Something Not Unlike Research

Coercion and the Value of Choice

post by Paul Kelleher

Earlier today I quoted Chief Justice John Roberts' opinion on the Affordable Care Act in which he, writing for a majority, argued that the law unjustifiedly "put a gun to the head" of states. This was in response to the federal government's power, under the ACA, to threaten to withhold all Medicaid funds from states that refused to participate in the ACA's expansion of Medicaid. I asked why SCOTUS sided with the states on this issue, when the flipside is that without Medicaid expansions, some people will face "guns to the head" in the form of serious illness or even death. 

This was too quick on my part. I should have acknowledged that moral assessments of similar outcomes can nonetheless diverge because of how they came about. For example, I bear a stronger duty to give you one of my kidneys if I was the negligent cause of your renal failure than I would bear if I had nothing to do with your unfortunate predicament. Likewise, the court seems to be saying that it is wrong to actively make it the case that states have "no choice" but to expand Medicaid, but it is not wrong to merely refrain from aiding unfortunate others.

Characterized this way, I think the better way to question the Court's logic is to note that its decision displays special concern for the autonomy of states without acknowledging the special costs this may have for the autonomy of those who will remain without coverage. The whole point of offering low income folks access to Medicaid is to give them options and choices they would otherwise not have. To do this, Congress chose to curtail the autonomy of states by making access to Medicaid funds contingent on expansion. Is this wrong? To show that it is, one needs to explain why it is wrong to balance states' autonomy against the autonomy of folks who face sickness and death without any recourse for adequate treatment or palliation. But the Court didn't do this. It simply pointed to the fact that states stand to lose 10% of their budgets if they don't expand, and it declared on that basis that ACA permits unconstitutional coercion. I simply think this reasoning is much too quick, and that those who might remain uninsured are owed an explanation of why their diminished capacity to choose cannot justify diminishing that of states. 

Health Care Reform: 2012-06-28

post by Bill Gardner

The Supreme Court has decided. After the ground stops shaking, stop and recollect the aims of health care reform: 

Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.

These aims have not been accomplished by the preservation of the Affordable Care Act, even though the alternative of overturning it might have been worse. 

1. Lack of insurance is not the only obstacle to accessing care, and even there the Affordable Care Act does not quite achieve universal access.
2. The US lacks the effective means to even measure many aspects of population health, let alone improve it.
3. There are striking disparities in life expectancy and morbidity, depending on your race, your social class, and where you happen to live. 
4. Health care costs continue to grow too fast. Merely reforming insurance will not be sufficient to reduce the growth of health care costs while preserving access and improving the quality of care. We need to develop better and if possible cheaper treatments for most conditions, and transform the institutions and professions that deliver care.

The task is about 1% completed.

The SCOTUS Decision, Medicaid, and Coercion

post by Paul Kelleher

Here are a few thoughts on one of the real surprises in today's Supreme Court decision (pdf) on the Affordable Care Act.

Ezra Klein tweeted a question this morning (before the release) that asked whether anyone had blog posts or news story prepared just in case SCOTUS upheld the ACA's mandate but struck down its Medicaid expansion. This was tweeted as something of a joke, I gather, since many (maybe most) experts thought the Medicaid expansion would be upheld without a problem. They were wrong. The mandate was upheld, but SCOTUS ruled that (1) that states can opt out of the ACA's Medicaid expansion (which sought to give Medicaid coverage to those below 133% of the federal poverty line), and (2) that the federal government cannot withhold all Medicaid dollars to states who refuse participate in the expansion. 

This part of the decision is a huge deal. As law prof Tim Jost wrote a month ago,

The ACA provides that, beginning in 2014, individuals will be eligible for refundable premium tax credits if they 1) are not eligible for health insurance coverage through an employer or through a government program; 2) are citizens of or lawfully present in the United States and not incarcerated (other than pending final disposition of charges); and 3) have modified adjusted gross  household incomes (MAGI) between 100 percent and 400 percent of the federal poverty level.

Thus, in light of today's ruling, a person below 100% of the poverty line will be ineligible for exchange subsidies even if she does not qualify for Medicaid under her state's eligibility criteria. This means the ACA may not in fact cover all Americans. In short, we have a new donut hole to deal with. 

