Category: Medicine
If only we had the will do this
If Democrats want to avoid this headache, they could follow the recommendation of my American Prospect colleague Paul Starr. Instead of fining those who go without insurance, Starr has proposed that "For five years they would become ineligible for federal subsidies for health insurance and, if they did buy coverage, no insurer would have to cover a pre-existing condition of theirs." They would not be fined for avoiding the new system, but neither could they benefit from or exploit it. This period of ineligibility, Starr adds, "deters opportunistic switches in and out of the public funds, and it helps to prevent the private insurers from cherry-picking healthy people and driving up insurance costs in the public sector."
Of course you can generalize that idea just a bit further.
I hadn't known the Senate version of the bill has a fine of only $95 for the first year; somehow I had thought it was $200 or so. (As Jeff Ely indicated, who said there's no public option?) How, politically, will the fine be amended? Will the Democrats call for change, the Republicans will cynically oppse it, and what? What if the Republicans run at least one house of Congress? Will they be willing to improve the operation of the program? Why should anyone sign up?
Very good sentences
"A Shanghai hospital cultivated and reintroduced human brain tissue in 2002 after taking a sample from the end of a chopstick implanted in a patient's frontal lobe following a disagreement at a restaurant."
The article, on scientific, medical, and regenerative research in China, is interesting throughout. For the pointer, I thank MR commentator JamieNYC.
Innovative Solutions to the Shortage of Transplant Organs
Millions of people suffer from kidney disease, but in 2007 there were just 64,606 kidney-transplant operations in the entire world.
Today in the WSJ I discuss innovative solutions to the worldwide shortage of transplant organs from places like Iran, India, Singapore, Israel and elsewhere. One interesting bit I haven't blogged about before is routine removal of organs without the donor's or their families consent. China? No. America. It's been legal here for decades.
In a number of U.S. states, medical examiners conducting autopsies may and do harvest corneas with little or no family notification. (By the time of autopsy, it is too late to harvest organs such as kidneys.) Few people know about routine removal statutes and perhaps because of this, these laws have effectively increased cornea transplants.
Here is another bit on the shadowy definition of death:
Organs can be taken from deceased donors only after they have been declared dead, but where is the line between life and death? Philosophers have been debating the dividing line between baldness and nonbaldness for over 2,000 years, so there is little hope that the dividing line between life and death will ever be agreed upon. Indeed, the great paradox of deceased donation is that we must draw the line between life and death precisely where we cannot be sure of the answer, because the line must lie where the donor is dead but the donor's organs are not.
In 1968 the Journal of the American Medical Association published its criteria for brain death. But reduced crime and better automobile safety have led to fewer potential brain-dead donors than in the past. Now, greater attention is being given to donation after cardiac death: no heart beat for two to five minutes (protocols differ) after the heart stops beating spontaneously. Both standards are controversial–the surgeon who performed the first heart transplant from a brain-dead donor in 1968 was threatened with prosecution, as have been some surgeons using donation after cardiac death. Despite the controversy, donation after cardiac death more than tripled between 2002 and 2006, when it accounted for about 8% of all deceased donors nationwide. In some regions, that figure is up to 20%.
More on markets for organs, presumed consent, and point systems at the WSJ,
The trials of Tony Judt
This is an excellent piece, excerpt:
The standing ovation was tremendous. "I was initially shocked by the disjunction between his intellectual capacity, which is completely undiminished and in many respects unequaled, and the physical degradation," says Richard Wolin, a professor of history at the Graduate Center of the City University of New York, who was in the audience. "But after five minutes, I lost sight of any physicality and focused on his words and their importance." He adds, "It was one of the most moving scenes I have ever witnessed."
Here is my previous post on Tony Judt.
Markets in Everything: Placebos
Is there any drug that helps more conditions with less risk than a placebo? Now you can buy placebos. The site actually has some good information about placebo studies.
Hat tip: Metafilter.
Moving essay by Tony Judt on ALS
During the day I can at least request a scratch, an adjustment, a drink, or simply a gratuitous re-placement of my limbs–since enforced stillness for hours on end is not only physically uncomfortable but psychologically close to intolerable. It is not as though you lose the desire to stretch, to bend, to stand or lie or run or even exercise. But when the urge comes over you there is nothing–nothing–that you can do except seek some tiny substitute or else find a way to suppress the thought and the accompanying muscle memory.
