Aaron E. Carroll's Blog, page 113

The CDC Director bought tobacco stocks. Should we laugh or cry?

The Director of the Centers for Disease Control resigned yesterday after Politico disclosed that

[She] bought shares in a tobacco company one month into her leadership of the agency charged with reducing tobacco use — the leading cause of preventable disease and death and an issue she had long championed.

The CDC’s core mission is the prevention of mortality and morbidity. According to the CDC,

Smoking is the leading cause of preventable death. Worldwide, tobacco use causes nearly 6 million deaths per year, and current trends show that tobacco use will cause more than 8 million deaths annually by 2030.

Investing in a tobacco stock while running the CDC is such brazenly deviant behaviour that one wants to laugh. But there is something significant at stake.

C. S. Peirce remarked that asserting a proposition entails a commitment to its truth.

What is the nature of assertion? We have no magnifying-glass that can enlarge its features, and render them more discernible; but in default of such an instrument we can select for examination a very formal assertion, the features of which have purposely been rendered very prominent, in order to emphasize its solemnity. […] This ingredient, the assuming of responsibility, which is so prominent in solemn assertion, must be present in every genuine assertion. For clearly, every assertion involves an effort to make the intended interpreter believe what is asserted, to which end a reason for believing it must be furnished. But if a lie would not endanger the esteem in which the utterer was held, nor otherwise be apt to entail such real effects as he would avoid, the interpreter would have no reason to believe the assertion.

Saying something with the intention that others should believe it makes us responsible, to the best of our abilities, for the truth of that statement. When scientific journals require authors to give their final approval of a manuscript, that ritual expresses that responsibility and commitment. Conversely, when someone repeatedly lies, we learn that their statements are just performances, with at best accidental connections to facts.

Something similar happens with values. When you espouse a value, you assert that it is a reason motivating your actions. Hence leaders of organisations are responsible for ensuring that the actions of employees comport with the organisation’s values. So when people behave in ways that traduce their espoused values, we learn that those espousals are just performances — empty signals of virtue — not the provision of reasons for action.

It’s wise to be sceptical about the statements of fact and espousals of values by leaders of nations or organisations. Nevertheless, it corrodes democracy when leaders have little honesty or integrity. We can’t have reasoned public discourse about laws or policy if there’s no glue attaching statements to facts or actions to values.

@Bill_Gardner

Preventive Care Saves Money? Sorry, It’s Too Good to Be True

The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

The idea that spending more on preventive care will reduce overall health care spending is widely believed and often promoted as a reason to support reform. It’s thought that too many people with chronic illnesses wait until they are truly ill before seeking care, often in emergency rooms, where it costs more. It should follow then that treating diseases earlier, or screening for them before they become more serious, would wind up saving money in the long run.

Unfortunately, almost none of this is true.

Let’s begin with emergency rooms, which many people believed would get less use after passage of the Affordable Care Act. The opposite occurred. It’s not just the A.C.A. The Oregon Medicaid Health Insurance experiment, which randomly chose some uninsured people to get Medicaid before the A.C.A. went into effect, also found that insurance led to increased use of emergency medicine. Massachusetts saw the same effect after it introduced a program to increase the number of insured residents.

Emergency room care is not free, after all. People didn’t always choose it because they couldn’t afford to go to a doctor’s office. They often went there because it was more convenient. When we decreased the cost for people to use that care, many used it more.

Wellness programs, based on the idea that we can save money on health care by giving people incentives to be healthy, don’t actually work this way. As my colleague Austin Frakt and I have found from reviewing the research in detail, these programs don’t decrease costs — at least not without being discriminatory.

Accountable care organizations rely on the premise that improving outpatient and preventive care, perhaps with improved management and coordination of services for those with chronic conditions, will save money. But a recent study in Health Affairs showed that care coordination and management initiatives in the outpatient setting haven’t been drivers of savings in the Medicare Shared Savings Program.

There’s little reason to believe that even more preventive care in general is going to save a fortune. A study published in Health Affairs in 2010 looked at 20 proven preventive services, all of them recommended by the United States Preventive Services Task Force. These included immunizations, counseling, and screening for disease. Researchers modeled what would happen if up to 90 percent of these services were used, which is much higher than we currently see.

They found that this probably would have saved about $3.7 billion in 2006. That might sound like a lot, until you realize that this was about 0.2 percent of personal health care spending that year. It’s a pittance — and that was with almost complete compliance with recommendations.