So why did the court rule against this part of the ACA? Here is the rationale as expressed in Chief Justice John Robert's majority opinion (pp. 51-52, minus the citations):

In this case, the financial “inducement” Congress has chosen is much more than “relatively mild encourage­ment”—it is a gun to the head. Section 1396c of the Medi­caid Act provides that if a State’s Medicaid plan doesn’t comply with the Act’s requirements, the Secretary of Health and Human Services may declare that “further payments will not be made to the State.” A State that opts out of the Affordable Care Act’s expansion in health care coverage thus stands to lose not merely “a relatively small percentage” of its existing Medi­caid funding, but all of it...The Federal Gov­ernment estimates that it will pay out approximately $3.3 trillion between 2010 and 2019 in order to cover the costs of pre-expansion Medicaid. In addition, the States have developed intricate statutory and administrative regimes over the course of many decades to implement their objectives under existing Medicaid. It is easy to see how the Dole Court could con­clude that the threatened loss of less than half of one percent of South Dakota’s budget left that State with a “prerogative” to reject Congress’s desired policy, “not merely in theory but in fact.” [In contrast,] The threatened loss of over 10 percent of a State’s overall budget, in contrast, is economic dragooning that leaves the States with no real option but to acquiesce in the Medicaid expansion.

If I read this correctly, the court says that it is unconstitutional coercion to force a state to choose between expanding its Medicaid program and losing all its Medicaid dollars. This is a remarkable claim in the context of a law whose purpose is to prevent individuals from having to choose (in some cases) between serious illness (or even death) and financial ruin or worse (who wouldn't break a law to get one's child desperately needed medical care?). So I ask: why is it a "gun to the head" situation when states face losing their federal Medicaid dollars but not a "gun to the head" situation when individuals face death for lack of insurance? 

Relatedly, it was also tweeted this morning (I can't remember who said it) that if the court can rule that the ACA's mandate penalty is really a tax (despite not being called a tax in the law), what other semantic distinctions in the law can the court ignore? I think we found another in this Medicaid issue. From pages 52-54 of Roberts' opinion:

JUSTICE GINSBURG claims that Dole is distinguishable here because here “Congress has not threatened to withhold funds earmarked for any other program.” But that begs the question: The States contend that the expansion is in reality a new program and that Congress is forcing them to accept it by threatening the funds for the existing Medicaid program. We cannot agree that existing Medicaid and the expansion dictated by the Affordable Care Act are all one program simply because “Congress styled” them as such. [...]

Here, the Government claims that the Medicaid expansion is properly viewed merely as a modification of the existing program because the States agreed that Congress could change the terms of Medicaid when they signed on in the first place. [...]

The Medicaid expansion, however, accomplishes a shift in kind, not merely degree. The original program was designed to cover medical services for four particular categories of the needy: the disabled, the blind, the elderly, and needy families with dependent children. Previous amendments to Medicaid eligibility merely altered and expanded the boundaries of these categories. Under the Affordable Care Act, Medicaid is transformed into a program to meet the health care needs of the entire non elderly population with income below 133 percent of the poverty level. It is no longer a program to care for the neediest among us, but rather  an element of a comprehensive national plan to provide universal health insurance coverage.

This really is amazing. The court concedes that Medicaid is currently a program that covers several different classes of people. But as soon as Congress seeks to cover yet one more class of individuals (those making less than 133% of the poverty line), all of a sudden Medicaid is transformed into an entirely new program. Um, OK.

Tyler Cowen on Health Care Egalitarianism

post by Bill Gardner

From a post by Cowen arguing that "conservatives and libertarians... should have been looking for the following qualities in a health care policy." As is often the case, it is not entirely clear whether he is expressing his own view, as opposed to trying to clarify others' views. In any event, he proposes

A rejection of health care egalitarianism, namely a recognition that the wealthy will purchase more and better health care than the poor.  Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence.  We need to accept the principle that sometimes poor people will die just because they are poor.  Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree.  We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes. 

This is thrilling writing: how often have you read anyone defend "the principle that sometimes poor people will die just because they are poor"? When someone embraces a principle that you thought was an argument for your view, what do you say?

