Rational Arguments

For those of you who like to see my smiling face, I was on CNN HLN this morning doing my myth busting thing:

If you follow my blog at all, you know I’ve never been a big defender of the public option.  I think that a lot of people think it’s single payer lite (it’s not).  Others thing its awesome power will force prices to come down (not likely).  And some think that the fact that it should have less administrative overhead would make it so much cheaper than other options (not likely either).

But I also scoffed at opponents of the piblic option who said it would “limit competition”.  As if competition existed right now.  Quoth the AMA (not a very progressive organization):

The AMA’s most recent look at the health insurance market — “Competition in health insurance: A comprehensive study of U.S. markets,” released Feb. 23 and based on 2009 data — finds that 99% of 313 metropolitan areas tracked would be considered to have “highly concentrated” insurance markets under guidelines used by the U.S. Dept. of Justice and the Federal Trade Commission. In its 2009 version of the study, the AMA found that 94% of metropolitan areas were ranked “highly concentrated.”

Only Miami, Fort Lauderdale, Fla., and Colorado Springs, Colo., are not considered to have highly concentrated markets. But even these metropolitan areas are not deemed to have competitive markets but instead are rated as “moderately concentrated.” The Justice Dept. and the FTC would consider a highly or moderately concentrated rating as a point against a merger or acquisition of plans within the same market.

One insurer held 70% or more of the health plan market share in 24 of 43 states measured, up from 18 in 42 states in the previous year’s study. In 92% of the 313 markets in the report, one insurer held at least a 30% share.

In past releases of its survey, the AMA has noted that insurer market dominance has allowed health plans to force physicians into take-it-or-leave-it contracts. But this year the AMA — echoing other experts — noted that market dominance has allowed plans to give patients take-it-or-leave-it pricing.

Are you getting that?  Competition has gone down since last year.  Almost 100% of markets are highly concentrated, as calculated by the number of available options and their individual market share.  That means there are limited choices available, leaving people at the mercy of rate increases and coverage decreases.  Adding a public option would increase that number significantly, and therefore increase competition.

And that’s the best argument I’ve heard yet for a public option.  I still don’t think we’re going to get one right now, and I don’t think it’s worth sinking the bill over.  But if the insurance industry wanted to make sure that Democrats considered adding one in later, they sure are on the right path.

An eagle eyed reader pointed me to this study:

Purpose

Uninsured children face health-related disparities in screening, treatment, and outcomes. To ensure payer status would not influence the decision to provide emergency care, the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986, which states patients cannot be refused treatment or transferred from one hospital to another when medically unstable. Given findings indicating the widespread nature of disparities based on insurance, we hypothesized that a disparity in patient outcome (death) after trauma among the uninsured may exist, despite the EMTALA.

Methods

Data on patients age 17 years or younger (n = 174,921) were collected from the National Trauma Data Bank (2002-2006), containing data from more than 900 trauma centers in the United States. We controlled for race, injury severity score, sex, and injury type to detect differences in mortality among the uninsured and insured. Logistic regression with adjustment for clustering on hospital was used.

Results

Crude analysis revealed higher mortality for uninsured children and adolescents compared with the commercially or publicly insured (odds ratio [OR] 2.97; 95% confidence interval [CI], 2.64-3.34; P < .001). Controlling for sex, race, age, injury severity, and injury type, and clustering within hospital facility, uninsured children had the highest mortality compared with the commercially insured (OR, 3.32; 95% CI, 2.95-3.74; P < .001], whereas children and adolescents with Medicaid also had higher mortality (OR, 1.19; 95% CI, 1.07-1.33; P = .001).

Conclusions

These results demonstrate that uninsured and publicly insured American children and adolescents have higher mortality after sustaining trauma while accounting for a priori confounders. Possible mechanisms for this disparity include treatment delay, receipt of fewer diagnostic tests, and decreased health literacy, among others.

Here’s the gist – people wanted to see if being uninsured was associated with worse outcomes at the emergency room after trauma.  Because, you know, we have a universal system where everyone can get free care at the emergency room.  Or not.

The researchers looked at tons of data, almost 175,000 children injured between 2002 and 2006.  They controlled for race, injury severity score, sex, and injury type.  And even after doing that, children who were uninsured had more than three times the odds of dying from comparable injuries than children covered with private insurance.

