U.S. politicians have abandoned arguments from the humanitarian side because they know, or fear, the reaction of the vast swathes of dumb white trash peckerwoods: hence the overemphasis on practicalities, invented or not, and putative cost savings attributed to a large social welfare program by other means.
I'm not sure your example is that useful (ideally, you prevent in full some of the time, not just delay), but your broad point is valid - the cost savings are not the slam-dunk everyone talks about. You might need 10 or 20 extra doctor visits in a population to prevent one hospital stay, at which point it could be a wash cost-wise.
I hear thirdhand that Kaiser (being an integrated system) has generally found that managing chronic conditions, while improving people's health, does not actually reduce costs. In this metric-obsessed world, we need some kind of metric that coherently joins up the different outcomes of health care that people value, not just cost, and I don't know what that's going to look like.
abandoned arguments from the humanitarian side
Modern conservatism is laced through and through with sadism. It's all one unending search for people to condemn as unworthy. Why, those people aren't even poor: they have telephones! Wireless telephones with custom ringtones!
re: 2
QUALYs?
http://en.wikipedia.org/wiki/Quality-adjusted_life_year
Which would be the standard sort of thing that NICE would use:
http://en.wikipedia.org/wiki/National_Institute_for_Health_and_Clinical_Excellence
And those kinds of questions are exactly the sort of thing NICE is supposed to answer.
Viz:
[Hit Post before I'd finished the previous two]
In the past year, my insurance company has spent $46,000 on me and I've spent $5,000 on copays and uncovered things plus $900 on medication.
I am very glad I have insurance, but I really, really hate the whole thing. I'm pretty sure I'm in exactly the same shape I would have been in* if nobody had spent any money at all.
*That's probably not true. I have lots of pain meds that I love, and I'm getting my gallbladder out in January, which may solve/alleviate some things. Whatever it is still super stupid overall.
Anyway discussions about insurance, quality of life, etc make me feel uncomfortable. There's always all this stuff about preventative care and young healthy people. TOO LATE FOR ME. WHERE'S MY ICE FLOE.
I agree with 1 & 2 that it's both understandable why preventative care is being sold as a technocratic good ("saves money, good for everyone") rather than a political good ("makes society better") but it's disappointing because the latter seems like a stronger case*.
Also: but your broad point is valid - the cost savings are not the slam-dunk everyone talks about. You might need 10 or 20 extra doctor visits in a population to prevent one hospital stay, at which point it could be a wash cost-wise.
Let me use this excuse to link to this comment again because I still think that's a useful set of links:
"When we think of prevention, we tend to think of the individual who benefited," Russell writes. We conjure up an image of the woman who caught breast cancer early, averting expensive treatments, or the man who brought his weight down and lived a long, healthy life. That, however, discounts all the mammograms that didn't detect cancer and didn't prevent anything and all the individuals for whom weight management programs didn't work. All those costs add up to the point that most preventive interventions cost more than they save.
* The one problem with the political argument is that you get into the weeds of, "how do you prioritize and where do you stop." The position of, "we're just trying to save people money" does avoid that, even if somewhat disingenuously.
Minivet is correct, that preventive care doesn't usually actually save money. (http://www.nejm.org/doi/full/10.1056/NEJMp0708558) If we're going to do it, it would need to be for humanitarian rather than financial reasons.
I actually attribute the reason that we hear this argument so much is the increasing heft of technocratic liberalism (the "liberalism" here being more akin to center-leftism or neoliberalism, as opposed to left-liberalism). The belief that what is they consider to be morally superior must be practically superior as well (saves money, produces incontrovertibly superior results, etc.).
10: That sounds awful. I hope your doctors know what they are doing. Can you get (have you gotten) second opinions about treatment?
I think the shift in American center-left politics to instrumental/technocratic arguments for progressive causes is at least in part traceable to the development of (what seemed at the time to be) really strong instrumental arguments for conservative causes during the period from the 1960s to the 1980s (freshwater economics, public choice theory, and the like). I think there was a period during the 1980s and 1990s during which progressive academics in the social sciences (at least those who weren't far enough left to go full Marxist, which would include most of those who were interested in interacting with mainstream American politics) and progressive intellectuals generally felt that they were very much on the defensive. Of course this mixed with conservative trends in national politics (first Reagan, then the loss of the House in 1994). And I think the progressive instrumentalist language you hear used today was a developed in response to that felt need.