Well, you can point to a number of problems here.

1. Health care egalitarianism doesn't need to imply that we are seeking to "equalize health care consumption." I can't think of a serious egalitarian who either proposes this or whose view implies it. I can see a line of thought that would argue that people with equal health care needs should have equal health care consumption. This would argue for greater health care consumption by the poor, because they have poorer health. To my mind, a far more plausible health care egalitarianism would argue that everyone should have access to sufficient health care, with sufficiency determined through democratic deliberation.
2. "we already let the wealthy enjoy all sorts of other goods... which lengthen their lives and which the poor enjoy to a much lesser degree."  One might have thought that equitable access to care would be important precisely because the poor suffer so many insults to their health.
3. Consider also how the previous line of argument might be extended. 'We already let the wealthy have much more influence in politics; why should we try to guarrantee the poor equal access to the ballot box?' 'We already let the wealthy have much better treatment by the police and the courts; why should we try to guarrantee the poor equal access to justice?' Really, given that inequality will always be with us, why care about it at all?
4. "We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes." I too think we shouldn't screw up our health care institutions. However, the premise that "fighting inegalitarian principles" (does he actually mean 'institutions'?) will "screw up our health care institutions" assumes precisely what needs to be proved. 

 

Population Health, Health Inequality, and Leveling Down

post by Paul Kelleher

The British epidemiologist Geoffrey Rose made the following simple but powerful observation:

a large number of people at a small risk may give rise to more cases of disease than the small number who are at a high risk.

The point can be usefully illustrated with a toy example. Suppose the population of your country has a ritual of tossing coins at noon, and suppose you are a policy maker wanting to maximize the number of coinflips in the population that turn up heads. The vast majority of the population usually flips fair coins (50% chance of landing on heads, 50% chance of landing on tails), while a small segment of the population has coins with tails on both sides (giving them a 100% chance of getting tails). Assume that you can choose one of two options in your quest to maximize the number of coinflips turning up heads: (1) You can replace the coins held by the majority with coins that come up heads 51% of the time (rather than 50%); or, (2) You can replace the tails/tails coins held by the minority with heads/heads coins, changing their probability of flipping a heads from 0% to 100%. Now ask: Which strategy should you choose if your goal is to maximize the number of coinflips that come up heads? The answer, Rose tells us, is that in a very large population, you should pick option (1), since the 1% change in probability for the vast majority will yield more additional cases of heads than a 100% change for a much smaller group. Similarly, reducing the majority's average cardiovascular risk by a small amount may prevent more deaths than eliminating altogether the high risk faced by a disadvantaged minority.

This is a powerful insight. It leads to the conclusion that if we wish to maximize population health, the best strategy may be to bring about small but favorable shifts in the entire curve (i.e. the population's distribution of risk), rather than focus all our efforts on those folks with the highest risks who reside in the "tail" of the curve. Here's how that might look (figure taken from Frohlich & Potvin). Note, the x-axis measures the relevant health risk factor, with "bad" to the right and "good" to the left; and the y-axis measures the percentage of the population that carries that level of risk:

The before-and-after depicted above shows the effects of a population health intervention that reduces everyone's risk by the same degree. That is what is meant by saying that the entire curve has been shifted in a favorable direction. But sometimes our best bet for boosting population health comes from interventions that do more for the advantaged majority than they do for disadvantaged minorities. Here's what that would look like.

The above before-and-after reflects an intervention that actually widens inequality at the same time it boosts population health. Indeed, population health is boosted even as those with the highest risk (i.e. those residing in the rightmost tail of the distribution) are not helped much at all. This raises the question of whether and how the goal of boosting population health should be balanced against the goal of constraining health inequality.

In a recent paper that will become a staple in my course syllabi, Joan Benach et al. provide a useful typology of different ways in which changes in population health can be paired with changes in health inequality. In the following scenarios (click to enlarge), the solid lines represent the starting distribution and the dotted lines represent the distribution after the intervention. In general, distributions that move to the left signify an improvement in population health, while a flatter resultant distrubtion signifies increasing inequalities.

