By Katherine Baicker, Ph.D., and Amitabh Chandra, Ph.D.
The New England Journal of Medicine, December 21, 2017

In these times of heated rhetoric about what various health care reforms can and cannot accomplish, both hopeful and doomsday stories abound. Proponents and opponents of reforms often claim that their views are grounded in evidence, but it’s not always clear what they mean by that — particularly given the wide range of often incompatible views. Voters, physicians, and policymakers are left to wade through a jumble of anecdotes, aspirations, associations, and well-designed studies as they try to evaluate policy alternatives. Having a clear framework for characterizing what is, and isn’t, evidence-based health policy (EBHP) is a prerequisite for a rational approach to making policy choices, and it may even help focus the debate on the most promising approaches.

EBHP, we believe, has three essential characteristics. First, policies need to be well-specified; a slogan is not sufficient. For example, “expand Medicaid” isn’t a policy. “Expand existing Medicaid benefits to cover all adults below the poverty line” is closer — but, of course, moving to a specific, implementable program requires vastly more detail.

Second, implementing EBHP requires us to distinguish between policies and goals. This distinction is important in part because different people may have different goals for a particular policy.

Third, EBHP requires evidence of the magnitude of the effects of the policy, and obtaining such evidence is an inherently empirical endeavor. Introspection and theory are terrible ways to evaluate policy.

What makes for “rigorous enough evidence”? Professional medical societies have developed gauges of the strength of evidence to support clinical guidelines, and we should demand nothing less for health policy. No study is perfect, and important policy questions are rarely answered definitively by any one study. Nor does pointing to a large literature with similar results prove a point if those studies share a common weakness such as an inability to control for confounders.

There is also a key difference between “no evidence of effect” and “evidence of no effect.” The first is consistent with wide confidence intervals that include zero as well as some meaningful effects, whereas the latter refers to a precisely estimated zero that can rule out effects of meaningful magnitude. These nuances are often lost when “evidence” is deployed in policy debates.

The effect of a policy, of course, also depends on the design and implementation details and the program particulars, and evidence needs to speak to those particulars. It is also important to consider the full range of a policy’s effects — its costs and benefits, and how each of these evolves over time.

Making health policy on the basis of evidence will always be a fraught and uncertain endeavor, and each component we outline here comes with challenges.

In addition, just as the distinction between policies and goals is often muddied, interpretations of the evidence are often flavored by the implicit goals of the analyst.

Finally, even a rich body of evidence cannot guarantee that a policy will achieve its goals, and waiting for that level of certainty would paralyze the policy process. In health policy — as in any other realm — it is often necessary to act on the basis of the best evidence on hand, even when that evidence is not strong.

Just because something sounds true doesn’t mean that it is, and magical thinking won’t improve our health care system. EBHP helps separate facts from aspiration. But as important as evidence is to good policy choices, it can’t tell us what our goals should be — that’s a normative question of values and priorities. Better policy requires being both honest about our goals and clear-eyed about the evidence.

http://www.nejm.org…

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Comment:

By Don McCanne, M.D.

What role should evidence-based health policy play in the design of our system of health care financing? Before answering that, we need to decide what the goals are. Then we need to survey various policies that might achieve those goals. Finally we should look at the evidence as to how effective each of those policies might be. How are we doing?

Of course, the goals are most important. At PNHP we believe that everyone should have access to comprehensive health care that is of reasonable quality and is affordable – goals achievable only through the collective effort of government working with the public and private health care delivery system. Others believe that health care should be an individual responsibility thus they have a goal of minimizing the role of government. Obviously the selection of policies, whether evidence-based or not, would be quite different for these sharply divergent goals.

When you have a system that is designed to cover absolutely everyone, what evidence-based studies do you need to be sure everyone really is covered? Silly question – you don’t need any studies, everyone is automatically covered. Accessible? Regional planning with appropriate allocation of resources – no policy studies, you just do it. Comprehensive? Simply cover appropriate care (which might be guided by evidence-based health care studies, but you don’t need evidence-based policy studies). Affordable? Fund the system using progressive tax policies – you do not need an evidence-based policy study to show that those who can afford it need to pay more than those who can’t.

A prime example of placing evidence-based policy before goals is the classic RAND Health Insurance Experiment. That study showed that requiring cost sharing payments when receiving health care reduced total spending on health care. Although it is conceded that cost sharing (deductibles, copayments, or coinsurance) does reduce the use of beneficial health care, little attention has been paid to that. Instead, the policy of cost sharing, especially high deductibles, has been used for the goal of reducing spending, while ignoring the goal of affordable access to health care. This demonstrates why the goals are so much more important. This tradeoff satisfies the supporters of individual responsibility in health care but fails for those who support health care for everyone.

We are seeing a similar process with ACOs, MACRA, MIPS, APMs and other policies that supposedly replace volume with value, or quality instead of quantity. What are the goals? Although some lip service is given to quality, reduced spending is the real goal. The goals of health care justice as supported by PNHP are nowhere in sight. So we have moved forward in implementing these policies, but are they evidence-based? Many studies have been done and many more are in process, but the evidence is that they are relatively ineffective. Yet the public and private bureaucrats are implementing them because of their perceived goal when, in fact, they do not have adequate evidence that these policies are effective.