11- As soon as you decide some treatment is ineffective and declare that the government won't pay for it, it's called a Death Panel. We don't need no stinkin' evidence. For example, look up the story about Lucentis vs. Avastin:
-NIH says they're equivalent
-Medicare is forbidden from rejecting an FDA approved treatment on cost grounds, or negotiating prices
-Doctors get cost + 6% on a treatment, so they use Lucentis at $2000/dose instead of Avastin at $40/dose and make an extra $100+ for themselves.
-Medicare spends an extra $1.5B/year on this treatment, and patients an extra $370M in copays.
WHERE'S MY ICE FLOE.
At this rate, you'll be one of the few in your age cohort to get your own ice floe. The rest will have to share because global warming.
Seriously, that sounds just awful. I hope your doctors are excellent.
Following 17, screenings can also be super-expensive to do across an entire population. The government is trying to get rid of PSAs for men, to moderate uproar. Remember the PR nightmare of changing breast cancer screening recommendations? Also, you apparently need to put nearly 400 patients on statins to save one life. I am very curious what happens if we see some negative effect, like dropping liver function, for patients on statins longterm.
Doctors get cost + 6% on a treatment
That's about as insane as any insane thing I've ever heard.
At the health provider level, which is my level and is coloring my thinking, QALYs require a huge amount of data and hinge on so many difficult assumptions (lots of surveys trying to get people to quantify a year with X disability vs. a year of life lost) that they don't mesh with capabilities. Maybe it would be more technically feasible for them to be a criterion in national-level policy decisions, although I think it would take some doing to get people okay with the idea of giving a life-year a dollar value; NICE is often denigrated here on those grounds.
re: 21
As far as I can tell, although sometimes they make wrong decisions, NICE does a pretty good job. The UK of course, has better health outcomes than the US for much less money.*
* blah blah free-riding off US investment, blah blah.
20: Fortunately just the case for doctor-administered drugs (injections), but yes, barking mad.
2: I'm way too brain dead at the moment to remember the acronym, but organizations that fight poverty have a way of calculating not just years of life and cost savings, but quality of life. Like man-hours, but for estimating the benefit of preventing blindness or what have you in a population.
Hey, and ttaM has it a few comments later.
22: Yeah, hard for us, not as much for you.
"I am very curious what happens if we see some negative effect, like dropping liver function, for patients on statins longterm"
You mean statin-induced myopathy, including rhabdomyelosis? Why yes, there is. Turns out that isoprenoids (in particular geranyl pyrophosphate via the HMG CoA reductase pathway) are a useful thing for some cells like myocytes to have.
Messily, this is really just my experience, but do be aware going in that some people (me!) have to stay on whatever they call the gall bladder diet after the surgery. Mine was 6+ years ago and I can't digest much fat and have had to learn to eat accordingly or face the consequences. It's not a particularly bad thing, but I'd heard so many people whose removals were no big deal and had no impact on their lives after, and neither had anything in common with my experience.
And I think the progressive instrumentalist language you hear used today was a developed in response to that felt need.
Thinking about it, I agree with the quoted sentence, I don't think I should have used "disingenuous" in 13. I do think Democrats, generally speaking, are clear that their preference would be to extend availability to health care/insurance to everyone. The technocratic language is their way of signaling that they are being "responsible" in their policy proposals.
While there are lots of poor people who are unlucky, and who would benefit from just getting some cash, there's also a pretty wide spectrum of people who are incompetent.
Some are mentally ill, others have a hard time making reasonable money decisions. Helping these people means depriving them of complete agency, not easily done. I agree that contemporary US conservatives are a spiteful caricature of humanity. But suggesting to just give poor people money is about as simple-minded.
I hope your doctors know what they are doing
Some of them seem to. Others, not so much.
My gallbladder is not really functioning right now anyway* so it's unlikely that things will be worse after it's out. Either better or the same. My mom had hers out last January and after a couple of months was back to normal. Hopefully genetics are a factor in the recovery process.