The authors discuss each scenario with reference to real-world interventions that have or might have affected popluation health in the manner depicted. For example, in the context of scenario (e), where population health improves while inequality increases, Benach et al. note that it mirrors "the historical effects of anti-smoking campaigns, in which there is an overall improvement in the population health, but mostly for the better-off." 

Consider now what Benach et al. say about scenario (g):

Scenario (g) portrays a complex picture in which health inequalities are reduced but overall population health remains the same in such a way that for social groups with better health outcomes, the situation worsens. This scenario contrasts with the so-called “leveling up” approach, which argues that inequalities must be tackled by improving health levels for less privileged groups without damaging the situation of the better-off, and therefore that a “leveling down” approach is not equitable under any circumstances.

I don't agree with the  authors' claim that (g) is an example of "leveling down." To see why, consider a passage from Whitehead and Dahlgren (pdf), which is the source Benach et. al. cite as making the case that "a 'leveling down' approach is not equitable under any circumstances" (emphases added by me):

Policies Should Strive to Level Up, Not Level Down

Nobody would seriously suggest trying to close the health gap by bringing healthier people down to the level of the least healthy. A worsening in the infant mortality rate of the babies of rich parents, for example, with no change in the mortality rate of poor babies, would not be seen as a success, but would rather be seen as a tragedy – even if it led to a narrowing of the differences between the two groups, purely in terms of measurement. Yet, opponents of an equity policy have warned of this danger. Therefore, to make it absolutely clear, the principle set out in this paper emphasizes that the only way to narrow the health gap in an equitable way is to bring up the level of health of the groups of people who are worse off to that of the groups who are better off. Levelling-down is not an option.

The example of leveling down given by Whitehead and Dahlgren is one in which inequality is lessened by worsening the health of rich persons' babies while holding the health of poor babies fixed.  Here's what that would look like:

In (i), inequality is reduced solely by increasing the health risks of the better off. In my view, the term "leveling down" should be applied only to (i), not to (g). So Benach et al. can rest assured that in supporting some interventions that look like (g), they are not supporting leveling down. The example they give is resdistributive policies designed to improve the health of the worst off, but which carry the side effect of reducing the health of the better off (mediated through a relationship between income and health). If there is something morally problematic with this sort of policy, it cannot be because it amounts to leveling down.

Informed Consent and Standards of Care

post by Paul Kelleher

Austin Frakt has an important post today about the still rocky terrain of informed consent in medicine. You should read the whole (short) post, which revolves around this case:

The date was July 19, 1999, when as a third-year resident I saw a highly educated 53-year-old patient. In June 2002, my residency and I were served with court papers.[...]

On that day in July 1999 I saw the 53-year-old man for a physical examination. I discussed with him, and documented in his chart, the importance of colon cancer screening, seat belts, dental care, exercise, improved diet, and sunscreen use. I also presented the risks and benefits of screening for prostate cancer and documented the discussion. I never saw the patient again, and after I graduated, he went to another office. His new doctor ordered prostate-specific antigen (PSA) testing without discussing the risks and benefits of screening with him. Unfortunately for the patient, his PSA level was very high and he was subsequently diagnosed with incurable advanced prostate cancer. [...]

My residency was found liable for $1 million.

Frakt gives a little more background on the trial that led to this verdict:

[S]everal physicians testified that it was standard to conduct a PSA test without asking the patient. Hence, in the eyes of the law and despite the shared decision making process he employed, Merenstein delivered sub-standard care.

Perhaps the rationale for defining adequate care as that which would be provided by most of one's peers can be ratified by adapting that old Churchillian quip: it's the worst form of government, except for all the rest. After all, do we really want courts to be making decisions about what appropriate medical care consists in, especially when so much of the profession is united on what should be done? On the other hand, it is just as easy--and maybe easier---to raise important worries about determining the standard of care in this "prevailing practice"-based way. Perhaps Frakt's case of the resident and the PSA test is enough to convince you that we need a different standard. If not, consider this case, which comes from Rebecca Skloot's book The Immortal Life of Henrietta Lacks (pp. 129-135): 

Southam injected HeLa and other living cancer cells into more than six hundred people for his research...Patients who'd unknowingly been injected with cancer cells by Southam read the articles and began contacting reporters. New York State Attorney General Louis Lefkowitz learned about Southam's research through media as well, and immediately lauched his own investigation. In a scathing five-page document filled with exclamation points, he accused Southam and Mandel of fraud and unprofessional conduct, and demanded that the Board of Regents of the University of the State of New York revoke their medical licenses. [...]