But then comes the night. I leave bedtime until the last possible moment compatible with my nurse's need for sleep. Once I have been "prepared" for bed I am rolled into the bedroom in the wheelchair where I have spent the past eighteen hours. With some difficulty (despite my reduced height, mass, and bulk I am still a substantial dead weight for even a strong man to shift) I am maneuvered onto my cot. I am sat upright at an angle of some 110° and wedged into place with folded towels and pillows, my left leg in particular turned out ballet-like to compensate for its propensity to collapse inward. This process requires considerable concentration. If I allow a stray limb to be mis-placed, or fail to insist on having my midriff carefully aligned with legs and head, I shall suffer the agonies of the damned later in the night.
Read the whole thing. I thank The Browser for the pointer. Here is previous MR coverage of Tony Judt, an excellent thinker and writer.
Transparency in health care pricing doesn’t come easily
The health care reform bill before the U.S. Senate would require hospitals to publicize their standard charges for services, but New Hampshire and Maine have gone much further in trying to make health care costs more transparent to consumers.
New Hampshire and Maine are the only states with Web sites that let consumers compare costs based on insurance claims paid there.
In New Hampshire, the price variation across providers hasn't lessened since the Web site went live in 2007.
The link is here. You'll find the background data from New Hampshire, and a study, here. Here are some anecdotal accounts. Here is a CBO background paper on the topic. I can think of a few hypotheses:
1. People don't check the website.
2. People can't interpret the information on the website.
3. People still go where their doctors recommend or to facilities they are familiar with.
4. Many local choices, especially in these states (somewhat rural, so-so road connections), don't involve a lot of competition.
5. All of the above.
Other?
No Give, No Take in Israel
In January, Israel will become the first country in the world to give people who sign their organ donor cards points pushing them up the transplant list should they one day need a transplant. Points will also be given to transplant candidates whose first-degree relatives have signed their organ donor cars or whose first-degree relatives were organ donors.
In the case of kidneys, for example, two points (on a 0-18 point scale) will be given if the candidate had three or more years previous to being listed signed their organ card. One point will be given if a first-degree relative had signed and 3.5 points if a first-degree relative had previously donated.
In Entrepreneurial Economics I argued for a point allocation system like this–which I called a "no give, no take" system–as a way to increase the incentive to sign one's organ donor card. One advantage of a no-give, no take system over paying for organs is that most people find this type of system to be fair and just–those who are willing to give are the first to receive should they one day be in in need.
The new policy will be widely advertised in Israel and will be transitioned into place beginning in January. I think this new policy is very important. If organ donation rates increase in Israel, I expect that other countries will quickly follow suit.
By the way, is it peculiar that the two countries in the world with the best organ donor systems are now Israel and Iran?
Hat tip to Dave Undis whose Lifesharers group (I am an advisor) is working on implementing a similar system in the United States.
How the penalties will work
This has changed a number of times and I've been wondering where it was at. Ezra Klein now reports:
If you don't have employer-based coverage, Medicare, Medicaid, or anything else, and premiums won't cost more than 8 percent of your monthly income, and you refuse to purchase insurance, at that point, you will be assessed a penalty of up to 2 percent of your annual income. In return for that, you get guaranteed treatment at hospitals and an insurance system that allows you to purchase full coverage the moment you decide you actually need it. In the current system, if you don't buy insurance, and then find you need it, you'll likely never be able to buy insurance again. There's a very good case to be made, in fact, that paying the 2 percent penalty is the best deal in the bill.
Ezra Klein is happy
I hadn't heard of this before but it seems good:
Page 12:
Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups.
Pricing transparency!
How bad is it to be uninsured today?
Ezra Klein raised a big stir by suggesting that the possible failure of the health care bill will cost a large number of lives; he cited a figure of 20,000 per year. (You'll find pushback from Michael Cannon on the number.)
Rather than disputing the number, my question is a simpler one. Let's say the figure were a correct one. How would you fill in the following blank?:
"Being uninsured in 2009 is, in terms of life expectancy, as bad as being insured in the earlier year ????"
What is the correct year for this comparison to hold?
Simply knowing the correct year is my main concern in this post, but there is an additional angle. Twenty years from now there will also be some uninsured Americans, even if the current bill passes. There will be pleas to help them. If you wish to help them, does that mean that the insured today also deserve additional health care subsidies? Or is the whole comparison just about equality? How about caring about inequality across time? If you favor additional subsidies for the uninsured today, are you also committed to wishing there had been additional subsidies for the insured back in year ????
I thank Bryan Caplan for a useful conversation related to this blog post.
Chris Blattman on why aid seems to fail
Aid, if it achieves the UN’s goals, is often saving the lives of the poorest. In this respect, we can say aid has been successful. And it is this very success that could explain why we don’t see any effect on growth. In fact, for the first few decades of aid, it’s conceivable that it would appear to reduce per capita income growth.
