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You are here: Home / Anderson On Health Insurance / EHB and public goods

EHB and public goods

by David Anderson|  December 6, 20167:03 am| 27 Comments

This post is in: Anderson On Health Insurance

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Essential Health Benefits (EHB) are things that a Qualifying Health Plan (QHP) must cover under the ACA.  The area I want to focus on right now is the EHB’s for preventive care.  These are the well visits, these are the contraception requirements, these are the screenings and these are the vaccinations.  The Republican plans have been arguing that one of the reasons why the ACA premiums are too high is the list of covered services is too long. I am assuming that contraception requirements will be axed within seventy eight seconds of inauguration but on a cost basis those benefits are minor as the savings from not having effective no-cost sharing contraception are roughly balanced out by the increased unplanned pregnancy costs.  If anything as IUD’s have gotten cheaper, contraception is a net money saver.

Instead I want to focus on the vaccinations right now as they have a different set of economic properties than all of the other preventive care requirements.  They are at least partially public goods with non-linear returns to scale. What does that mean?

Let’s look at a preventive service that is almost entirely a matter of private consumption.  If I was to have a colonoscopy to screen for colon cancer, I get all of the benefit of the scan.  I am either told that there is nothing to worry about for the next long while or there is a problem that was caught early.  If there is a problem, the polyps can removed and any treatment could get started as needed.  If I have colon cancer, I can not give it to anyone else.  I fully internalize the benefits of the cancer screening by either receiving peace of mind, early treatment or avoiding high cost end stage treatment.

The HPV vaccine is different.  If I was young enough to have been in a HPV vaccine receiving cohort I would have received the vaccine.  It provides me with significant benefits.  It dramatically lowers the risk of me catching an infection and thus lowers the risk of developing a set of cancers later on in life.  It also provides other people within my cohort benefits even if they are not vaccinated.  If I was with a partner who has not vaccinated, she could not catch HPV from me.  Any of her other partners would not get HPV that originated from me.  I also could not get HPV from her.  I am a blocking point in any potential infection chain.

Here the modeling of benefits gets funky and non-linear.  If I am the only person in the world to have received the HPV vaccine, I internalize almost all of the benefits of the vaccination.  Using traditional economic logic, I should pay for the vaccine fully myself.  If I am the last person in the world to get vaccinated, there is almost no marginal benefit to me as there are no possible ways for me to get infected by HPV anyways.  That scenario illustrates herd immunity.  If there is a large number of people already vaccinated and I choose to get vaccinated, I internalize some of the benefits but the marginal increase in herd immunity is real as more potential infection chains are broken and the community as a whole benefits.  More importantly, the people with compromised immune systems benefit the most as they get some additional indirect protection without risk.

The same logic applies to other vaccines.  I went with HPV because I was in a three meeting on vaccination strategies yesterday.

Optimal vaccination levels, once we consider total cost, are not 0% and it is not 100%.  It is probably in the high 90’s for most infectious diseases where the externality of herd immunity.  Right now the United States is significantly below that for the entire array of early childhood vaccines.  We are still able to generate significant positive externalities by increasing vaccination rates.

Since we can significantly increase total social welfare by increasing vaccination and since not all of the benefit of a vaccination is accrued by the person who received and paid for the vaccine, this is a textbook case that calls for public subsidy to promote further vaccination.  Vaccines are one of the hills to fight hard for in any replace bill as it is good policy in both the short and long run and the economic logic is air tight.

 

 

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27Comments

  1. 1.

    Lahke

    December 6, 2016 at 7:56 am

    Uh, you might want to reconsider your breezy dismissal of the benefit of contraception, Richard. It makes a BIG difference to half of us, plus partners. Also, big drop in abortions rates since free contraception came in. Not that that will persuade the wingers– it’s women enjoying sex that they hate.

  2. 2.

    cmorenc

    December 6, 2016 at 7:57 am

    But…but…autism!
    :=)

  3. 3.

    Central Planning

    December 6, 2016 at 8:02 am

    Speaking of vaccines, we got a call from the school nurse for my 11 year old. Back in 2010 (glad they are on top of things!) he got the flu mist vaccine at a weekend clinic at the pediatrician. A few days later he had his normal 5 year old physical where he got the varicella and MMR vaccines.

    Turns out, you’re not supposed to get more vaccines within 4 weeks of getting a live virus vaccine. If we don’t get those 2 vaccines in the next two weeks, he’ll be suspended from school. The funny (frustrating) thing is that the private school he goes to lets totally un-vaccinated kids in without a problem (there’s one who has alternative medicine parents), but mine would be suspended. Granted, when he gets to public school next year he would need the vaccinations (and we’re going to get them in the next two weeks), but the inconsistency is maddening.

    I’m also surprised that the doctor’s office hadn’t found this issue earlier either. I can understand how he slipped through the cracks with a walk-in flu clinic and then a physical a few days later, but it seems like the office should be running some reports to find kids that are within that 30 day window and getting them back in for boosters.

  4. 4.