Many doctors testified before the Board of Regents and in the media on Southam's behalf, saying they'd been conducting similar research for decades. They argued that it was unnecessary to disclose all information to research subjects or get consent in all cases, and that Southam's behavior was considered ethical in the field. Southam's lawyers argued, "If the whole profession is doing it, how can you call it 'unprofessional conduct'?" [...]

The suspensions of Southam's and Mandel's licenses were stayed...[and] soon after the end of his [one year] probationary period, Southam was elected president of the American Association for Cancer Research. 

Our mothers were right: just because everyone else is pushing cancer patients off the Brooklyn bridge doesn't mean it's OK for us to do it. And perhaps, just perhaps, the fact that most other doctors conduct the PSA test without first getting informed consent from the patient does not mean that this is acceptable conduct either. I won't pretend there aren't forcing pulling in different directions. But that is why we need clear examples of when informed consent is required, so we can distill generalized lessons from them.  

Mental Health: Fight Stigma AND Improve Care

The Mental Health Commission of Canada has a campaign to destigmatize mental illness, and I support this campaign. Stigma makes it hard for people with a mental illness to accept that they need help. That in turn can delay their seeking care.

Having said this, I wonder whether it makes sense to have anti-stigma as the primary message of a mental health strategy. It needs to be paired with a second message: Better Care. 

Mental health centers often have long waiting lists in both Canada and the US. Some of this is because ministries or departments of health underfund mental health care, or because insurance do not cover mental health care as generously as non-mental health care. And that is due, in part, to stigma.

But it is also true that mental health care is often disorganized and inefficient. It's time to get out of denial: Resources are not going to increase. We must work out how to serve more patients with existing resources. Even worse, mental health providers have been slow to commit to implementing evidence-based practice and measured quality of care. Our patients should be doing better: and it's on us to make that happen.

There is a danger if the anti-stigma message becomes the principal message that the public hears. The danger is that when mental health providers say this, they are implicitly saying to the public that "the problem is YOU." I don't want us to say one word less against stigma. What I want is for us to balance that message with "the problem is US." We need to get our house in order and improve the quality of mental health care.

Can Subsidies Replace the Mandate?

post by Paul Kelleher

In "Just in Case: How Reform Might Survive Without the Mandate," Jon Cohn writes:

Without a mandate, wouldn't healthy people stop getting insurance, since they could always buy it once they get sick? [...]

But some people choose not to get insurance because it seems (and frequently is) too expensive, at least relative to the benefits they'd get. If your household income is $40,000 a year and the annual premiums for family coverage add up to $12,000, with huge out-of-pocket costs and gaps in coverage, why would you bother? The law's subsidies and, to a lesser extent, regulations on benefits should alter that calculus: Coverage will start to seem like a much better deal and many of these people will start buying. The net effect will be to bring many more people into the insurance pool, many of them relatively healthy, making it possible for insurers to spread the cost of high medical bills more broadly and keep costs down. 

Just to be clear, striking the mandate would introduce a new element of uncertainty into health care reform: Nobody has ever tried a system with generous subsidies but no mandate.

This is precisely the sort of system that Mark Pauly, the so-called "father of the mandate," appears now to endorse. In Health Reform Without Side Effects, published just after the ACA passed in 2010, Pauly writes:

The point here is that a subsidy does more than increase the takeup at a given loading [where "loading" is the difference between total premiums paid and total benefits received]; it actually permits a dramatic reduction in loading itself because it reduces the cost of persuading people to take coverage. Subsidized  insurance is more efficient with regard to administrative cost because of a kind of self-fulfilling prophecy:  by making premiums more attractive, selling costs can  be lowered, but at lower selling costs, attractive premiums can eventually become financially feasible.  This powerful point, which I believe is not well recognized either in the health policy or the insurance economics literature, has two important implications, one fairly obvious and the other less so.    

