On Ending a Health Care Fallacy

Introduction
Here it’s argued that we need to retire the health care fallacy, “We spend more on health care than other rich countries but have worse outcomes.” The fallacy implies U.S. health care is deficient in spite of being costly. Indeed our health care costs too much, but there is little evidence that our care is less effective than care in other countries. On the other hand, there’s plenty of evidence that our social determinants of health are worse.

The argument segues off a recent article by Victor Fuchs. The case is presented by using a simple linear model to explore how life expectancy might change when we substitute the numbers of other countries’ determinants of health for U.S. numbers. After making these substitutions and holding health care spending constant the model predicts U.S. life expectancy is right there with the other OECD countries, 81.6 years compared to their average 81.4 years. This what-if modelling makes clear what should be obvious but the fallacy hides, that health care is only one part of population health.
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On Refusing to Expand Medicaid

Robert Pear wrote in the Times that the refusal by “states to expand Medicaid will leave millions of poor people ineligible for government-subsidized health insurance…” 1 Indeed, the refusals will do that, as well as worsen what instead should be remedied. In the following I present a graph of two chronic diseases over the 50 states. Those states which have opted out of the Medicaid expansion are identified. Additionally each state’s poverty rate is indicated. The take-away is that populations in greater need are being further disadvantaged. A conjecture is presented as to why. Continue reading

  1. http://www.nytimes.com/2013/05/25/us/states-policies-on-health-care-exclude-poorest.html?hp&pagewanted=print

A Fresh Look at Health Care Cost Growth

In this post I recast the visual display of international health care expenditures. For select OECD countries, this clearly shows the growth of average costs has been moderating while U.S. cost-growth has been accelerating. The graph methodology is discussed along with a caution about marginal thinking. A conjecture is presented as to why the OECD cost-growth is moderating followed by a couple thoughts for action. Continue reading

Hold that Health Care Shibboleth

“We spend far more on health care than other peer countries yet have worse outcomes. Why is U.S. health care so expensive?” I’m sure you’ve encountered similar statements, maybe even expressed it yourself. It occurs often, including by knowledgeable people and health-related institutions. However, it’s a fallacy because it confuses health care with population health. Continue reading

The Human Cost of Ideology IV

Introduction
Our environments of education, living, and work manifestly determine our health and are often referred to as Social Determinants of Health (SDH). The social determinants are in addition to our genes and behaviors. They are external attributes, rather than internal. What I find striking about international comparisons is other developed countries promote healthier SDH and have superior population health outcomes. Why is the U.S. different? Continue reading

The Human Cost of Ideology: Health, Medicaid and Conservatism

Medicaid is on the table again. This is good, and in principle so are the discussions related to costs and policy intentions. Nevertheless, my view is that too much of the conversation has been at the 20,000 foot level, kept aloft by ideologies. Here are my impressions of what’s being said: We will not go along with a massive increase of the Medicaid program, especially under Obamacare, and furthermore such entitlement programs weaken us as a people. Meanwhile different voices assert: There is a need for Medicaid, cutting it back will hurt our most vulnerable populations. Expansive commentary about Medicaid has been elevated since the Supreme Court ruled on the Affordable Care Act in late June and boosted again beginning early September by Bill Clinton’s speech at the Democratic National Convention.

Let’s drop down a few thousand feet. Using data freely available on the Internet, the accompanying chart gives a more detailed view. The chart’s three plots all share the same horizontal axis, the percentage of people in each state that self-identify as politically conservative. The vertical axes represent child poverty, coronary heart disease, and Medicaid expenditures. The average trend lines are highly significant. In one sentence, the chart shows health needs increasing while providing for those needs through Medicaid deceases, all as the concentration of conservatism deepens.

Here is the context. Child poverty is both about children’s current health and a determinant of future health. It is the human-society equivalent of a canary in the coal mine. Children raised in poverty, on average, have more health problems both as children and as adults. And poor children are more likely to grow up to be poor, almost one-half become poor adults. As for heart disease, over the past 30 years there’s been a marked reduction in mortality rates. This is a major health-care success story. Nevertheless, coronary heart disease is still the leading cause of death in the United States and the most expensive to treat. Poor children, and adults with coronary heart disease, are a large part of the Medicaid caseload and budget. Nationally children make up about two-thirds of Medicaid beneficiaries while adults account for over two-thirds of the costs, a good part surely due to heart disease.

The prevalence of child poverty and coronary heart disease changes with the sway of conservatism as it moves across the states. Additionally, the chart provides a glimpse of the nation’s vigor. Not shown is that the two health outcomes correlate with other impairments of health, such as diabetes and poor health status. Thus child poverty and coronary heart disease can also be viewed as population-health indicators, not just isolated outcomes.

So what’s driving the strong relationship with conservatism? I submit it is the dual ideologies—which have elevated status in the United States—of unregulated markets and individualism. The belief that the market rules and everything has a price, that competition is the wherewithal, that we’re totally self-reliant, and all that’s worthwhile derives from great men so that an unequal society is a good society. I use conservatism as a proxy. If direct measures had existed, the horizontal axis of the chart would have been more accurately labeled “neoliberalism and extreme individualism.”

The average trend lines over the 50 states show that relative to conservatism there is less provision for health as the need increases. It is the lack of resources that weakens us. We would not expect to have a thriving garden without good soil, favorable climate, and attentive care. Are we less than a garden? We also require supportive conditions to flourish. People who think otherwise have their head in the clouds.

Note: A PDF version of this post is here.