    Mathguy

    December 6, 2016 at 8:11 am

    @cmorenc: Beat me to it. Darn.

    This antivaxxer nonsense is something I wish would go away, because it’s always brought up when someone is on a BroderismBothSidesDoIt kick.

  5. 5.

    manyakitty

    December 6, 2016 at 8:14 am

    I suspect both of those essential public health items will get chopped almost immediately. Birth control because of “teh slutz” and vaccines because shitgibbon is antivax and I think the rest of those in control want to punish the poors, too.

  6. 6.

    Richard Mayhew

    December 6, 2016 at 9:02 am

    @Lahke: Oh I agree, contraception is a big fucking deal. I am making a political judgement that contraception will be dropped in thirty three seconds as an essential health benefit because of who is going to be in charge of HHS. If I was in charge of HHS, I would be 100% on board with no cost sharing birth control and diverting what funds I could legally divert towards funding low cost LARCs. I’m not in charge, Tom Price will be in charge.

  7. 7.

    MomSense

    December 6, 2016 at 9:19 am

    @Richard Mayhew:

    And I know that Price doesn’t care to understand that the birth control pill is used to treat other things that aren’t even for contraception. Maybe women can get a no sexy time waiver so they can get it to treat endometriosis, Poly Cystic Ovary Syndrome, blood disorders, migraines, amenorrhea, Primary Ovarian Insufficiency (which affects cancer patients!!), menorrhagia, etc.

  8. 8.

    Botsplainer

    December 6, 2016 at 9:23 am

    @manyakitty:

    If I ever get the opportunity, I’m taking steaming dumps on the graves of Jean Calvin and Ayn Rand, two of the most reprehensible figures of history.

  9. 9.

    Jack the Second

    December 6, 2016 at 9:32 am

    On the plus side, many IUDs last more than 4 years, so if you get one now and are lucky and in 2020 President Charismatic WhiteGuy McDemocrat restores contraceptive coverage to TrumpCare, you might be able to coast across the period of no coverage.

  10. 10.

    manyakitty

    December 6, 2016 at 9:45 am

    @Botsplainer: Let me know when you’re planning it – I’ll join you!

  11. 11.

    SP

    December 6, 2016 at 9:55 am

    “good policy…economic logic”
    Oh, Richard, you’re so cute sometimes.

  12. 12.

    raven

    December 6, 2016 at 10:20 am

    @MomSense: He understands it fully, it’s pandering to the fucking goobers.

  13. 13.

    MomSense

    December 6, 2016 at 10:34 am

    @raven:

    Yup. He chooses not to consider other possibilities.

  14. 14.

    Jack the Second

    December 6, 2016 at 10:44 am

    @Botsplainer: What’s your problem with Calvin?

  15. 15.

    Another Scott

    December 6, 2016 at 10:47 am

    @Central Planning: We moved a lot when I was a kid, had lots of different physicians, and never kept very good records. I remember getting one vaccination in 3rd grade at school (with the air-gun thingy that leaves the ~ 1 cm diameter scar on your arm) and I don’t recall if any paperwork went with it (it was surely lost over time). When I moved to a different high school, they needed records for various vaccines that we didn’t have, so I had to get the shots again (including for something I had as a kid (rubella?)).

    I’d like to think that with (reasonably) secure cell phones, electronic records, and direction from DC, that issues like these are slowly being addressed and they’ll eventually go away for most people. But getting there is a much more difficult slog than it needs to be, and, as always, it hits to poor and near poor much harder than the folks who vote regularly, never move, always keep good records, and who let their congresscritters know what’s more important (“you better cut my taxes or else!!11”).

    (sigh)

    Cheers,
    Scott.

  16. 16.

    cmorenc

    December 6, 2016 at 11:19 am

    @Richard Mayhew:

    contraception is a big fucking deal. I am making a political judgement that contraception will be dropped in thirty three seconds as an essential health benefit because of who is going to be in charge of HHS.

    There are three levels to the GOP (and Tom Price’s potential) hostility to contraception coverage:
    1) government-subsidized contraceptive coverage in health care insurance plans;
    2) Roe v Wade constitutional protections for women’s choices about at least the first half of pregnancies;
    3) Griswold v Connecticut’s constitutional “privacy” protections for personal choice (and access to) contraception.

    It’s important to recognize that, as important as Roe v Wade is wrt women’s options during pregnancy, actually the far more fundamental ballgame is the extent to which a far right-dominated SCOTUS might potentially gut Griswold’s protection for contraception choices via either permitting states to enact enforceable provisions defining life-begins-at-conception (and anti-abortion fundamentalists’s concept of what that means), or else via fabricating out of whole cloth a constitutional “life begins at conception” federal constitutional doctrine. (I say “fabricated” because the common-law at the time the constitution was enacted and even forward to enactment of the 14th amendment was that the fetus had no legal rights until birth (or at least viability). I suspect for that reason, a far-right dominated SCOTUS would choose to let states enact their own choice of doctrine about where life begins, rather than make a general federal declaration – meaning that legal, and not just practical, access to contraception would be vastly different in California v Alabama.

