard did no harm in the majority of patients (which is touted often as the result of the study) because they were healthy.  And, of course, getting less care when you’re healthy leads to few short term negative results.  But for those who were unhealthy, who comprised a minority of patients in the study, removing the moral hazard led to significant and dangerous consequences.

This study in the NEJM was of elderly people, who were all excluded from the RAND HIE.  They were inherently sicker.  And the results of the RAND HIE for sicker people held.  They fare poorly.  And it might not even save money.

I know it feels like higher co-pays are a good thing.  It seems right to ask people to have more skin in the game.  It looks like it’s fairer and more likely to reduce waste.  But that’s only true for healthy people.  And they’re not who we need to protect.

Here’s a break from health care reform.

Besides health policy and health services research, I also have an interest in medical myths (see the book down there on the right of this page).  CNN Headline News does a series called “Beyond the Surface” and they taped Rachel and I for a number of pieces on medical myths.  Here’s the latest one:

Speaker Pelosi weighs in.  And she doesn’t like the idea:

“There are some things that sound easy, but you might as well send somebody a get well card, because they don’t have any more impact, except maybe they make you feel good for the moment,” said Pelosi, who paused and rethought her comparison.

“Maybe a get well card might be more effective, as a matter of fact, because it’s sincere,” she said.

Strong words.  But she backed up the rhetoric with a rationale:

“Some people have suggested that we should do [insurance reforms] freestanding, but it’s important to note the following: You can’t do that freestanding unless you have the basic underpinnings of a bill, because otherwise you’re making a statement, but you’re not making a difference in anyone’s life, because it’s not tied to the accountability of the insurance companies,” she said. “You could get all of those things–insurance companies will price it out of everybody’s range. So they would be factors for increased costs and premiums, rather than reforms of the insurance industry, unless they go along with a bill that is underlying, that we hope that we will be able to pass before too long.”

Yep.

There’s a bit of a hubbub about a new study that many are touting as proof that abstinence-only education works.  From the abstract:

Outcome Measures The primary outcome was self-report of ever having sexual intercourse by the 24-month follow-up. Secondary outcomes were other sexual behaviors.

Results The participants’ mean age was 12.2 years; 53.5% were girls; and 84.4% were still enrolled at 24 months. Abstinence-only intervention reduced sexual initiation (risk ratio [RR], 0.67; 95% confidence interval [CI], 0.48-0.96). The model-estimated probability of ever having sexual intercourse by the 24-month follow-up was 33.5% in the abstinence-only intervention and 48.5% in the control group. Fewer abstinence-only intervention participants (20.6%) than control participants (29.0%) reported having coitus in the previous 3 months during the follow-up period (RR, 0.94; 95% CI, 0.90-0.99). Abstinence-only intervention did not affect condom use. The 8-hour (RR, 0.96; 95% CI, 0.92-1.00) and 12-hour comprehensive (RR, 0.95; 95% CI, 0.91-0.99) interventions reduced reports of having multiple partners compared with the control group. No other differences between interventions and controls were significant.

Here’s the deal.  They randomized group of young African Americans in 6th and 7th grade to receive one of a number of different types of sexual education.  One centered on “abstinence-only”.  Another group got a “safer-sex” intervention.  Yet another got a combination of the two.  There was also a control group that got none of this.

It’s important that you understand just what was meant by each of these.  So I’m giving you their descriptions (may be behind a paywall for you):

Abstinence-Only Intervention

The 8-hour abstinence-only intervention encouraged abstinence to eliminate the risk of pregnancy and STIs including HIV. It was designed to (1) increase HIV/STI knowledge, (2) strengthen behavioral beliefs supporting abstinence including the belief that abstinence can prevent pregnancy, STIs, and HIV, and that abstinence can foster attainment of future goals, and (3) increase skills to negotiate abstinence and resist pressure to have sex. It was not designed to meet federal criteria for abstinence-only programs. For instance, the target behavior was abstaining from vaginal, anal, and oral intercourse until a time later in life when the adolescent is more prepared to handle the consequences of sex. The intervention did not contain inaccurate information, portray sex in a negative light, or use a moralistic tone. The training and curriculum manual explicitly instructed the facilitators not to disparage the efficacy of condoms or allow the view that condoms are ineffective to go uncorrected.

