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By John Goodman
Health Affairs Blog
March 19, 2009

Here is a paper (link below) with as many as 100 references that you almost never see cited in Health Affairs, or in the Journal of the American Medical Association (JAMA), or in the New England Journal of Medicine (at least not in their public policy articles). In fact, if you are a regular reader of these publications, I think you are going to be very surprised.

My colleagues Linda Gorman, Devon Herrick, Robert Sade and I discovered that public policy articles in the leading health journals (especially the health policy journals) tend to cite poorly done studies over and over again in support of two propositions: (1) Our health care system needs radical reform and (2) the reform needs to be modeled along the lines of the systems of other developed countries. At the same time, these articles tend to ignore contravening studies that are often published in economics journals and subject to much more rigorous peer review.

In our rest-of-the-story literature review, we focus on eight questions:

1. Does the United States spend too much on health care?

2. Are U.S. outcomes no better and in some respects worse than those of other nations?

3. Is the large number of uninsured in the U.S. a crisis?

4. Does lack of health insurance cause premature death?

5. Are medical bills causing bankruptcy?

6. Are administrative costs higher for private insurance than public insurance?

7. Are low-income families more disadvantaged in the U.S. system?

8. Can the free market work in health care?

****

Response to “The U.S. Health System: The Rest Of The Story”

By Don McCanne

John Goodman says that he wants us to hear the rest of the story, but then he doesn’t tell it to us.

He and his colleagues have pieced together a document using classic Goodman rhetorical deceptions. They pull out of the literature isolated items that support their position without identifying them as exceptions to the great body of information available in the health policy literature. They repeat the use of many studies that have been discredited as manipulations or distortions based on libertarian ideology, even though they are aware of the highly credible challenges to those reports. They use silly diversions to attack some of the most solid and important studies in the health policy literature. Patching these deceptions together creates magical conclusions that would seem to refute the most fundamental principles that can be gleaned from a couple of decades of solid health policy science research.

Using health policy reports retrieved from the refuse bin, they then end with the conclusion that we should adopt their favored proposal for reform, health savings accounts, a non sequitur to the specious arguments they have presented. Even though the policy community has dismissed HSAs as a serious response to the tragic dysfunction of our health care system and its financing mechanisms, the authors persist in abandoning their academic purity in pushing their cause.

“The Rest of the Story” might appeal to ideologues, but it is repulsive to those of us who are outraged by the the physical suffering and financial hardship faced by the millions of U.S. residents who are victims of a flawed financing system, unable to afford or receive the care that they need in a $2.5 trillion health care industry.

http://healthaffairs.org/blog/2009/03/19/the-us-health-system-the-rest-of-the-story/comment-page-1/#comment-24954

Paper on health care reform by John Goodman et al:
http://www.ncpa.org/pdfs/sp_Do_Other_Countries_Have_the_Answers.pdf

by Jonathan B. Oberlander and Barbara Lyons
Health Affairs
March 17, 2009

Given the enormous political and fiscal barriers to adopting legislation that aims for universal or near-universal coverage, it could be tempting for Congress and the Obama administration to follow the expansion of children’s health insurance with further incremental measures. The political appeal of such a strategy is understandable: maximizing consensus on incremental policies while avoiding harder, more polarizing, and more expensive reforms is a time-tested strategy in U.S. health policy. Indeed, it is the exact political formula that produced SCHIP’s enactment in 1997. Advocates of incrementalism have long recognized that political constraints mean that the alternative to imperfect, limited reforms is, alas, often to do nothing. In that context, incrementalism looks quite appealing–a fallback position seemingly validated by the repeated failure of big-bang reform.

Yet there are real limits to incremental health reform. After all, despite gains in Medicaid and SCHIP, almost nine million children remain uninsured. The insurance system for children, notwithstanding their sympathetic status, is beset by the same problems that plague the rest of the U.S. health care system: fragmentation, inequality, and alarming coverage gaps. It is a sobering reminder of just how far the country has to go in health reform that we have not been able to secure universal coverage even for children.

There are also limits to a health reform strategy premised on demographic incrementalism that insures Americans group by group. Unlike children or the elderly, most uninsured Americans do not fit into sympathetic population subgroups that can be neatly matched to public programs. The SCHIP formula can only take us so far, since “all the ‘good’ (that is, politically attractive) populations are taken.” To make significant progress toward covering all Americans, we will have to adopt insurance expansions that don’t simply target politically attractive populations.