*They found this out by injecting radioactive something into my blood and tracking its progress through my digestive system. I am still waiting for the supernatural powers to develop.
Minivet is correct, that preventive care doesn't usually actually save money. (http://www.nejm.org/doi/full/10.1056/NEJMp0708558) If we're going to do it, it would need to be for humanitarian rather than financial reasons.
Even if preventive care doesn't save money, it makes people healthier (subject to things like statin side-effects as mentioned above, or excess false positives from screening unlikely candidates) than they would otherwise be. So it just becomes very cheap (net net) healthcare. Which is a good thing, surely. If you rely on after the fact care, you still get the fact.
I think I bitched here before about the way my old insurance company handles preventive care. I need to get a colonoscopy* which is fully covered as preventive care. Unless they find a polyp and take it out at which point it's surgery, covered only 80%. Stupid.
* Grandfather had colon cancer, Dad died from it.
I hear thirdhand that Kaiser (being an integrated system) has generally found that managing chronic conditions, while improving people's health, does not actually reduce costs.
Our insurance coverage is changing in MANY ways to basically lavish free treatments on people who can get certified with three chronic conditions, it's diabetes, high blood pressure and something else. Suddenly co-pays, co-insurance, deductibles no longer apply if you are a high-risk person. So they certainly want people to stay healthy until they hit Medicare age, at least.
Gotta get patients some skin in the game, to prevent all those frivolous surgeries.
34 is actually not a bad turn of events. If insurance companies want people to stay damn healthy until they can pawn them off, then more people stay damn healthy for a while.
the 1% (for lack of a better word - those who sabotage progessive reform) don't see that it is in their own best interests to ameliorate poverty.
I've abandoned the idea that conservatives see their best interests in the same practical, materialistic way that I do. I repeat apo in 3:
Modern conservatism is laced through and through with sadism.
If 4-year-olds get untreated cancer, that isn't a bug, it's a feature. Serves their parents right for not working hard enough or for choosing not to get insurance.
Sure, we pay more in the US, but we've got the best healthcare system of any developed country - for certain values of "best."
If 4-year-olds get untreated cancer,
it's just the way Jesus decided he wanted things.
lw--seriously mentally ill people often get deprived of their agency. They get guardians.
As far as preventative care goes, I have mixed feelings. I think that a lot of the stuff about preventative care is really the lifestyle stuff: healthy diet, some exercise, and adequate amounts of sleep. Counseling people on the value of this can be useful; sometimes even asking people how much exercise they get has an effect, but it's also about resources--how much time and money you have and not always adequately addressed my the medical system.
And then there's a point which should be obvious (but isn't) people get sick even when they do everything right. But you still get assholes, like John Mackey of Whole Foods, who basically argue that sick people are to blame. My junior boss who works with poor people on Medicaid and is, by all accounts, reasonably compassionate in that role, said that she thought it was good for her to pay lower health premiums because she submitted to a test that showed she was healthy--lower BMI, good cholesterol and all that. I find that intrusive and puke-worthy.
I suppose that on one level, it makes sense to make reproductive healthcare visits free, since undesired children are very expensive. In MA, there is no copay at all on the birth control pill, but if you happen to be one of the sick people, say, you need antipsychotics, then it doesn't seem entirely fair to me that you should have to pay lots of money. Isn't part of the role of social insurance to protect people from expenses that are unevenly distributed?
34: It might be COPD. Those were the chronic conditions that I was trying to target with my last job using tele-medicine.
Similarly, we often talk about preventing expensive ER use by the uninsured by getting them insured, but that doesn't pan out literally: the AHA estimates hospital uncompensated care at about $40 billion a year, but ACA spending on getting people coverage (Medicaid, premium subsidies, small employer tax credits) adds up to more like $180 billion a year. It's more about standards, dignity, and health outcomes.
I think there is some disjuncture between what different people are calling preventative care here. Isn't the horror story always about some black woman in the ghetto who had some unpleasant symptom that a person with good insurance would have checked out, and then some surgery or whatever, but instead she ignored it and it turned out to be cancer and now she's dead? Vs. if everybody who's a bit overweight and has high blood pressure exercised for 90 minutes a day, mortality due to cardio-vascular disease would drop 8.9% in 30 years or something. Seems like those are totally different things.