Evidence-based health policies may be of value in limited circumstances. But the real debate is over the goals. Let’s fight that one out now. Universality, access, equity, affordability, comprehensiveness, and administrative efficiency are the goals to which we should aspire. We do not need decades of building an evidence-based case for implementing the policies that effectuate these goals.

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By Katharina Janus and Etienne Minvielle
Health Affairs Blog, December 15, 2017

Unlike the United States, where abolishing Obamacare was a key pillar of the new president’s pre-election platform and a big focus of his first year in office, Germany and France seem to agree that they would, in general, like to keep the systems they have. After all, they perform relatively well in terms of outcomes, life expectancy, and other critical indicators in comparison to resources consumed as a percentage of GDP.

What can we learn nevertheless from each other across the pond, taking the newly established European axis as one unit and the evolving United States system as the example from a new world.

Solidarity, “Health Care For All,” And (Almost) “The Same Services For All”

Many European health care systems go back to the idea of Bismarck (roughly 150 years ago) that when individuals’ incomes and ability to pay for care are unequal, we carry a social responsibility as citizens to redistribute resources. Under this redistribution, administered by the government, the rich pay for the poor, smaller families pay for larger families, and the younger pay for the older. Most Europeans willingly accept this notion—it is deeply ingrained in their culture. What is more, Europeans accept that we have to kick in some money, from time to time, to prevent the failure of an important market—such as the health care market— that has not found its own equilibrium. On the other hand, large parts of the United States society have elected leaders who favor a smaller government and believe that market forces require only limited regulation. Instead of fearing market failure, these leaders seem to relish a Darwinian view of health care markets where only the wealthy have true access and wide choice in the care they receive.

Free Choice—No “Gated Health Care Community”

A major right of both French and German health care systems is the right to choose your doctor freely and have those services he or she deems necessary covered with co-pays that are as little as €10 in Germany and more nuanced in France where a visit without referral to any specialist might reduce reimbursement rates to 30% of total costs, but is covered with referral. How can Europe afford this luxury of free choice and (nearly) full coverage?

The first answer is to look at prices: If you compare services in Europe with those in the United States, you will realize that prices for regular lab, x-ray, and doctor visits are a fraction of what they amount to in the United States.

Second, European medicine does not have the same level of provider dominance as the United States where clinicians, making all diagnostic and treatment decisions, have the greatest influence on costs. In European systems, governmental regulation frequently caps expenses. Developing closed networks to keep costs in check, the United States system has essentially rationed access while requiring additional resources to manage and coordinate these networks.

This management awareness in the United States has facilitated advances in population health management and created a better mindset for actually managing care in pathways across sectors.

The Comparative Paradox

And here lies the cross-pond health care system paradox: European systems—like Germany and France—pursue a strictly regulated ideological framework that is based on solidarity, equality, and social responsibility but once people have been socialized into this framework they can eat à la carte—choosing to utilize care freely and as much as they want. The United States represents the opposite: a free market system as a framework in which participants can (or cannot, due to limited financial resources) choose freely from the “prix fixe formule” (as one says in France). In this scenario, one can buy insurance at various levels, pay co-pays and deductibles, eventually having to find help to understand all these options, and then once they are “in”—though not necessarily fully covered—they must live with limited choices in a gated system.

What can we learn from each other? This question puts Europe in a much better position because, even though the United States might benefit from learnings from Europe at a macro-level (including those social care reforms that improve living conditions and are known to reduce health care costs as a consequence), these ideas are unlikely to find fertile ground in the United States where ideology makes many policymakers less receptive to such lessons. Europe in turn can learn a lot from the United States system on a micro level—how to manage populations and connect sectors. Nobody really coordinates or manages care in many European systems, so there is room for improvement. As a caveat, one might say that the European systems work well and one should never change a system that is already running well.

It remains to be evaluated whether a further investment in health care management contributes to better outcomes as a result of coordinated care pathways. And the assessment to what extent these outcomes are “better” than with less management will most likely lie in the eye of the beholder.

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From the comment by Ted Marmor:

This article raises issues about learning policy lessons in health care, especially between the industrial democracies of continental Europe and the US. The descriptions are useful, the evaluation of the European experience is optimistic, but the interpretation of their meaning for lessons is misleadingly simple and negative. The US cannot learn because our ideology prevents. Why then did Medicare pass, which in 1965 was an example of social insurance (Part A in the model of Germany’s sick funds)? What about Social Security as social insurance? There is no reason to cut off discussion and limit the discussion so sharply.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

What can we learn from Europe about health care? That’s simple – solidarity, equity, and social responsibility.

And what can Europe learn from the United States? Managed care under the nebulous ideology of free markets? But the authors appropriately caution, “one might say that the European systems work well and one should never change a system that is already running well.”

