I’m not sure I’m ready for 20 — if not God forbid 68 or 116 — months of Scott Walker. Are you?
Costs and value
Ezra Klein is pushing back against the Healthcare Reform 2.0 talk with an interesting and I think wrong post at Vox.
both parties agree that the biggest problem in American health care is cost. The closest thing Republicans have to a health-care plan — Rep. Paul Ryan’s budget — is focused on cutting costs. Now leading Democrats tell Sarah Kliff that now that Obamacare is up-and-running they’re going to turn their attention to cost. It’s as if the point of having a health-care system is to spend less on it.
But both parties are wrong. Cost is not the biggest problem in America’s health-care system. Value is….
take Obamacare’s surprising success holding down premiums in its private insurance offerings. The innovation there is “narrower networks“: insurers are regulating where people can go for care more tightly. That cuts costs by cutting access to expensive providers. But while I think narrower networks are a good idea, there’s no evidence that they improve quality….
Value is defined as stuff divided by price of that stuff. In the framework that Klein is using, value is health divided by the cost of achieving that health. I think he is missing two very big things in his argument.
Reducing the denominator, in this case the cost of services by increasingly using narrow networks to exclude very high cost providers reduces costs. He is arguing that narrow networks for them to improve value have to also increase the numerator. That is a quick sleight of hand. So far all of the evidence has shown that narrow networks have the same value. As a basic matter of math, holding the numerator constant while shrinking the denominator makes the dividend bigger.
My six year is trying to teach herself long division and this basic concept is blowing her mind.
Secondly, and this is the more disappointing thing as I know Ezra knows better (given how much he was in love with Quality Health Partners at WonkBlog) but PPACA and the Centers for Medicare and Medicaid (CMS) have plenty of experiments that are seeking to improve total health at either budget neutral or budget positive terms. I know on the ACO models are aggressively trying to increase health while also decreasing costs. Some are succeeding at both counts while plenty more are succeeding at holding quality constant at lower costs. I know the Medicare penalities for re-admissions have been driving better health and lower costs. I know other care coordination efforts are ongoing; some will work, some will muddle through and others will be failures, but there are plenty of attempts to move both the end product (better health) and cost needles in oppositive and improving directions.
Will they all work? No, but there is a consensus that the value proposition for American medicine sucks, and plenty of ideas to change that value proposition so value increases by either better health, lower costs or both.
Athletics as a luxury good….
My soccer assignor called me last night. The Regional league is starting soon (or it will once temperatures gets back into the 20s), and they need referees. This league has teams driving six or eight hours for a pair of games on Saturday, stay overnight and then play one more on Sunday morning before driving back home. I like to ref this league as the teams are composed of highly skilled players with good coaches, so the games involve a lot of running, but they are predictable. Players put the ball where the ball should go, and they don’t randomly attempt to take out people’s knees. The fouls which occur make sense. The best teams will dress eighteen players of which fifteen or more will get some scholarship money to play in college. Unless I am laid off and go on the elite showcase tournament circuit to referee, this is the best youth soccer that I will see this year.
That league is overwhelmingly composed of middle and upper middle class white players coming from stable, two income, two parent homes. I know that is not a representative sample of where the US soccer talent pool lies as I’ll see local travel teams that are a whole lot poorer, a whole lot less white, and a whole lot more unstable in their home situations which could run with most of the Regional teams if they could afford to organize bi-monthly bus trips to another state to play. And those kids get forgotten unless they are so unbelievable that one of the Regional teams sponsors the kid to be the best player on the field. One of the local Regional league teams does that with a current high school All-American who has a full ride on offer from half a dozen elite NCAA schools which he may turn down in order to go to a European B-league. If a kid is “just” talented enough to be a solid Division 2 half scholarship player, but can’t afford the $5,000 a year in travelling expenses, they probably aren’t playing on a Regional league team which will help them get that D-2 scholarship.
Andrew McCutchen of the Pittsburgh Pirates makes the same point on baseball — in the US, it is becoming a middle class sport as the breeding ground of future high level players:
But all the scraping and saving in the world wasn’t going to be enough for my family to send me an hour north to Lakeland every weekend to play against the best competition. That’s the challenge for families today. It’s not about the $100 bat. It’s about the $100-a-night motel room and the $30 gas money and the $300 tournament fee. There’s a huge financing gap to get a child to that next level where they might be seen.
I’m complicit in this cost structure as referees aren’t cheap, and refs are incorporated into the tournament fee, but sports at anything more than “here is a ball, chase it” level of play is increasingly a luxury good.
Repeat after me
Single Payer is not an option if the Roberts Court decides to turn their back on several generations of administrative law precedent to gut PPACA in two thirds of the country.
