Shrewd Decision on ACA

The way I see Roberts decision is that it was Solomonic: he gave Obama what he wanted, the ability for ACA to go forward; he gave conservatives what they wanted, a limit on Congress's power to regulate interstate commerce; he gave Romney what he wanted, the ability to beat Obama up over his "raising taxes" without the necessity to come up with positive proposals to replace ACA.

Just my two cents.

[Updated: Ezra Klein agrees.]

The "Nanny" State, Keeping Us Alive

Sarah Kliff at Ezra Klein's blog provides data from the New England Journal of Medicine on what we die of.  (Around 1812 some of us exploded.)  There's a chart summarizing the differences between 1900 (my parents were alive) and 2010 (I'm alive).  I'm copying the graph:

I think the declines in many causes are attributable in part to "nanny" government, that government which ensures people, particularly in urban areas, have clean water and good sanitation, which oversees inoculations for things like diptheria and flu, which fights  TB (which my mother had),  (I understand some will argue against government intrusion.  I remember when I got my TB vaccination in school, then my arm started to get swollen and painful.  It was then I learned  about mom's TB, which meant that my body reacted to the shot. There are gains to government intrusion, as there are costs, but I'm more impressed by the gains, at least in the field of public health.)

You really ought to read the Journal article in its entirety.  Who knew that in 1912 they were worried about sedentary life caused by the automobile, or boasting of the superiority of Americans at the Olympics because of the diversity of our races?  It's  fascinating how other strands of our history appear in the annals of medicine.

A Great Parenthetical Statement

"(Liston operated so fast that he once accidentally amputated an assistant's fingers along with a patient's leg, according to Hollingham. The patient and the assistant both died of sepsis, and a spectator reportedly died of shock, resulting in the only known procedure with a 300% mortality.)"

Atul Gawande, on 200 years of surgery, here.

Get Educated and Live Longer

Ran across a map of the country this morning, the URL for which I lost, but here's a close replacement, showing color-coded counties, representing their life expectancy.  The pattern is for the coasts to have the highest life expectancy, Appalachia, the Delta, and reservations to have the lowest.

The color coding meant that there was only one county in upstate New York which stood out as long-lived: Tompkins county.  Why?  That's where Ithaca is, the home of Ithaca College and Cornell University.  Education makes a difference.  Maybe the best way to cut healthcare expenditures is to improve our education system?

[Updated with the url from the Rural Blog which triggered this post. Interesting how color coding and different metrics affect one's perspective.]

Communitarian Liberalism as Zero Sum

Ross Douthat in the NYTimes sets up a strawman, communitarian liberalism, on his way to attacking the Obama administration.

But there are trade-offs as well, which liberal communitarians don’t always like to acknowledge. When government expands, it’s often at the expense of alternative expressions of community, alternative groups that seek to serve the common good. Unlike most communal organizations, the government has coercive power — the power to regulate, to mandate and to tax. These advantages make it all too easy for the state to gradually crowd out its rivals. The more things we “do together” as a government, in many cases, the fewer things we’re allowed to do together in other spheres.

Sometimes this crowding out happens gradually, subtly, indirectly. Every tax dollar the government takes is a dollar that can’t go to charities and churches. Every program the government runs, from education to health care to the welfare office, can easily become a kind of taxpayer-backed monopoly.

 His specific point is the rule providing that health care facilities which offer healthcare insurance must include contraception, etc. among the benefits.  This is particularly offensive to those facilities run by the Catholic church.

What he fails to acknowledge in his lead-in are the ways in which the government encourages those "alternative expressions of community".  For example, contributions to religious and charitable organizations are tax-deductible; property owned by such organizations is tax-exempt.  From my point of view, rather than there being a zero-sum game played between government and NGO's, there's a complex interweaving of interests, sometimes symbiotic, sometimes parasitic, among all the players.

His argument would be more effective if he offered an example of a government monopoly in education, in health care, in welfare.  I can't think of one.  

Doctor: What Would You Choose To Do for Yourself?

