New York Department of Health – Ass kicking or over-reaching?

New York City has long been a progressive place.  It has served as a laboratory for many proposals and policies.  Some have been brought to the national stage (think many New Deal initiatives). Some have been adopted by other municipalities (smoking bans in bars).  Some have started fads (no-trans fats).  Some have fallen on their face (congestion pricing).  But I have to say that the New York City Department of Health (Department of Health and Mental Hygeine to be accurate) has been on a role. Let’s count the ways:

1. Strong smoking bans in all indoor public spaces.  I think accurately it is any indoor place where a person might work. I don’t think NYC was the first, but it was early, strong, and a major leader in a trend that has hit NJ, CT, and much of the U.S.

2. A pack of cigarettes now costs $8.00 per pack due to huge taxes.  Consequently, smoking rates have been nose-diving.  And yes, it is due to the tax more than the ban. Plus, nicotine pacth giveaways all over the city!

3. Trans-fat ban that is hitting all restaurants this summer. 

4. Calorie count. Any restaurant that has more than 10 locations nation-wide must post their calories.  You may think twice about ordering that vente caramel…500 plus calorie latte or that 1,000 calorie Chipotle burrito.

5. Greener NYC.  Hybrid cabbies, 1 million new trees, cleaner buses, etc.  This may not be the Department of Health exclusively, but I’m sure they played a role.

6. Widespread condom giveaways.

7. The latest is that there is a push to test everyone in  the Bronx for HIV/AIDS (voluntary of course). Since the Bronx has the most deaths, not infections (I believe that belongs to Manhattan), they want to catch the disease early so treatment can be started.

So are these measures draconian or public health genius? Which ones do you like?  Which ones step on your toes?

Headlines – 6/17/08

  • The Urban Institute put out a report on the Massachusetts health plan two weeks ago.  It’s findings were mostly positive.  More than half of the unisured in 2006 are now insured (greater than expectations), most people like the plan, access to care has improved, and out of pocket costs have dropped.  The bad side is that budget costs have run over budget (but so has national spending) and there is a shortage of primary care doctors.  For the NYTimes read here and here.
  • Ben S. Bernanke, chairman of the Federal Reserve, told Congress on Monday that health spending would “rise relentlessly” unless lawmakers overhauled the health care system, and he recommended an eclectic approach.”  Read more here.
  • Employer health care costs are expected to rise nearly 10% in 2008 and in 2009, respectively. Much of the extra expense is due to a hospital building boom and the cost of cross-subsidizing the uninsured and public programs.  The study comes out of PriceWaterhouseCoppers and was reported by the AP.

What a Perspective!

I believe one fundamental difference that divides perspectives on health care is the whether you believe it is the community’s obligation to take care of one another.  Some believe that with the exception of a few basics the government (community) should not interfere.  Basically it is every man or woman for themselves.  Others believe that a community must take care of its weakest. This debate has taken an interesting twist in several comments and posts of friends of mine regarding organ donation.  Organ donation (especially while alive and for a stranger as in a kidney) is quite possibly the strongest recognition that one can make that the community does in deed have an obligation to take care of its own.  Organ donation strips the  barriers that most people construct around their bodies.  Bodies are personal, private, not communal.  But a friend of mine is considering a more communal perspective so that her community can better take care of its own.  By giving of ones body to another (in the form of a blood donation, bone marrow, kidney) you are offering yourself (quite physically) to another in the community.  What a perspective!

Now if only more in our community would be willing to give up monetary resources so that all could access health care.  What a small sacrifice.  What a small perspective compared to those who give of themselves quite physically!

More Health Care Equals Better Health. Wanna Bet?

Quiz:

You are 80 years old and have two years to live.  Which hospital would you prefer, Bellvue (large NYC public hospital) or Columbia-Presbyterian (NYC academic private hospital)? 

I assume that most who know these hospitals would jump at Columbia-Presbyterian.  I think that is a safe assumption, but…(you knew it was coming)

I was listening to the Brian Lehrer show on WNYC (NPR) and was fortunate enough to listen to an interview discussing Consumer Reports findings (based on Dartmouth Atlas of Health Care 2008) in which consumer reports says that, especially at end of life (data comes from Medicare), more aggressive health care leads to worse outcomes.  Too many pricks, tests, procedures, hospital acquired infections, extensive recoveries, pharmaceutical mix-ups, etc.  Exposure to more health care can be bad for you. Sometimes conservative health care is better.  Sometimes the primary care physician is better than the specialist.  Sometimes the neighborhood hospital is better than the state-of-the-art hospital.  Bigger is not always better – a lesson Americans are slow to grasp.  SUV’s are not necessarily better than compact cars.  The 6,000 square foot mansion is not necessarily better than the 1,000 square foot apartment. The truth is that the private hospitals have perverse incentives to do more – to the point of harm.  The public hospitals might have incentives to do less.  Both extremes can be to the detriment of the patient.