If the past decade has proved anything in American health policy, it is that incrementalism is not enough. A decade of incrementalism and inaction has left us with higher costs and rising numbers of uninsured Americans; absent decisive action, those trends will only worsen in coming years. It is encouraging, then, that both the Obama administration and key players in Congress are now pursuing bolder reforms. Perhaps we are entering a new era where U.S. health policy will finally move beyond incrementalism.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w399v1

Comment:

By Don McCanne, MD

Incrementalism: the crossroads of policy and politics.

When each attempt at comprehensive reform fails, the usual response is for everyone to walk away. A few come back to try to retrieve whatever little bit that seems to be politically feasible.

The path of incrementalism has failed to slow the increase in costs and has resulted in increases in the numbers of uninsured and now greater increases in the underinsured. Lauding the mini-successes rings hollow when the health care system continues to have “fragmentation, inequality, and alarming coverage gaps.” By any reasonable standard, incrementalism has been a miserable policy failure.

The incrementalists tell us that the Children’s Health Insurance Program (CHIP) shows us that incrementalism can be a very successful approach to reform. There is no question that this program has been beneficial at least for those children covered. The primary detriment is that it reduced the political pressure for more comprehensive reform.

As the authors point out, children are perhaps the most attractive group for demographic incrementalism. It passes the test of politics, but fails on policy. The CHIP program that “covers all children” has left 9 million children without coverage, perpetuating “fragmentation, inequality, and alarming coverage gaps” for children! The very best incremental program that we have enacted in the past four decades has fallen far short of our goals for reform because beneficial policies were traded away in the politics of reform.

We are now at a rare moment in time when the politics seem aligned so that we can set aside incremental approaches for the time being and seriously consider comprehensive reform. The difficulty is that those leading the reform process are already abandoning important beneficial policies in what they believe will be a successful strategy to keep the politics aligned.

Let’s look at one important example. In their article, Oberlander and Lyons describe the fight over “crowd out,” the concept that, as you raise the qualifying income level for a government children’s insurance program, you increase the number of children that will move from private health plans to the public program that provides a better value. The qualifying income level is very problematic because it is middle-income families that have incomes too high to qualify for the program yet too low to readily afford private insurance. Although the opposition to crowd out could be perceived as an attempt to protect the private insurance industry, the policy principle is much more fundamental.

As the authors explain, “The SCHIP debate revolved around the same boundary issues that will determine the fate of comprehensive reform in 2009 and beyond: the balance between public and private insurance, who should be eligible for government subsidies and at what income level, whether health care is an individual responsibility or social good. Those issues are far from resolved.”

So… the intersection of policy and politics. Those who are leading the reform process and who should believe that health care is a social good are supporting policies that will leave the private insurers in charge, invoking the politics of appeasement to satisfy those who believe that health care is an individual responsibility.

If we are going to achieve our goals of affordable, high quality health care for everyone, it is absolutely imperative that we adopt policies that advance health care as a social good. Policies that shift the responsibility to the individual will further increase our problems with fragmentation, inequality, and alarming coverage gaps.

Whether following a path of incrementalism or the enactment of comprehensive reform, this political divide will never go away. Appeasement politics will always be ruinous for the social good of health care.

The bottom line: The politics must support the policies of health care as a social good, with no compromise. The battle must continue until it is successfully executed. Perceptions of defeat are only perceptions. That is not the time to walk away and eventually crawl back on the ragged path of incrementalism. We must continue the charge, no matter the battle scars, until we achieve health care justice for all. Our finances, our health, and our lives depend on it.

By David J. Lee, PhD; Byron L. Lam, MD; Sahel Arora, BS; Kristopher L. Arheart, EdD; Kathryn E. McCollister, PhD; D. Diane Zheng, MS; Sharon L. Christ, MS; Evelyn P. Davila, MPH
Archives of Ophthalmology
March 2009

The association between low eye care utilization rates and lack of, or inconsistent, health insurance coverage, even after adjustment for income and educational attainment, suggests that overall ocular health care access would be enhanced if progress is made toward securing coverage for the 46.6 million Americans who do not currently have health insurance. Our findings have also identified troubling gaps in eye care utilization among adults with health insurance coverage. Adults who reported an interruption in health insurance coverage in the 12 months prior to the interview were less likely to report a visit to an ocular health care provider than were those who were consistently insured. In our analyses, 3.8% or an estimated 7.8 million US community-residing adults annually reported such a coverage gap in the past 12 months.