Frankly, other than having my "almost completely necrotic" gall bladder out last year, and the temporary mood boost/weight loss I got from Welbutrin, I don't think any of the medical interventions I've had in the past 10 years have done a damn bit of good. Maybe the flu shots. Stuck in an unhealthy rut, that's me.
41 reminds me that on the ACA in particular there may also be some intellectual cross-contamination from the development of instrumentalist arguments that this was a matter that could properly be addressed at the federal level using the commerce power. (For all the good those arguments did us in the end.)
Congress is allowed to do things to protect the national economy that it can't do to protect the 4-year-old with cancer.
That said, I don't know whether that particular effort was big enough to affect the broader public discourse. Probably not.
preventing expensive ER use by the uninsured by getting them insured, but that doesn't pan out literally: the AHA estimates hospital uncompensated care at about $40 billion a year, but ACA spending on getting people coverage (Medicaid, premium subsidies, small employer tax credits) adds up to more like $180 billion a year.
What you're saying is of course completely true on the national level. But I suspect it will have real and meaningful local financial impact (hopefully positive) on the hospitals that are right now disproportionately providing emergency care to uninsured patients.
Oooh! Oooh! Can I be in one of the states that's not expanding Medicaid?
44: Is what I said inconsistent with that? We're spending more than would be needed to simply pay hospitals for every penny of their uncompensated care, because there's all other kinds of medical services being brought into the mix.
I'm going to push back a bit against point 1 in the OP, because like Natilo says, there's many things that can mean "preventative care". The reason for the big push against things like diabetes isn't that the number of people getting it is static and they're trying to put it off, it's that the rate of people getting type II has gone way up.
Although actually, specifically on the hospitals that disproportionately serve uninsured/Medicaid, the effect may be more neutral, because even as people get covered, Disproportionate Share Hospital payments from both Medicare and Medicaid are being slashed. So in some cases the federal government will be taking from safety-net hospitals with one hand what it gives with the other.
Slightly hearteningly, the first two years' small cuts to DSH (2014 and 2015) were eliminated in the just-passed budget deal, but some of those restorations came out of 2016.
44: Right, what you said is not inconsistent at all. I just wanted to lift up the point about local impact.
45: Sure, why not? Twelve and a half million Pennsylvanians are.*
*Allegedly our governor is proposing an alternative plan but all signs point to it being a) terrible and b) late.
In MA, there is no copay at all on the birth control pill, but if you happen to be one of the sick people, say, you need antipsychotics, then it doesn't seem entirely fair to me that you should have to pay lots of money.
Without that a significant co-pay, people would just be taking anti-psychotic medication willy-nilly. They need "skin in the game" to provide the proper incentives for use. This is especially the case for people who are psychotic.
One criticism of QUALYs is that they tend to devalue the lives of the disabled. If you give one intervention credit for preventing blindness, the same metric might wind up giving less credit to an intervention that extends the life of a blind person, because you are adjusting a life-year with blindness down for low quality.
16 gets it right on the historico-political reasons for the turn to economic justifications (which we're calling instrumentalist or technocratic) for public investment in preventative care: it's defensive.
Way back at 2: I hear thirdhand that Kaiser (being an integrated system) has generally found that managing chronic conditions, while improving people's health, does not actually reduce costs.
From what I can tell, QALYs don't account for the other costs of failing to manage chronic conditions: people wind up not being able to go in to work. Loss of productivity.
50: Exactly, the Medicaid co-pay is only about $3, but it can add up to $30 or $40 which is no small sum for someone on disability.
51: I was looking at a job blogging for an organization that does everything by QALY. This devaluation of the value of a disabled life does concern me.
I think part of the whole "let's talk prevention" is as a way of shifting the health spend around & away from heroic interventions at end of life. And in that sense it probably will save money, and probably will do various other good things.
55: Really? In my experience, opportunities for "heroic" care pop up around time of death regardless of how healthy the person was before. Cancer, heart problems, etc. are also a symptom of the body generally failing. I think the way to improve end-of-life care cost and quality is to tackle it directly, as with palliative care.
Continuing 52: I believe these other costs to society are called externalities by economists. That would mean costs that aren't normally included in the measurement of costs. To call them external seems to dismiss them, but they're far from minor.