Most health economics and policy makers grant that health care resources have diminishing returns the more you receive.  Meaning the first few interventions will have dramatic effects, but each additional resource used will have less and less impact until the care actually becomes harmful. Some patients reach that point in some of our hospitals. 

Overuse reaches the point where some states, hospitals, cities use 3x more health care resources than others with unmeasurable effects.  Why?  Because more is not always better, just richer. Health care needs to be smarter. Cars need to be smarter. We need to be smarter. However, getting back to the quiz…

With all that said I would still choose Columbia-Presbyterian, however, I would ask the questions to determine if the care proposed is really going to be good for me.   

Cesareans Lead to Higher Priced Insurance

Watch out!  If you have a Cesarean delivery you may find it more difficult and more expensive to find health insurance in the individual insurance market.  Go ahead and add Cesarean to the growing list of pre-existing conditions. Since the individual market is growing (18 million people) and the Cesarean rate is growing (31.1% of births or 1.2 million Cesareans a year) one could assume that many people have faced this issue.  You can read about a few women who have discovered this reality here.

No Individual Mandate, Really?

I’m resisting an individual mandate despite my left leaning ways.  Underneath it all I do not like large programs that dictate behavior. Liberty is important, but more than anything mandtaes can be impractical. How would you enforce such a thing? How much would enforcement cost?  How effective are mandates? And do we want to be punitive toward those who do not obtain insurance? These are all tough questions and questions I would direct to Hillary Clinton.

Under “My Prescription” all people would have equal access to health insurance while establishing equitable tax incentives to purchase insurance. Those people not purchasing health insurance are losing out on their tax credit and thus throwing money away. It changes the calculation.  Currently, a person looks at the $8,000 premium and walks away. No health insurance, but $8,000 in their pocket. Under “My Prescription” they look at the tax credit (let’s say $3,000), and they have the choice whether to spend $5,000 on the insurance ($8,000-$3,000 tax credit) and have health insurance or do I pay $3,000 more in taxes and not have the insurance.  That changes the game (these numbers are fictitious, but make the point) because people would now practically be paying to not have insurance. 

So do we need a mandate? I would like to give the “My Prescription” plan a chance to work without a mandate. I believe it would lower the number of uninsured tremendously.  It would eliminate the excuse that a person could not get insurance becasue of their medical history. It would make obtaining insurance very appealling, and lastly, it would have a better chance of political passage without such a mandate. If I turned out to be too optimistic in my estimates toward universal health care a mandate could be added later, but in the meantime “My Prescription” would improve quality by stimulating competition on costs and quality. It would improve incentives for public health and prevention of disease.  It would improve relationships between patient, doctor, and insurer by improving continuity of care. It would align the incentives with cost controls and quality of care. No, for now, I’m going to pass on the mandate.

Now We Build

Part of the “My Prescription” series.

But before we do let’s recap. In brief we need a new foundation. The employer based system is not working. So I am suggesting two fundamental changes: Health insurance exchanges and tax reform.

Health Exchanges will provide the pooling mechanism. They would be run by the States and would regulate the plans much like the New York Stock Exchange regulates stocks. The exchanges would have to force the plans to accept all applicants, to have a fairly standardized set of benefits, and I believe use a modified community rating. Community rating is when the premiums are based on the risk of the community as a whole, not the risk of the insured person and their specific circumstances. The modification is that insurers would charge everyone within their plan the same amount, but that each insurer can set that price (and thus compete on price).

I can hear the screams right now, “What about smokers? I don’t want to pay for them?” Neither do I, but I do want to make sure that the cancer survivor has access to good medical care. Further, competition would make smoking cessation programs financially viable. Second, I can anticipate, “You need to let the market operate unregulated.” I believe in the market, but without regulation insurers will only compete by avoiding high risk people, not on quality and price. Under this plan competition is limited in several aspects. I won’t deny it, but there is still competition. The insurer is competing on quality of care and efficiency of providing that care. And, “Won’t this make premiums more expensive?” Yes, community rating makes insurance premiums higher. Insuring sick people costs money, but I do believe that it is the morally correct choice.  Let’s see if this competition can reduce costs over time through directed competition.

So the next big thing is that we need publicly reported information about the quality of health plans, hospitals, physician groups, and physicians. There is an emerging movement already, but it needs to be a national priority. Competition only works when the consumer is an informed consumer. Let’s educate!

So we have exchanges that regulate health plans and use community rating. All people are included and all can choose their own plan. The plans are portable from job to job providing consistency of care and long-term relationships with insurers. The tax credits provide equity in the tax code, but still preserve the employer’s incentive to contribute. Employer’s continue to facilitate health insurance, but no longer sponsor it. Quality measures are reported to the public forcing health care plans, hospitals, and providers compete on quality and price while minimizing selection issues.

Next time we’ll discuss a few nuances of the tax proposals, why an individual mandate may not be necessary, and the need for either re-insurance or risk adjustment.