One reason for this is that all prevention is not the same. The task force doesn’t model costs in its calculations; it models effectiveness and a preponderance of benefits and harms. When something works, and its positive effects outweigh its adverse ones, a recommendation is made.

This doesn’t mean it saves money.

In 2009, as part of the Robert Wood Johnson Foundation’s Synthesis Project, Sarah Goodell, Joshua Cohen and Peter Neumann exhaustively explored the evidence. They examined more than 500 peer-reviewed studies that looked at primary (stopping something from happening in the first place) or secondary (stopping something from getting worse) prevention. Of all the interventions they looked at, only two were truly cost-saving: childhood immunizations (a no-brainer) and the counseling of adults on the use of low-dose aspirin. An additional 15 preventive services were cost-effective, meaning that they cost less than $50,000 to $100,000 per quality adjusted life-year gained.

But all of these analyses looked within the health care system only. If we really want to know whether prevention saves money, maybe we should take a wider perspective. Does spending on prevention save the country money over all?

A recent report from the Congressional Budget Office in the New England Journal of Medicine suggests the answer is no. The budget office modeled how a policy to reduce smoking through higher cigarette taxes might affect federal spending. It found that such a tax would cause many people to quit smoking — the desired result. In the short term, less smoking would lead to decreased spending because of reductions in health care spending for those who had smoked.

In the long run, all of those people living longer would lead to increases in spending in many programs, including health care. The more people who quit smoking, the higher the deficit from health care — barely offset by the revenue from taxing cigarettes.

But money doesn’t have to be saved to make something worthwhile. Prevention improves outcomes. It makes people healthier. It improves quality of life. It often does so for a very reasonable price.

There are many good arguments for increasing our focus on prevention. Almost all have to do with improving quality, though, not reducing spending. We would do well to admit that and move forward.

Sometimes good things cost money.

@aaronecarroll

The Connection Between Retiring Early and Living Longer

The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

You may not need another reason to retire early, but I’ll give you one anyway: It could lengthen your life.

That’s the thrust from various research in recent years, and also from a 2017 study in the journal Health Economics.

In that study, Hans Bloemen, Stefan Hochguertel and Jochem Zweerink — all economists from the Netherlands — looked at what happened when, in 2005, some Dutch civil servants could temporarily qualify for early retirement.

Only those at least 55 years old and with at least 10 years of continuous service with contributions to the public sector pension fund were eligible. Men responding to the early retirement offer were 2.6 percentage points less likely to die over the next five years than those who did not retire early. (Too few women met the early retirement eligibility criteria to be included in the study.)

The Dutch study echoes those from other countries. An analysis in the United States found about seven years of retirement can be as good for health as reducing the chance of getting a serious disease (like diabetes or heart conditions) by 20 percent. Positive health effects of retirement have also been found by studies using data from Israel, England, Germany and other European countries.

That retirement promotes health and prolongs life isn’t obvious. After all, work provides income and, for some, health insurance — both helpful for maintenance of well-being. It also can provide purpose and camaraderie. Evidence is mounting that loneliness and social isolation are linked to illness, cognitive decline and death. One study of American retirees found them less likely to be lonely or depressed.

Some work involves physical activity, which can help keep bodies healthy, too. One study found that those accustomed to getting exercise through physically strenuous jobs — like construction or landscaping — are more likely to become obese upon retirement than those who don’t have such jobs.

But for many people, work can be stressful, take time away from exercise, and promote bad habits like excessive alcohol consumption. The Dutch study found that half of the mortality reduction associated with retirement is attributable to cardiovascular and digestive system diseases. Obesity, smoking and alcohol consumption, as well as reduced exercise and stress, can all contribute to these. If you drive to work, that’s another life-threatening risk.

Teasing out the causal effect of retirement on health isn’t straightforward. After all, some people retire precisely because they are in declining health. Without careful analysis, you might conclude that retirement causes poor health and an earlier death.

Indeed, some studies find retirement associated with worse health and reduced longevity. One found that retirement raises the risk of cardiovascular disease and mortality. Another found higher risks of cardiovascular disease and cancer. But another such study found that poor health outcomes were more pronounced among retirees who were unmarried, reduced their physical activity, and had less social interaction. In other words, it isn’t retirement itself that affects health, but what you do in retirement.

Keeping active and developing healthy habits are good ideas. Physical activity is associated with prevention of disease and reduced mortality in older people. Lack of time, perhaps due to work, is a chief reason many adults don’t exercise. Retirees are more likely to exercise, and those who do are better off for it. One study found retirees get more sleep and spend more time doing household work and gardening — both of which are more active than a desk job. Another study found that better health in retirement may be because of the reduced likelihood of smoking.