The obvious implication is that with a subsidy, the specific administrative arrangement for insurance becomes both less important and less of a factor in takeup. For example, the Massachusetts Connector may well have relatively low administrative cost, but so would almost any other way of administering insurance given that state’s large subsidy to people with incomes below 300% of poverty and its penalty for uninsurance to others. It is not the whole bundle of features of a high-performance (and high-regulation) health system that lowers individual insurance administrative cost; the active ingredient is the subsidy. [...]

The less obvious point is that lowering price with a subsidy might even lower administrative costs so much as to eliminate (or at least greatly reduce) the need for a  subsidy. More formally, there may be a break-even equilibrium  at a low insurance premium with high volume,  but markets may currently be trapped in another equilibrium  with high premiums and low volume.

I highly doubt the second point would pan out for the robust plans that the ACA envisions everyone having affordable access to. But then again, Pauly doesn't want to engineer a system in which everyone has plans at least that robust. He would prefer more scope for personal preference than that. Still, his hypotheses about the virtuous "self-fulfilling" nature of subsidies seems something to think about as we move closer to a Supreme Court decision on the ACA. 

 

After Florida v. US DHHS

post by Bill Gardner

In a few days, the US Supreme Court will release its decision concerning Florida v. United States Department of Health and Human Services and the constitutionality of the Patient Protection and Affordable Care Act. I am so not a lawyer, therefore I have no prediction about the decision and I can't tell you what legal principles are at stake. However it comes out, one group of partisans will crow, while the other will proclaim the end of the Republic and rend their clothes.

But whatever the Court decides, it will remain the case that 17% of US children and adolescents are obese, 19% have untreated dental caries, 9.4% have asthma and 150,000 children have diabetes. In the coming year, about 6 million children will be reported for child neglect or abuse, more than 10,000 children under 15 will be diagnosed with cancer, and 7 in every 100,000 adolescents will commit suicide. Despite a very different health care financing system, the situation of Canada children is not much better. I can list many other pediatric disorders and problems, or I could begin detailing those of adults, but you get the point.

It is this mass of human suffering that should be in the scales when we survey the state of health care. It is a continental mass: we do not appreciate its scale because it does not move. Yet suffering is what truly matters. Whatever the Court decides, our work will remain undone.

Newcomb's Health Care Reform Paradox

post by Paul Kelleher

Suppose you are a left-leaning health care reporter who wants to see the Affordable Care Act upheld. Perhaps you're Jon Cohn, or Ezra Klein. Or maybe you're a health economist or a health services researcher with a well-read blog. In any case, you want to see the the law upheld by the Supreme Court and you'd love to be the first to break the news about the verdict on your website. Perhaps a scoop like that could do wonders for your career. Or maybe it'd just be the thrill of a lifetime.

Suppose also that you---and you alone---know that in addition to being a highly accomplished jurist, Chief Justice John Roberts is also a great prognosticator. That is, he seems to be able to see the future. You've interviewed him hundreds of times---maybe even thousands---and before every interview, Roberts insists that you play a little game. He asks you to pick a number between 1 and 1000. If he guesses the number correctly, your interview will last 5 minutes only. If he guesses wrong, you get all the time you want and he'll answer every question you ask truthfully and comprehensively. Sadly for you, he has guessed correctly every time, and your untold interviews with him have lasted only 5 minutes each and have all been pretty bland affairs.

So one day in early June, 2012, the Supreme Court's courier delivers an envelope to your office. Inside the envelope is a letter and a second envelope. The letter reads:

Dear [Your name here],

Inside the envelope included with this letter is my majority decision in National Federation of Independent Business v. Sebelius and Florida v. United States Department of Health and Human Services. As you know, this decision was made very soon after oral arguments ended in March, but the Court is unlikely to announce the ruling until the end of June. However, you are at liberty to open the envelop and break the news now. Just one other thing: Before casting my deciding vote in March, I made a prediction as to what you will do. If I predicted that you would open this envelope and break the news, then I cast my vote against the Affordable Care Act. If I predicted that you would not open this envelop, then I cast my vote in favor of the Affordable Care Act.

Sincerely yours,

John Roberts

So what are you going to do?