According to this post (hat tip Marginal Revolution), doctors don't choose heroic measures at the end of life. I note VA has just announced a database for advance health directives.  That's something I really should do.
[updated with the registry link]

Healthcare: The Importance of Bureaucracy

Suzy Kliff has a post talking about participation in ACA/healthcare reform, noting the very low participation in the pre-existing condition plan.  She focuses on CHIP--Children's Health Insurance Program for its lessons:

What does CHIP do to get kids enrolled? It all revolves around reducing red tape. Eliminating face-to-face enrollment interviews, for example, significantly increases enrollment numbers. Allowing for renewal of benefits by mail, rather than in person, helps too. Pre-populated enrollment forms, where a lot of a beneficiary’s information is already filled out, are currently being tested. In total, anything that makes it easier to sign up tends to increase enrollment. And that’s going to be key to moving 32 million people into an insurance system pretty soon.
One other thing we can learn from CHIP: enrollment levels could end up varying widely by states, and how many of these streamlining strategies they use. In Vermont, 92.4 percent of eligible kids are enrolled in CHIP; in Nevada, only 62.9 percent are. The disparities show just how much can hinge on how states decide to structure their enrollment processes

In other words, it's all about bureaucracy: how well do the bureaucrats at HHS and the state departments design their processes, their forms and websites.  I hope Dr. Berwick is a skilled bureaucrat.

Props to Fed Bureaucrats

Kevin Drum posts a chart comparing the accuracy in processing health care claims.  Which organization is best?

HHS--Medicare.

Saddest Phrase of June 12: Prison Is a Safe Place

"...prison appears to be a healthier place than the typical environment of the nonincarcerated black male population." 
From a study reported by Barking Up a Wrong Tree, comparing death rates of prisoners with civilians. Part of it may be healthcare differences.

Brooks and Economics of Healthcare

One of the things I miss in the current chattering classes commentary is a focus on market structure.  The questions of monopoly and pricing power don't play much of a role in current debates.  For me, I remember the strain surrounding the receipt of the monthly (I think) milk check and egg check.  We'd shipped off our milk and eggs, consigned my parents' work to the fates, and waited to see what we'd receive in return.  Open the envelope and see the check amount: maybe it's up, maybe down.  The closest parallel I can come to in today's life is the arrival of the bills for electricity and water/sewage.

In both cases, the person has no pricing power; they're at the mercy of the market structure.  

David Brooks has a piece  on healthcare saying Democrats believe in the power of government experts to cut costs, Republicans believe in the power of competition and consumer choice.  I'd say that misses the fact that government, as purchasing agent for consumers, can have pricing power; consumers in the context of the healthcare market don't.

More on Supply Side Solutions for Medicare III

Foreign Policy, via Charles Kenny, has a piece on outsourcing medical care to Thailand (lousy pun in Kenny's link)

Suzy Khimm, guest blogging for Ezra Klein, discusses primary care doctors and a NYTimes oped  suggesting making med school education for primary care doctors free.

Blew My Mind

Texas lawmakers allow rural hospitals to hire doctors, to help relieve shortages.  That's the heading on the RSS feed for this.  Although the article explains the situation somewhat, I still find the original prohibition strange.

More on Supply Side Solutions for Healthcare

I posted earlier on some measures to increase the supply of healthcare professionals.  The Post has an article today; seems the Republicans refuse to fund a measure in the Obamacare law to increase the supply.

Supply Side Solutions to the Cost of Medical Care

I commented on this on Yglesias's blog in the past. Rather than focusing only on cutting demand, either by regulating what procedures and devices are approved (Obamacare) or by cutting the money available to spend on medical care (Ryancare), we need to seriously expand the supply of care, thereby cutting prices and hopefully costs..

We could do this by opening our gates to all medical professionals from other countries. Here's an interesting post on Chris Blattman's blog about the effects of such migration, including these sentences: "For decades, more nurses have left the Philippines to work abroad than leave any other country on earth. Yet in the Philippines today there are more Registered Nurses per capita than in the United Kingdom. This happened because so many Filipinos trained up as nurses to take advantage of opportunities abroad that this more than offset the departures."

We could do this by contracting with some universities to develop new schools of nursing and medicine.

We could do this by changing the laws so someone licensed as a nurse or doctor in one state could practice in any state.

We could  reduce certification requirements, offsetting the laxity with increased transparency. I'd rather be treated by a doctor with lesser qualifications but a long history of success than vice versa.