The age for full Social Security retirement benefits has been on a schedule, increasing gradually from 65 to 67 (67 for those born in 1960 and later). Those working longer as a result are in worse health than earlier cohorts. To retire, they’d have to rely more on their own savings.

But according to a recent national survey by the Board of Governors of the Federal Reserve System, many Americans don’t have the resources to retire. About 20 percent of Americans over 44 years old have no retirement savings. Half of Americans are at risk of being unable to maintain their standard of living in retirement. If you want to retire, whether for health benefits or otherwise, you’ll have to start preparing when you’re still young.

@afrakt

Are Medicaid work requirements legal?

That’s the title of a new piece of mine that came out in JAMA this morning. It’s pretty timely: a lawsuit was filed last week challenging CMS’s approval of Kentucky’s waiver, which includes work requirements. More waivers, and more litigation, are sure to come.

I’m no fan of work requirements. They’re harsh, stigmatizing, and ineffective. And they will hurt people, including the disabled, to no good end. But I’m skeptical of the litigation.

[In general,] the courts have not been moved by the argument—true though it may be—that Congress never meant for section 1115 to be a vehicle for the adoption of sweeping, controversial, and partisan reforms to Medicaid. Instead of winning in court, the opponents of work requirements may need to win some elections.

For a contrary view, take a look at Emily Parento’s and Nicole Huberfeld’s op-ed in the Lexington-Herald Leader.

@nicholas_bagley

Healthcare Triage: Behavioral Economics Aren’t that Convincing in Medicine

There have been a lot of stories about using behavioral economics to change a wide array of human behaviors. Studies have looked at adherence to treatments, weight control, and lots of other areas, and have found that trying to change people with economics isn’t all that effective.



This episode was adapted from a column I wrote for The Upshot. Links to further reading and sources can be found there.

@aaronecarroll

Come work with me (job posting 1, re-up)

Colleagues and I are still advertising for research data analysts. If that’s you, this is an opportunity to work with us at the Partnered Evidence-based Policy Resource Center (PEPReC). Though PEPReC is a center in the Veterans Health Administration, the position will be filled through Boston University.

Apply here. (We are also looking for policy analysts.)

PS: Yes, the job posting has a typo: “SA” should be “SAS”.

@afrakt

Health and Financial Literacy Courses in Kentucky’s Medicaid Waiver

The following originally appeared on The Upshot (copyright 2018, The New York Times Company). It also appeared on page A12 of the print edition on January 23, 2018.

If you’re on Medicaid in Kentucky and are kicked off the rolls for failing to meet the state’s new work requirements, Kentucky will be offering a novel way to reactivate your medical coverage: a health or financial literacy course you must pass.

The precise content of the courses is not yet worked out but may include instruction on household budgeting, how to open a checking account, weight management and chronic disease management, said Kristi Putnam, a manager with Kentucky Health, the state’s new Medicaid program that includes work requirements. She said quizzes would be included that people must pass to complete the course.

Kentucky says the courses, along with the bigger elements of the recently approved waiver it received from federal Medicaid rules, will help to “empower individuals to improve their health.”

The courses are just one way people subject to and failing to meet work requirements could regain coverage. But some health policy experts express dismay with the approach. For one thing, many Americans, not just those who seek Medicaid, struggle with health and financial literacy. And to some, literacy quizzes — however well intentioned — evoke the tests used to impede voting registration of black Americans in the Jim Crow South.

“Requiring people to pass a health literacy course to get care — care for conditions that might prevent them from passing — is just expensive, punitive and cruel,” said Atul Gawande, a surgeon and a health care researcher with the Harvard T.H. Chan School of Public Health.“It serves no health benefit whatsoever. You have to be concerned about requirements like literacy tests, which states have a bad history of applying selectively and arbitrarily.”

Ms. Putnam said that the courses were “intended to be a tool/support for people to improve both health and finances, and not a barrier in any way.” Her agency, she said, is looking into ways to provide help to people who might struggle with understanding the courses.

There is no standard definition for health literacy. Ms. Putnam said Kentucky’s “pertains to learning about healthy habits, how to manage chronic conditions, effectively utilizing health care benefits and understanding commercial market insurance concepts.”

However defined, health literacy is related to literacy and numeracy more generally. To understand and use health-related information, you need some fluency with written or spoken language, and usually with numbers and basic math as well. People with low skills in other forms of literacy or numeracy also have lower health literacy.