If you look at the cost/performance ratios of the various health systems, the United States is an outlier, in the worst way. Maybe it is time for us to finally accept the facts and start becoming more diligent students of better systems of health care.

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December 18, 2017

H.R. 1, the Tax Cuts and Jobs Act, not only increases inequality, it further expands the deficit in the face of an austere budget. That will create greater pressure to reduce essential spending on important social programs, including Medicare. These tax policies are the exact opposite of what we need. Please vote against this cruel tax bill.

Don McCanne, M.D.
San Juan Capistrano, CA

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Comment:

By Don McCanne, M.D.

What does this message to my congressman have to do with single payer?

We already have a major budget deficit.

The congressional leadership has already indicated that spending on social programs, including Medicare, will have to be modified to reduce the deficit.

The tax bill before Congress, H.R. 1, the Tax Cuts and Jobs Act, will be voted on this week, and that would further increase the deficit if it passes (considered a near certainty now).

Therefore even greater reductions in social programs will be used to close the deficit gap.

Medicare is already an inadequate program, paying only about half of the health care costs of our senior citizens. If we expect to use an improved version of Medicare as the basis of a single payer national health program then we need to halt the march towards the privatized premium support model (vouchers) that would shift even more costs onto the backs of Medicare beneficiaries.

We need to protect, improve and expand Medicare instead of taking a sledge hammer to it. Tell your members of Congress today to vote against this cruel tax legislation. (My Senators, Dianne Feinstein and Kamala Harris, have already committed to voting against it.)

Incidentally, this tax bill includes applying chained CPI to the tax code. This will negatively impact future Social Security benefits. The process of clobbering social programs has already begun.

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By Thomas M. Selden, Brandy J. Lipton, and Sandra L. Decker
Health Affairs, December 2017

Abstract

Affordable Care Act (ACA) provisions implemented in 2014 provide a valuable case study regarding the merits of using public versus subsidized private insurance to help low-income people obtain and finance health care. In particular, nonelderly adults with incomes of 100–138 percent of the federal poverty level gained Medicaid eligibility if they lived in states that implemented the ACA’s Medicaid expansion, whereas those in nonexpansion states became eligible for subsidized Marketplace coverage. Using data for 2008–15 from the National Health Interview Survey, we found that as of 2015, adults with family incomes in this range had experienced large declines in uninsurance rates in both expansion and nonexpansion states (the adjusted declines were 22 percentage points and 18 percentage points, respectively). Adults in expansion and nonexpansion states also experienced similar increases in having a usual source of care and primary care visits, and similar reductions in delayed receipt of medical care due to cost. There were, however, important differences: Adults in expansion states experienced larger reductions in out-of-pocket spending but also faced greater difficulty accessing physician care relative to adults in nonexpansion states.

From the Discussion

Since we focused on the population with incomes of 100–138 percent of poverty, it might not have been surprising that the magnitude of the decline in uninsurance rates was similar in both groups of states. This is likely because Medicaid coverage imposed zero or near-zero premiums on enrollees, and adults in nonexpansion states with incomes in this range were eligible for Marketplace subsidies—which limited premiums to 2 percent of income for the second-lowest-cost silver plan.

From the Conclusion

As a general rule, care should be taken when applying the results of any study to other policy settings. Applying our findings to reform proposals with different combinations of premium subsidies, patient cost sharing, provider incentives, and eligible populations would be no exception to this rule. In particular, we urge caution in extrapolating our findings to lower-income adults, who may have greater unmet need, additional financial barriers, and different responses to public versus subsidized private insurance.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

By comparing states that expanded the use of Medicaid with those that did not, it was possible to examine the merits in Medicaid versus ACA exchange plans for low-income adults. Medicaid was more effective in reducing out-of-pocket spending whereas the private  ACA plans provided better physician access.

The reasons for the differences are intuitive. Medicaid uses very little cost sharing, thus providing greater financial protection for the beneficiaries, but in most states payment rates are so low that many physicians refuse to accept Medicaid patients, thus impairing access. In contrast, private ACA exchange plans use greater deductibles and other cost sharing, exposing patients to greater out-of-pocket spending, though physicians are more likely to accept patients with private insurance plans.

The authors caution against applying these results to other policy settings because of the great variability in coverage design and needs, so from this study alone we cannot say which is better, public or subsidized private insurance.

What we can say is that design is crucial. In a system designed to provide health care for everyone, design features should remove financial barriers to care and improve access through better resource planning and commitment. Well designed public plans do just that, whereas private insurance depends heavily on empowering patient-consumers to forgo beneficial care because of out-of-pocket costs, plus the only concern they have about distribution of resources is where the more lucrative areas are for them to market their plans.

Both Medicaid and ACA exchanges increased coverage, but we need to increase access and affordability, and neither did both. Rather than accepting trade-offs, we should enact a single payer national health program wherein no trade-offs in patient care are necessary. The trade-offs that do occur within the medical-industrial complex shouldn’t concern us beyond transitional issues.

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