We could forgive a portion of student loan indebtedness for those medical students who go into primary care for x years.

We could allow nurses to do in medical clinics what we allow them to do in schools.

We could encourage medical tourism: people going to Mexico or India for operations (as the Amish do now).

Are the Conservatives Right on Healthcare?

One of the major arguments people like Megan McArdle use against the healthcare reform passed last year is that the cost-saving measures included in the plan won't work. People like Ezra Klein and Matt Yglesias say they will work, they hope.

This Politico article provides ammunition for the conservatives.  Various interest groups and lobbyists are rising up against the Independent Payment Advisory Board.  If one is a cynic, watch for the lobbyists to get legislation weakening it or killing it included in some big package of must-pass legislation.

Why Healthcare Is Costly

A nugget from a NYTimes article on the problems of providing adequate Wi-Fi connectivity to conferences, particularly of techies.

"“I’ve been to health care conferences where no one brings a laptop,” said Ross Mayfield, president of the business software company Socialtext and a technology conference regular."

 That's sad, and also revealing.  I doubt there's any conference in USDA where laptops aren't present, at least those conferences where there are worker bees.

There's Transparency and There's Transparency Which Works

The Reston Hospital Center has tried to be more transparent, by measuring the response time in their ER and posting the expected wait time on the Internet. (It was 9 minutes when I checked in when drafting this.)

I don't know whether they're measuring the extent to which people are using this, but they should. It seems to me like something which would be useful, assuming you're a person who uses the ER as a substitute for a doctor.  Maybe I'm naive, but I'd guess there's not too many of those in Reston--it's rich enough most people will have health insurance and a doctor.

Of course there's also the issue of image building.  Even if no one uses this, it does give the image of an up-to-date institution, which one wants if you have to go to the hospital.  And it might have been easier to sell the idea of measuring ER response time to your ER staff if sold as a way to inform the customers, rather than as a way to make them more productive.  I'm assuming that if they can cut the response time, they've reengineered their business process to be more efficient.

Kudos for Sibelius

The NYTimes today had a chart grading the first 6 months of the PPACA healthcare reform.  Regardless of one's opinion of the act, it's worth noting and appreciating the fact that HHS has done a good job the first six months in getting regulations written and other practical steps needed to implement.  We all can agree if the act is poorly implemented it will be a bad thing.  Some of us think it will be a good thing if well implemented.

One item where the authors give poor marks is the effectiveness of state governments, though that seems to reflect the opposition of Republican governors to the act.  (Which leads me back to the theme of the weakness of the federal government.)

How Smart Phones Will Drive Down Healthcare Costs

I think it's reasonable to say we're only just realizing how much of a game changer the smart phone can be.  By combining computer, camera, sound, and Internet in one small package it opens up new possibilities.  One of them seems to be health care.  Federal Computer Weekly has posts on using smart phones for  general outreach, for remote dermatology and for mental health.  Now much of this is probably boys with toys seeing nails everywhere to use their new hammers on, but out of many ideas will come some worthwhile innovations.

Obviously one of the big holdbacks for this is geezerdom: us old folks who haven't bought a smart phone yet and who generally are technologically backward.  What's worse is there's probably a high correlation between lack of adoption and iffy health.  (Though maybe not, I think I remember seeing that adoption of cell phones is higher among minorities.  So maybe it's the old WASP geezers in the hills of Appalachia like those I grew up amongst who are most resistant.)

One of the big advantages would be outsourcing the emergency room.  See Megan McArdle's post I referenced here.

Food Price Trends

Matt Yglesias comments on a David Leonhardt article on housing costs; Leonhardt sees the issue as whether housing is a luxury or a utility.  If the former, then prices might rise; if the latter, prices will track other necessities.It's an interesting article which has also attracted comments from other bloggers.  One in particular was saying "housing" combined houses and land, and most of the appreciation was in land.  {UPdated: Kevin Drum comments.  One thing I haven't seen discussed is the increase in square footage for  housing over the period.]

But all that is a side issue to me, because there's an associated graph of the proportion of household income by category over the last  80 years.  Basically clothing and food had their peaks in 1947 or so, with a consistent decline in each to the present (a bit steeper for food than clothing).  Meanwhile health care costs have been rising steadily since 1947.  The changes in both food and health care are astonishing.