If aid saves the lives of millions of poor infants, or mothers in childbirth, at roughly the same rate a country can industrialize, then we’ll see an increase in the number of poor people at about the same rate that we increase GDP per person. Unless aid is also spurring faster industrial growth, the growth figures essentially won’t change. The things that aid does well–increasing primary education, saving lives, and leading to a demographic transition (essentially lower population growth–may reasonably take a generation or two to impact industry.
So if aid has been good at saving lives now, but not (in the short term) at spurring industry, then we shouldn’t be surprised that we don’t see take-offs. Rather, in most countries aid might actually lower the short term, measured number.
But by almost any measure, though, aid would still be a huge success. Maybe the “failure of aid” is really a failure to industrialize, disguised.
The link is here. Lately I've been trying to think through the opposite point. How many uninsured do they have in China? Over a billion? Letting a lot of sick people die, or simply not treating them much, can help your per capita growth statistics. If you don't take individual preferences to have value in their own right, but simply wish to maximize measured growth per capita, you'll value human life at something like replacement cost.
Joseph Rago on health care
This passage (full article here) strikes me as something Arnold Kling would link to:
Take the nearly $47 billion in stimulus cash the White House has budgeted to prime the pump for health IT adoption. Mr. Bush says he's glad his industry is getting more attention from the bully pulpit, but that "It is kind of too bad that all these software companies that we're really close to putting out of business, these terrible legacy companies, with code that was written in the '70s, are going to get life support. That's why I call it the Sunny von Bülow bill. What it is, basically, is a federally sponsored sale on old-fashioned software."
"It's designed like a box-buying campaign," he continues. "You get this fixed chunk of money for a few years, you get to pay off your EMR, like its a thing. People in Washington think in terms of things that we'll buy and then they'll be there. Buildings. Roads. Tanks. What Lockheed Martin makes. Things.
"And this isn't that. This is a market: its a set of agreements, it's a language. What's needed is a way of exchanging value and making choices, that's ethical–and, you know, nobody, nobody, not nobody, has said a word about that.
Here is Rago on Medicaid:
State Medicaid programs, by the way, are easily the worst payers, according to Athena's annual ranking. In New York, for instance, claims must be tendered on a dead-tree form instead of electronically and in blue ink–black is grounds for rejection–and then go on to spend a full 161 days, or almost a half year, in accounts receivable.
I thank Yana for the pointer.
The endgame?
…the exchanges will get much bigger over time. Part of what’s going on in the United States is that the employer-based health insurance system is slowly unraveling. Both the House and Senate versions of reform consist not only of using exchanges to cover the currently uninsured, but also using exchanges to construct a kind of safety net so that as employer-based insurance continues to unravel, people will land softly in exchangeland rather than crashing into the rough ground of the current individual insurance market. The Senate bill will slightly accelerate the decline of employer-based insurance by slowly phasing out the tax subsidy for such insurance.
That is Matt Yglesias, here is more. Of course if this is true — and it may well be — the composition and nature of the exchanges means everything.
The Federal Employee Health Benefits Plan
Walton Francis has a new and very substantive book on health care policy, with the exciting title: Putting Medicare Consumers in Charge: Lessons from the FEHBP. It starts with a simple premise:
During the last half-century, the United States has operated a half-dozen major health-care financing systems in parallel, each operating in its own world, and with only minimal attempts to observe and learn lessons in program A that could be useful in program B.
Francis studies one of these programs, namely FEHBP, in detail. He portrays FEHBP as "premium support" in contrast to the "defined benefit" approach of Medicare. On top of it all are competing private insurance plans and the details of the plan you end up with are decided by competition, combined with some regulation. I now think of FEHBP as a somewhat indirect voucher scheme, albeit with complications. Francis argues that FEHBP is a better model for health care reform than is Medicare and that FEHBP is better for both offering diverse programs and inducing cost control. The employee pays about a quarter of the price and FEHBP also covers many retirees, apparently with reasonable success. Here is Wikipedia on FEHBP. Here is the program's own home page and it does I should add touch the Cowen family.
One question I have is what FEHBP would look like when scaled up to an entire country, including to people who have never had enough human capital to work for the U.S. government. (Here is one critique of a scaled-up FEHBP but I don't find it so convincing, at least not compared to the problems with other approaches.) Still, this book is essential reading for anyone interested in health care policy. I can't call it exciting, but it is a model of clarity and substance throughout.
Here is one report, from last night, that a modified version of the FEHBP idea will be substituted in for the public option. I don't yet have reliable details on what this might mean, or who it might cover (just the people on the exchanges?) but that is why I am accelerating this post even though I do not have fully formed thoughts on FEHBP as a model for broader reform.
Addendum: Michael Tanner offers related comments.