Commenter Tripod thinks it is a viable option, and is extremely wrong:
The political answer is to start saying single payer over and over. Obama tried the Republican way, they blew it up, now they get to enjoy a socialist fisting.
My question to single payer advocates is how to get to 218 and 51 if I am being generous and if I am being an ass, 218 and 60. Progressive change is hard in this country both because of the multiple veto points in the system and the general way that representatives are elected. Building a pathway for a single payer majority is damn difficult, and I just don’t see it as a feasible choice set in under a decade and more likely single payer will happen as soon as commercial fusion will — just another thirty years.
Let’s make the following assumptions based on history.
Scope and hope
Brad Delong is puzzled about the state of healthcare discourse in this country and he looks at a former Heritage bigwig for his puzzlement:
Can someone point me to something Stuart Butler has written in the past three years that has turned out to be correct?
I mean, it seems to be blinkered, partisan, wrong–and obviously wrong at the time, both in its analysis of the political forces and of the policy substance…..when I look at what Stuart Butler is writing today, I see no talk about how his root-and-branch opposition to Medicaid expansion, unwarranted budgetary and health-care spending-growth pessimism, and belief that the politics were still favorable for ACA repeal were all misjudgments. I see no talk about how the fact that the world has turned out to be a different place from what he claimed it was back in 2012 and 2013 has led him to rethink.
As a historical note, 2001 to 2015 contains an interesting case study of policy implementation and formulation by reactionaries and liberals in the United States. The liberal policy project was to greatly expand health insurance coverage while reducing total societal cost growth of health care spending. The conservative goal was to break and remake Iraq. One is succeeding, the other is a Hydra headed cluster-fuck.
The project that is successful in its stated goals was built from an effective pilot case (Massachusetts) in a shared cultural and political mileau. It took elements of a known society activity (private health insurance) and tweaked it a bit but not too much. The policy makers saw that subsidized private insurance worked in the S-CHIP program, it worked in Medicare Advantage, it worked in Massachusetts, it was just brought to scale. The other major component of coverage expansion was Medicaid expansion where the greatest barrier to expansion would literally be ordering sufficient ID card stock in some states. Other elements of the plan have significant structural impacts (guarantee issue, community rating etc) but those elements have a history of both policy examples and judicious study by experts who were listened to.
Have there been problems… yes, but the basic analytical insight that this is a fairly straightforward build out of tested programs and things can be muddled through as problems emerge. And that is basically what has happened.
The conservative big policy project was the invasion of Iraq with the goal of making it a Heritage Foundation designed paradise. Experts who knew better were shunted aside, evidence was ignored, interns who were ideologically reliable were given tasks of rebuilding foreign institutions where the local stakeholders were ignored, and the project was managed for television and not reality. Purple fingers were far more important than actual governance and institution building.
Basically any one who cheerleaded for the invasion of Iraq and believed that there was exclusively Good News ™ and painted schools in Iraq for the first decade of this century and then argues that a fairly straightforward health care coverage expansion is impossible should be ignored as they’ve proven that they have anti-judgement.
Brrrraaaaaiiiiiiinnnnssss…
Or rather…
MMMMMorrrrrronnnnns:
The reanimated corpse of Dr. Jonas Salk, the medical researcher who developed the first polio vaccine, rose from the grave Friday morning on what authorities believe is a mission to hunt down idiots.
The usual suspects beware.
Another drive-by post, but go read the whole of Andy Borowitz’s update to his eponymous report.* It’ll help your mood.
You’re welcome.
*Yes. I did put this post up solely for the purpose of getting to type “eponymous.” It’s the little pleasures…
Image: Antoine Wiertz, The Premature Burial, 1854.
Cause and effect in Louisiana
A major hospital in Baton Rouge, Louisiana is closing its emergency room because it is hemorrhaging money:
Baton Rouge General Medical Center-Mid City will close its emergency room within the next 60 days, a victim of continuing red ink and the Jindal administration withdrawing the financial support that kept it open….
The closest emergency rooms from Baton Rouge General’s Mid City campus is Lane Regional Medical Center, 30 minutes to the north in Zachary, and Our Lady of the Lake Regional Medical Center, 30 minutes to the south on Essen Lane. Mid-City’s ER recorded 45,000 patient visits last year…..
More and more poor and uninsured patients from the low-income neighborhoods of north Baton Rouge ended up at the Mid City hospital, which was the next-closest facility.
Mid City hospital reported losses of $1 million a month as more and more patients who could not pay arrived…. Officials projected losses would grow larger, reaching $25 million to $30 million in 2015.
Poor people can’t pay full freight nor are they likely to be covered by insurance. There just happens to be an extremely attractive offer to get lots of poor people covered by insurance. Medicaid expansion would help safety net hospitals in high poverty areas the most. Poor people covered by insurance will either be able to pay something towards their emergency room visits or divert to lower levels of appropropriate care.