We also found that adults who reported concurrent private and public health care coverage were generally more likely to report an ocular health care visit in the preceding 12 months than were adults who had private insurance only, even after adjustment for level of visual impairment, sex, and educational attainment. The NHIS (National Health Interview Survey) did not assess whether ocular care was included as part of the participants’ insurance coverage. It is nevertheless possible that public coverage filled in some of the well-known gaps in ocular health care coverage of many of the private health care plans offered in the United States. For example, Medicare and Medicaid typically include basic eye care services, such as annual eye examinations. Our findings point to the need for addressing the coverage limitations for ocular care in private insurance plans as well as addressing the broader need for health insurance for all Americans.

http://archopht.ama-assn.org/cgi/content/full/127/3/303

And…

Is Universal Vision Care Coverage the Best Way to Get People to See Their Eye Care Providers?

By Steven M. Kymes, PhD, MHA; Kevin D. Frick, PhD
Archives of Ophthalmology
March, 2009

In this issue of Archives, Lee et al present a report on the relationship between insurance coverage and recommended visits to ophthalmologists or optometrists. They find several important predictors of such visits, one of which is health insurance coverage. In their conclusion, they call upon vision care professionals to assume a role as advocates for universal health insurance coverage, in particular vision care insurance, for all Americans. They assert that providing universal vision care coverage would insure that financial resources are no longer a barrier for those seeking access to a vision care provider. However, we must also consider whether this would indeed be the most effective method to achieve the social goal of increased use of vision care services.

It is important to recognize that if we as a society provide universal health insurance coverage, it would not come without a cost.

(The authors then provide a highly dubious analysis that purports to show that “our health care system would pay $435 in annual insurance coverage for each new person who is motivated to seek vision care.”)

There is no doubt that providing preventive vision care services is important, as is providing care for those with chronic eye conditions. But before taking this step, we should ask if the benefit of spending $435 to motivate someone to seek an annual visit to their eye care provider outweighs the cost. Answering the question would involve a rigorous evaluation of the benefits of the ocular examination. What is the probability that an undiagnosed ocular condition will be found? What is the benefit of identifying that condition in reducing future health care costs? What is the benefit of regular examinations of people with chronic eye conditions in adjusting treatment strategies, insuring compliance, and making referrals for specialized care? By asking such questions, we can determine the balance between costs and benefits. The results would help policymakers and physicians to determine if providing insurance coverage would indeed be the best approach to promoting vision care or if other methods of improving access should be considered.

Lee and colleagues have made an important contribution to this growing literature by examining barriers to vision care. However, the principles of scientific inquiry should not be shortchanged simply because we are debating a policy question rather than a biochemical one. The vision care community has an obligation to fully consider alternative solutions and their consequences in seeking ways to remove barriers to vision care.

http://archopht.ama-assn.org/cgi/content/full/127/3/335

Comment:

By Don McCanne, MD

One single word, whether it’s “and” or “or,” can make such a difference in health policy.

This study confirms that what we already know about the importance of insurance in improving access and utilization of health care also applies specifically to eye care. Individuals with insurance have higher rates of access and utilization of eye care than those who are uninsured and those have have interruptions of their insurance coverage.

This study also indicates that those who have public coverage in addition to private coverage have significantly higher utilization rates than those who have private coverage alone. Public coverage seems to help fill in the gaps in private coverage.

The obvious policy conclusion is that everyone should be covered with health insurance that has adequate benefits, including eye care. Quite simple.

Apparently that is not the conclusion of the authors of the commentary on this study that appears in the same issue of Archives of Ophthalmology, a publication of the American Medical Association. To improve access to vision care, they do not suggest removing one of the more important barriers to care by providing everyone with health insurance. Without stating it explicitly, they imply that their estimate of a $435 premium (a straw man estimate) is too high of a price to pay for eye coverage. Instead they recommend the consideration of insurance coverage “or” the consideration of other methods of improving access. There is that all important “or” word, when most members of the policy community would have used “and.”

Just to indicate that this wasn’t simply a slip of words, they reinforce their view by stating that “the vision care community has an obligation to fully consider alternative solutions,” where “alternative” is another “or” word.

This study is a valuable contribution to the health policy literature, indicating, once again, that we must repair our health care financing system so that everyone has affordable access to all necessary health care. It is sad that there are those who continue to use garbage policy pseudo-science to battle the champions of health care justice. And it is especially tragic that they have continued to win.