  17. 17.

    trollhattan

    December 6, 2016 at 11:21 am

    @Jack the Second:
    He shot Hobbes in Reno, just to watch him die.

  18. 18.

    Mike R

    December 6, 2016 at 11:21 am

    Mr. Mayhew thanks for your writings, they provide many great facts to use in discussions with my right wing friends, they hate it.

  19. 19.

    Brachiator

    December 6, 2016 at 11:38 am

    @Jack the Second:

    What’s your problem with Calvin?

    Some people prefer Calvin to Hobbes.

  20. 20.

    John M. Burt

    December 6, 2016 at 11:43 am

    It is an unfortunate reality that priorities for coverage under TrumpCare* will have almost nothing to do with cost vs. benefit or public benefit.

    *He will insist that his name literally be on it, his company logo in gold lettering on a literal card, even though it will actually be PenceCare.

    @Botsplainer: I am now picturing a visitor bringing a stake which bears a plaque reading “For the Convenience of Those Wishing to Pay Their Respects”, and hanging from it a roll of toilet paper.
    And then leaving in as much haste as propriety allows….

  21. 21.

    Brachiator

    December 6, 2016 at 11:48 am

    @cmorenc:

    Griswold v Connecticut’s constitutional “privacy” protections for personal choice (and access to) contraception.

    I’m not quite sure what a modern attack on Griswold would be like. Here, the Court would have to resurrect the old argument that states had an affirmative role in promoting families and ensuring that, whenever possible, heterosexual married couples make babies when they have sex.

  22. 22.

    Davis X. Machina

    December 6, 2016 at 11:51 am

    How do you sell ‘public health’ in a country where half the political nation doesn’t think the word ‘public’ has any actually-existing referent? Or any social provision when half the political nation doesn’t believe that a ‘society’ is an actually-existing thing?

    One man’s well-considered piece of legislation is another man’s category error…..

  23. 23.

    Mnemosyne

    December 6, 2016 at 1:50 pm

    @Brachiator:

    The argument would be that the Pill causes abortions, and life begins at conception, so therefore state legislatures would be allowed to ban the Pill and other “abortifacient” methods to “protect life.”

    Of course, the Pill doesn’t cause abortions and never has, but we’re in a post-science time now where the facts don’t matter as long as legislators feel that’s what the Pill does.

  24. 24.

    cmorenc

    December 6, 2016 at 2:37 pm

    @Brachiator:

    I’m not quite sure what a modern attack on Griswold would be like. Here, the Court would have to resurrect the old argument that states had an affirmative role in promoting families and ensuring that, whenever possible, heterosexual married couples make babies when they have sex.

    No, the argument for a hard-core “originalist” majority on SCOTUS is far simpler and more straightforward than that – along the lines Justices Black argued in his dissent in the Griswold case. Which is: that the right to privacy (on which the right to contraception was based in Griswold) is nowhere to be found in the Constitution, and purporting to find such amounts to creating the sort of unsound open-ended “substantive due process” invention indulged by SCOTUS in the infamous 1905 decision, Lochner v New York (state legislation limiting employee working hours violated freedom of contract).

  25. 25.

    Jay S

    December 6, 2016 at 2:51 pm

    Part of the vaccine discussion should involve effectiveness of various types of vaccines and how that affects the perception and reality of public vrs private benefit of vaccination. Current mumps outbreaks news reports are indicating most of the cases were current with MMR, and I have heard arguments from relatives that because flu vaccines didn’t seem to stop people from getting flu there wasn’t much point in getting their family vaccinated. I would guess that the more effective a vaccine the greater the private incentive whereas less effective vaccines would be less a personal benefit than a society benefit.

  26. 26.

    Mnemosyne

    December 6, 2016 at 4:56 pm

    @Jay S:

    The problem is partly that people don’t entirely understand herd immunity: if not enough people in the “herd” get vaccinated, then the disease can spread even among those who have been vaccinated. Basically, once an epidemic starts, the vaccine can only do so much, though it usually does a decent job of shortening the course of the disease.

    Then you add in the folks who received the vaccine but their bodies didn’t create the antibodies for some reason, the folks who got a bad batch, and the folks who thought they were vaccinated but actually weren’t, mix them with the unvaccinated and — voila! Mumps epidemic.

    (Note: IANA scientist, but actual scientists have explained this to me. Any errors are sure to be my own.)

  27. 27.

    Jay S

    December 6, 2016 at 7:50 pm

    @Mnemosyne: Nope, while many may not understand herd immunity, some don’t think of themselves as part of the herd. Sometimes the risk ends up close enough to home to change that.
    What I am asking about is how to personalize and analyse the risk. Understanding that people experience vaccine failures personally means that they need a lot of faith in statistics to believe that they make a difference and even then unless they see something to lose they may not bother to get vaccinated.
    Perhaps the best we can do is change them from being anti-vax promoters.

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