So there you have it.  Being uninsured is associated with an increased risk of children dying, from injuries, in an emergency room.  Maybe someone should tell the people who claim there’s no evidence that uninsurance leads to a higher chance off death.

It’s unlikely you can get the whole article, because it’s probably behind a paywall, but it’s entitled, “Lack of insurance negatively affects trauma mortality in US children.”

I was on Sound Medicine again this weekend:

Well, it looks like the health care reform process that’s been alive, and then comatose, is now flickering back to life.As we record this mid-week, President Obama is laying out what he hopes will be the end-game to get the House to approve the bill that has already passed the Senate …with the understanding that then, the Senate will go back and amend its version so that both sides can pass it.

And as one step, the President has said that he SUPPORTS four adjustments to the measure that Republicans have proposed.

Here to walk us through what those changes would be is our regular analyst on this topic, Dr. Aaron Carroll.

Dr. Aaron Carroll directs the Center for Health Policy and Professionalism Research at the IU School of Medicine. He’s a regular contributor to this program.

Listen to the interview.

I’ve said it before and I will say it again.  There are legitimate issues with health care reform, and I know people on both sides of the political spectrum who oppose this bill for rational reasons.  Almost none of them are politicians.  That’s why you get things like this from Rep. Grijalva:

“As I weigh it, I think — for me — a ‘no’ vote is something that I continue to lean toward,” Rep. Raúl Grijalva, D-Ariz., the co-chairman of the Congressional Progressive Caucus, told Salon in a brief interview off the House floor Wednesday. “Especially the last additions — that was kind of a slap in the face for all of us who fought for the public option.”

Those provisions he’s referring to are the “Republican ideas” that President Obama has incorporated in order to placate those who oppose the bill.

Look, I’d have no issue with Re. Grijalva if he said that he thought that those provisions made the bill worse, or if he had policy objections to them.  But to oppose the bill because you think you haven’t been wooed as much as others?

You know who else has been slapped in the face throughout this process?  Me – and every other supporter of single payer health insurance.  We were told to give it up, for nothing in return.  We were told it wasn’t politically feasible, that it couldn’t be done.  We were told to get on the “public option” bandwagon instead.  Some did and some did not.  But I find it the height of hypocrisy for those same people who told single payers to suck it up are now acting as if doing the same is the greatest possible insult.

Real people are at stake here, politicians.  I have no problem with you representing your constituents and their interests.  Please don’t make this about you, and especially not about your “feelings”.

When I’m on radio or TV, or even here, I tend to speak with a pretty confident and direct tone.  Usually, that’s because I tend to stick to policy and research, and on that footing, I feel like I have enough evidence to know that’s it’s unlikely that I will be wrong.

When I’m guessing, or talking on a topic where I don’t feel confident, I will say so.  I will also use less declarative language.  This is especially true when discussing politics.

But if you turn on the TV today, you’re likely to see – sometimes in the same segment – people declaring as absolute truth that health care reform is going to pass or fail.  Obviously both can’t be true.  Even Megan McArdle notes this:

The opinions on both sides seem so confident, and so incompatible, that one group of people is clearly borderline delusional.  I don’t see how they can be right–even if passing health care makes the party better off (I’m doubtful), it does not improve the fortunes of members in conservative districts who do not get much mileage out of their affiliation with the Democratic Party (and will get even less mileage if they are seen as enabling unpopular legislation).

But of course, borderline delusional people don’t think they’re delusional, or else they wouldn’t be delusional.  So there you are: either it’s a done deal, or it’s dead.  There’s no longer much middle ground in between.

I was on Inside Indiana Business last weekend to talk about you know what:

This week health care reform was thrust back in to the national spotlight as lawmakers gathered for a health care summit on Thursday and Indianapolis-based WellPoint’s CEO Angela Braly testified on Capitol Hill. Dr. Aaron E. Carroll, Director, Center for Health Policy and Professionalism Research has perspective.

Go watch.

I’m starting to despair that no one in the media has any idea what they are talking about. I get why Republicans are trying to portray the passage of health care reform as some betrayal of principles or the tyranny of the majority, but it’s not.

Using reconciliation is not “ramming it through”.

Look – the bill has already passed through the Senate.  It got 60 votes.  It’s done.  Was that ramming it through?

Now, let’s say the House of Representatives passes the Senate bill, by a majority.  Is that ramming it through?

