The Newest Health Wonk Review—on Health Affairs

Chris Fleming hosts the latest edition of Health Wonk Review, a compendium of recent posts on health care blogs.

On Managed Care Matters, Joe Paduda offers 5 predictions for health care in 2013.  He’s convinced that all but a handful of states will expand Medicaid. (“The pressure from hospitals and providers will be overwhelming.”) He also predicts that “The feds and CMS will get even more aggressive on Medicare and Medicaid fraud.”  (For what it’s worth, I think he’s right on both counts.)

                                       Food for Thought

Some posts are likely to stir controversy, either because they’re rebutting the conventional wisdom, or because they’re questioning some deeply held beliefs.  I think these posts are important because they define issues that we should all think about.

Over at Colorado Health Insurance Insider, Louise Norris examines the question of whether smokers should pay more for their health insurance.  Under the ACA, smokers can be charged up to 50 percent more than nonsmokers.  . . .

“Norris prefers the carrot over the stick,” Fleming observes, “endorsing the requirement that all plans cover tobacco cessation programs as part of the ACA’s preventive services mandate, although she cites evidence showing that implementation of this requirement has been inconsistent. “ (It’s worth noting that tobacco cessation programs work. “Sticks,” behavioral psychologists tell us, just aren’t nearly as effective.) 

The Hospitalist Leader’s  Brad  Flansbaum suggests that our emphasis on getting everyone vaccinated during a severe influenza (and claims about Tamiflu) may well amount to “oversell.”  Eye-opening.

 At the Innovative Health Media Blog  David Wilson writes: “The Medicare Annual Wellness Visit  (AWV) is the perfect vehicle to address the increasing need for early detection of cognitive impairment.  The AWV” gives physicians the opportunity “to provide such a screening and receive reimbursement for it .

“Once a patient shows the need for additional testing physicians can use self-administered computerized tests to perform the additional screening without referring the patients to another doctor or office,” he adds. ” This also creates additional reimbursement for physicians.” 

MM–I can’t help but ask: “Since we have no cure or effective treatments for Alzheimer’s (or most forms of senile dementia) do you really want to know that, in three or four years, you may  be diagnosed with full-blown Alzheimer’s?”

Certainly, seniors who want this testing should have access to it. Perhaps, one day, accumulated data will help researchers understand the disease. But Medicare patients should know that they can say “No” There is no requirement that this be part of your Annual Wellness visit.

On the Health Business Blog, another David Wilson has published a post that is likely to be even more controversial. He argues that “The Nursing Shortage is a Myth.”

We have plenty of nurses,  Wilson suggests. In fact, in the future, he writes, “robots will be replacing nurses “just as robots have replaced “paralegals” and “actuaries.” (“Insurance companies used to hire tons of them, but their work can be done much more efficiently with computers.”)

Over at Wright on Health, Brad Wright takes a look at the recent Institute of Medicine report comparing health in the U.S. to health in other wealthy nations. He notes that data on preventable deaths among young people points to the importance of public health interventions, including reducing access to guns.


 Health Care Spending

In the last two weeks a number of healthcare wonkers have focused on health care expenditures,, including Adam Fein (who looks at spending on prescription drugs)   and Jaan Sidorov, who  questions claims by Richard Kronick and Rosa Po at HHS that the Affordable Care Act deserves credit for Medicare per-beneficiary spending growth of only 0.4 percent in 2012.

(Fleming notes “When the first sentence of Jaan’s post contained the words ‘North Korea,’ I had a sense this wasn’t going to end well for the ACA.”)

Over at Health Care Renewal Roy Poses suggests that one reason health care costs so much is because the policy community politely refrains from talking about widespread unethical behavior in our money-driven health care industry.  

Writing on Health Affairs, Arthur Kellermann and David Auerbach focus on the impact of health care costs on consumers from 1999 to 2011, observing that “if health care costs over this 12-year interval had kept pace with the growth of other consumer prices” a typical middle-class “family would have had an extra $6,000 to direct towards other priorities in 2011 alone. Imagine what that might have meant to them, to millions of middle-class families like them.” /

Exactly. The pain is becoming too great—and this makes regulation and legislation that reins in prices inevitable. 

On the Health Care Economist, Jason Shafrin offers the good news:  Over  the past 3 years, health care inflation has slowed significantly. Will the trend continue ?

John Goodman doesn’t think so. On his Health Policy Blog, he expresses skepticism that reform initiatives such as medical homes, coordinating care and practicing evidence-based medicine will reduce the cost of health care/

 (Though one would think that coordinating care  and paying attention to medical evidence when practicing medicine would improve the quality of care. And long-term, that should mean fewer hospitalizations –and lower costs.)

The Health Access Blog’s Anthony Wright is more optimistic.He believes that, after making some tough cuts, California is now in a position to leverage federal funding not just to expand Medicaid, but to improve it along with the entire state health infrastructure.  California has been in the vanguard of health care reform, and I have long thought that Governor Jerry Brown (who understood that “less is more” long before most Americans) may well turn California into an “Accountable Care State.”   