I saw much of this when I was in physical therapy, where people tend to be quite talkative, in a really good way: so many people confessing that they hadn't been able to go in to work for the past several months, and the guilt and stress and expense was impacting their home lives. That's not just about quality of life: it's also about societal costs, which are likely to have economic impacts.
Until I hear an assessment of the value of preventative care that accounts for these sorts of things, I will not take something like Kaiser's cost/benefit analysis seriously.
56 -- yes, obviously everyone dies just the same. But if you have a healthcare system constructed around prevention, then the bits dedicated to cure stop being as important. In particular, where there's limited resources, it helps stops them being sucked up into more and more surgery etc.
56: I suspect that there are more truly elderly whose spouses and children would turn down heroic measures vs a 65 year old. Older folks (I suspect) are more likely to have Do Not Resuscitate orders on file, etc. Of course, whether those orders are followed will certainly vary, but I think that people are more likely to agree to palliative care when they can say their relative had a good long life. I don't know whether there's real data on this, though, and there are plenty of elderly patients who linger for a very long time with expensive interventions.
was gonna leave a comment but the first one said what i was going to: we focus so much on practical reasons, #s, etc for prevention because nobody cares about the humanitarian side (at least, the people who make the laws).
RWJF [a client of mine] has lots of good resources on prevention and stats. http://www.rwjf.org/en/blogs/new-public-health/2013/04/national_public_heal0.html
Preventative care is also a matter of catching emergencies just a little bit earlier. When I got appendicitis a year ago, if I had had a crappy job with a crappy health plan, I might have said "it's probably nothing" until the pain really got unbearable. But my health plan and job are decent(In fact, one of my supervisors drove me to the hospital and waited with me in the emergency room for an hour or two, so I guess that makes my job a lot better than decent.), so I figured out it wasn't just a stomachache a lot earlier than I probably would have otherwise. I assume letting it get even worse would have made the surgery even more serious and expensive and the recovery time even longer. I'm not sure if that falls into one of the two categories discussed in 42 or is a third category or just isn't preventative at all, but it still seems relevant here.
Also, I need to become a better liar. My wife and I are going through a minor crisis, and I'm finding it hard to avoid giving people an honest answer when they give me a rote "Hey, what's up."
I said "people." Imaginary Internet characters don't count.
You could go presidential and tell us. I, for one, would try not to make the obvious inference.
My personal hunch is that while it may make the 1% wealthier it will also make them less powerful, and they know this. By the time you're in 1% status, money is no longer money. Money is power. Your ability to influence people and control them with your money has as much to do with their inability to say fuck off as what you're actually theatening to buy, and their ability to say fuck off is largely limited by how dire and close the poverty pool is.
How ironic that I can't engage in this thread because I am working late optimizing someone's spending on preventive care.
The preventive services that are required to be covered without cost-sharing under the ACA are determined by a technocratic body, the U.S. Preventive Services task force. Everything graded A or B by the USPSTF is on the list. Their evaluation gives no weight to putative cost savings; just health benefits (mostly avoided adverse events) and countervailing health risks. By design, they do not use a single common denominator like QALYs, but weigh the pros and cons in a more flexible deliberative process that invites public comment.
Meanwhile, back at the ranch, Mnsuregate continues to unfold: http://www.startribune.com/lifestyle/health/236395221.html
it drives me fucking nuts that the 1% (for lack of a better word - those who sabotage progessive reform) don't see that it is in their own best interests to ameliorate poverty.
I dunno, I don't find it that surprising that conservatives prefer to be a little poorer if it makes the world a little more fair (using their definition of fairness).
|| That reminds me, I finally got my bill of O-care yesterday (have to pay by 12/26 to be covered on 1/1). $220 less than current coverage. |>
Heh, thanks for the concern, and sorry if 64 seemed too standoffish. I probably will talk about it at some point. But it's not an emergency, I don't need to vent or ask for advice, and now's not the time.
In solidarity with 72: I paid my first ACA bill this evening: $347 per month less than current plan, for a lower deductible. Woot!
70: Very interesting to watch what's happening in MN (and MD and OR and HI). Right now I'm calculating about a 25% attrition rate for directors of state-based exchanges.