And then, the President signs the bill – passed by both houses of Congress.  Is that ramming it through?

No, it’s not.  It’s how laws (that overcome filibusters) are supposed to pass.  And then we would have health care reform.  No reconciliation.  No “ramming it through”.

That’s what the Democrats plan to do.

The bill will expand Medicaid, set up the exchanges, put in place an excise tax, establish subsidies, increase regulation – and everything else it’s supposed to do.  No reconciliation.  No ramming.

BUT – the House of Representatives and the Presiedent want to make some tweaks.  They want to delay and change the excise tax.  They want to increase the subsidies.  They want to add in another tax.  THAT’S what will go through reconciliation.

If the Republicans and the media want to outlaw reconciliation, health care reform could STILL PASS.  The House of Representatives can vote, and the President can sign.  Then we would just have the Senate bill as law. But no one is saying that.  They are claiming that the only way the bill passes at all is if it all goes through reconciliation.

That’s not true.  Stop saying it.

In yesterday’s health care summit, malpractice reform was all the rage.  It’s especially frustrating, because I cannot, for the life of me, understand why some people feel that it’s the magic bullet for reducing health care costs.  My frustration was lessenned by Sen. Durbin’s pretty darn good summary of the problem with that line of thought:

Of course that didn’t stop the continued assertions that – REALLY – malpractice costs were the biggest and baddest problem in all of health care.  And then Senator McCain was kind enough to whip out the examples everyone knows and loves:

And the — and the point is that we don’t have to go very far. There’s two examples right now of medical malpractice reform that is working. One’s called California, the other called — called Texas.

Sigh.

Well, I tackled Texas a little while ago.  You can go reread that one if you like.  And today, Kevin Drum was kind enough to explain the problem with using California:

We passed a law called MICRA in 1975 that limited noneconomic damages in malpractice cases to $250,000. Adjusted for inflation, that cap is now about the equivalent of $60,000. Nonetheless, its impact on malpractice premiums has been negligible. The chart below comes from the Foundation for Taxpayer and Consumer Rights, which definitely has a dog in the fight since it was founded by insurance industry scourge Harvey Rosenfield, who championed Proposition 103, an initiative that implemented state approval of insurance rates. It was passed in 1988.

Still, the results are pretty clear. After 1975, malpractice premiums continued to zoom upward, rising at an even higher rate than in other states. But after 1988 (that’s the green line for easy reference), California premiums leveled off while rates in the rest of the country continued to rise. The reason for this is pretty simple: large damage awards are actually pretty rare and don’t make up a huge proportion of total malpractice payouts. Capping them changes the picture, but it doesn’t change it that much. But it does substantially cut into trial lawyer income.

So what you’re seeing is that capping awards in 1975 did little to decrease the premiums in California over the next 13 years.  Allowing government regulation of insurance premiums since 1988, on the other hand, has done quite a bit to keep rates from rising.  So which method are the Republicans clamoring for?  Can you guess?

I said it about Texas, so I’ll say it again to be complete:  There are probably some examples that can support the cause of tort reform, but California sure ain’t one of them.  Please stop using it.

Lots of email about the summit.  I have to be honest and admit I couldn’t watch the whole thing.  I do have a job, you know.  But I caught as much as I could.

There were times I was in agreement with what was said; there were times I was literally screaming at the screen in frustration.  I wondered if this was possibly doing any good.

But then I wondered if anyone was watching who might actually be influenced by it.  I bet most of the people watching live were political junkies, media people, or people immersed in the health care reform process.  None of those people were likely undecided or going to change their minds.

Moreover, I’m sure that – once again – the media will cover the process more than the policy.  We’ll hear about the President’s exchange with Senator McCain, his disagreement with Rep. Ryan, or some other minutiae.

And I think the White House knew that’s how it would go.

So in the end, I think this was likely more about one process more than policy:

• The Democrats, and the White House, seem completely committed about passing this bill.  No more weaseling.
• Now they can say they tried to talk to the Republicans.  They tried bipartisanship one last time.
• They defended reconciliation.  No more talk about it being a bad idea.
• They pretty much said that if they can’t get compromise, they are going alone.

I think this was cover.  They tried.  And now they are going to push.  If they can get it through the House, this is going to happen.  I’m not sure they can do that, but they’re going to try.  I’m cautiously optimistic.