Workers’ Comp Insider’s Jon Coppelman points out that our century-old workers’ comp system is not designed to handle the increasing numbers of older workers in the modern workforce.   He offers a compelling case study.

Insure Blog’s Mike Feehan asks whether insurance co-ops will be able to compete with established insurers.  A good question.



4 thoughts on “The Newest Health Wonk Review—on Health Affairs

  1. Maggie:

    I am crying crocodile tears for smokers paying 50% more than the lowest cost insuree. This is a tough pill to swallow for smokers who self-inflict this damage to themselves. The 50% premium for smokers pales in comparison to the 300% above the lowest cost insure, the elderly will pay for just being old a condition which is unavoidable. Come on Louise, you can not be serious.

  2. run75411

    Good to hear from you.

    Smoking is all about poverty.

    Most people don’t know that the vast majority of adult smokers in the U.S. are low-income, didn’t complete high school, and leading very stressful lives. This is why they smoke. As a recent study of smokers in New Orleans and Memphis quotes one of the research subjects: “”So many things fill your mind and you go through so much, you need your cigarette to smoke to calm down and get things off your mind,” says one of the participants, quoted in an article about the study in the March/April issue of the American Journal of Health Promotion.

    “In our study, cigarette use was defined as a ‘buffer’ for dealing with multiple demands, financial insecurity and daily hassles,” say Bettina M. Beech, Dr.P.H., M.P.H., of the University of Memphis, Department of Psychology and colleague.

    More affluent better-educated Americans are far more likely to quite smoking than low-income very poor Americans for several reasons. 1)
    they have a reason to want to live. If you’re a black male who can’t find work, can’t put enough food on the table to feed your kids, and worry about what’s going to happen to them on the street, you’re angry, depressed and stressed. You are far more likely to engage in self-destructive behaviors –smoking, drinking, drugs.
    No matter how hard you try, chances are slim that your life is going to improve.
    Secondly, if you’re poor you cannot afford the nicotine patches and other drugs that making stopping so much easier for more affluent people. You probably also don’t have a doctor to prescribe these things.
    Louise is right– we need free smoking cessation clinics. The VA and Kaiser have both shown that they work.
    Of course poor people would like to quite smoking. A recent study in New York state shows that they spend 25% of their income on cigarettes. So why don’t they save up that money and buy a nicotine patch?
    Depression and stress sap a person’s will–and their ability to hope. Even if they stop smoking, they know that their lives are not going to suddenly get better.
    As the U. of Santa Clara points out on its Ethics home page: “, penalizing individuals for unhealthy behaviors could result in great injustice and social harm. While 18 percent of U.S. citizens with incomes above the poverty line smoke, for example, the figure almost doubles to 33 percent for those with incomes below the poverty line. A one-dollar cigarette tax would have a strongly regressive effect on the low incomes these individuals receive. Consider the added problem of tobacco addiction and the probable result of a tax is not less smoking or lower health care costs, but fewer dollars spent on nutritional food and other essentials – conceivably leading to more illness and higher health care costs.”
    By charging smokers more for insurance, you increase the chances that they won’t be able to afford it. Given the choice between cigarettes– which they are addicted to and which they associate with relief of stress–and insurance, they’ll choose the cigarettes.
    Bottom line, when we blame smokers for smoking, we are blaming the poor for being poor.
    Tobacco companies know why people smoke.
    Consider this confidential internal Philip Morris report: “”Lower class panelists smoke more and are much more likely to be smokers than upper class panelists…”

    It also found that lower class people tend to smoke nonfiltered cigarettes (tend to “avoid health filters”) and that they also tend to avoid 100 millimeter-length brands.

    The writers also observe that lower class people have more incidence of poor mental health, hypothesizing that people use smoking as a “strategy” to combat the stress of low class status as well as poor mental health:

    “…the incidence of poor mental health is greatest among the lower class…To the extent that smoking is one of the available strategies people can adopt to combat stress, we therefore would expect greater incidence of smoking among the lower social classes.”
    This is why in recent years, tobacco ads have targeted low-income people and African Americans. (Btw–they’re right, smoking is also associated with mental health problems.)

    • Thanks Run–
      I’m spent a lot of time thinking and writing about smoking–all the way back to the early Nineties
      when I wrote about the Tobacco companies. (At that time they were targeting kids and poor people. Among eduated middle-class and upper-middle class people, smoking had become socially unaceptable.)
      At the time, I realized that the problem is not the smokers–it’s the tobacco companies that sell an
      addictive product which kills people.
      It would be nice if there was a provision in the ACA
      that raised their taxes.
      Clearly their shareholders would feel this was unfair. But I really don’t see how
      people can invest in companies that make an
      addictive product that kills their fellow human beings.