Safer Sex–Only Intervention

The 8-hour safer sex–only intervention encouraged condom use to reduce the risk of pregnancy and STIs, including HIV, if adolescents had sex. It was designed to (1) increase HIV/STI knowledge, (2) enhance behavioral beliefs that support condom use, and (3) increase skills to use condoms and negotiate condom use. It was not designed to influence abstinence.

And, when all was said and done, the abstinence-only program resulted in fewer adolescents having intercourse in the three months before they did follow-up.  In essence, it resulted in less sex than the other interventions.  It also didn’t result in less condom use, which has been found in previous studies.

You should note that the abstinence only program described above is not the same as many other abstinence only programs.  It didn’t recommend no sex until marriage; it recommended waiting until you are “more prepared to handle the consequences of sex”.  It also was factually and theoretically based.  It also presented data on condoms accurately.  It also did not moralize.

And it worked.

That’s right.  If we’re going to hold with science, then we have to accept the results.  This study showed that this abstinence only program worked.  It should receive further funding and more investigation.  We should consider this type of curriculum as an option to implement.

You can’t ignore it because it doesn’t fit your ideology.

That said, you also can’t extrapolate further than the findings.  This study does not mean that all abstinence-only programs work.  In fact, many other studies have shown that other abstinence-only programs fail.  This was a specific, theory-based abstinence-only program.  It doesn’t vindicate one administration any more than it condemns another.

When you do science, you agree to accept the results.  We should acknowledge that this type of abstinence-only program may have a place in sex education for children in 6th and 7th grade.  And, we should do more research to make sure those results hold in other populations and other settings.  That’s how it goes in research.

Ugh.  The NYT Prescriptions blog has the latest on the Democrats’ bad idea of breaking health care reform into parts:

If Democrats break down their major health care legislation into components that could be approved separately, the first bill up for consideration could be a proposal to end the exemption from federal antitrust laws that insurers have enjoyed since 1945.

Austin Frakt has already pointed out why this isn’t necessarily a great idea.

It’s bad enough that passing health care reform in bits may do no good.  If it causes harm, that would be unspeakably bad.

(h/t Ezra Klein)

Here’s one mistake from last Friday’s Q&A, which has been all-the-rage this last weekend.

Rep. Tom Price said (emphasis mine):

Mr. President, multiple times from your administration there have come statements that Republicans have no ideas and no solutions, in spite of that fact that we’ve offered, as demonstrated today, positive solutions to all of the challenges we face, including energy and the economy and health care. Specifically, in the area of health care, this bill, H.R. 3400, that has more cosponsors than any health care bill in the House.

He’s correct that HR 3400, the Republican proposal for health care reform, has more co-sponsors than the Democrats’ bill.  But he is incorrect that it has more co-sponsors than any health care bill in the House.  Know which health care bill has more?

HR 676.  The United States National Health Care Act or the Expanded and Improved Medicare for All Act.  It’s a bill for single-payer insurance.

It has 87 co-sponsors.

Since the Republicans are obviously proud of their number of co-sponsors, I’m sure they are going to be impressed by this fact.  I’m also going to assume that Rep. Price isn’t lying, and that he just doesn’t know.  I’ll look forward to his correcting the record.  And I’ll look forward to the media reporting any of this to anyone.

Most of the time you hear me on the radio, it’s stricyly policy.

Regional NPR asked me to do something more opinion based.  So you get this.

From Sound Medicine.

I really don’t care which side you like.  Do yourself a favor and set aside an hour and watch this:

President Obama answered questions from House Republicans for an hour.  Both sides were completely civil.  Both sides treated each other with respect.  President Obama answered questions without using sound bites or rhetoric.  He was clear, and on the record, and he can be “fact checked” ad nauseum.

Moreover, when all was said and done, I bet both sides felt better.  I bet both sides feel they might have more in common than they previously thought.

I think this may do the country some good.  I wish it had happened earlier.  It should happen more often.