Apart from instruction aimed at specific populations with certain conditions — such as training to self-manage chronic diseases like diabetes and hypertension, or even birth training classes for pregnant women and their partners — health literacy courses are uncommon. (Say Ah! is one source for health literacy resources.)

Financial literacy courses are more widely available but still not a routine part of general education.

“If these topics are taught at all in primary education, they certainly aren’t addressed consistently or in an evidence-based way,” said Harold Pollack, a professor at the University of Chicago who was a co-author of a book on basic financial education. “But singling out the Medicaid population for classes as a condition for access to insurance suggests that shrinking and stigmatizing the program, not literacy, is the goal.”

Numerous studies document the widespread need for greater health and financial literacy. By one estimate, one-third of adults have health literacy deficits. For example, most people make errors in selecting health plans and don’t know basic features of the plans they choose.

The last large national survey of U.S. adult literacy (including health literacy) was conducted in 2003. One study found that 60 percent of Medicaid enrollees had only “basic” or “below basic” health literacy, meaning, for example, they could not recognize a medical appointment on a hospital appointment form (below basic) or would have trouble understanding why a specific test was recommended for someone with certain symptoms, even when given a clearly written and accurate explanation (basic).

But Medicaid enrollees are not the only ones. Nearly the same proportion of Medicare enrollees also had basic or below basic health literacy. Privately insured people scored better. They are typically younger than Medicare enrollees, and they typically have higher education levels and are less likely to have cognitive impairments than those with public coverage. However, only a small minority even of the privately insured had a “proficient” level of health literacy — meaning, for example, that they could deduce the employee share of health insurance costs from a table that listed that cost as a function of income and family size.

Another study, based on data collected in 2013, showed adults’ blood test results alongside the normal range (typical of reports many of us receive from our doctors after blood tests). Only about half of the subjects could recognize if the blood glucose level indicated on the test was outside the normal range. Of those with diabetes — to whom blood glucose measurement and levels should be familiar given the importance to their condition — only 56 percent could identify out-of-range values.

Poor health literacy is associated with worse health care outcomes and higher health care spending. But causality could run both ways. It is likely that people in greater need of health care are also less likely to have high literacy skills in general. It’s also possible that poor health literacy contributes to worse self-management of health and lifestyle issues that could result in worsening health and increased health care use.

Likewise, low financial literacy can contribute to insufficient or inefficient saving. One national survey found that only 14 percent of respondents got all the answers right on a five-question quiz about financial topics like interest rates, inflation, bond prices and mortgages. Only 37 percent got four out of five. (As an example of its difficulty, the true/false mortgage question was: “A 15-year mortgage typically requires higher monthly payments than a 30-year mortgage, but the total interest paid over the life of the loan will be less.”)

Other research documents high rates of errors in financial decision making even among highly educated people, including mistakes made in 401(k) investing, selection of mutual funds, use of credit, receipt of payday loansand others.

Addressing these issues through financial literacy education improves financial outcomes. A recent review of financial literacy research found that providing financial literacy education in school settings is effective. So is the approach of targeting education during teachable moments, as when individuals are making financial decisions: taking out a loan, establishing a saving plan, and the like. The Kentucky program would do neither.

Though policy experts are divided on the merits of Kentucky’s health and financial literacy program, there may at least be in agreement that education in both needs improvement. That’s true not just for would-be Medicaid enrollees, but for many of the rest of us, too.

@afrakt

Healthcare Triage Podcast: AIDS Research and Cool Jobs in the Midwest/East Africa, featuring Dr. Rachel Vreeman

This week on the HCT podcast, we’re talking to Dr. Rachel Vreeman, who is going to tell us about her super cool job. She works on a partnership between a hospital in Indiana and a hospital in Kenya, and researches AIDS treatment in Africa. Pretty cool. Plus, Rachel and Aaron answer your questions!

Rachel is a superstar, and I’m not just saying that because she was my first fellow and co-author on three books. She’s amazing for everything else she does. Go listen. You can find the podcast in all the usual places, like iTunes, Soundcloud, or even on YouTube.

#6: AIDS Research and Cool Jobs in the Midwest/East Africa, – Guest: Rachel Vreeman

@aaronecarroll

Healthcare Triage: Lawsuits as a Tool to Stifle Research

Health research is difficult for a bunch of reasons. One of those reasons is the practice of using lawsuits to stifle research. A researcher finds that a product is harmful, and the producers of that product attack the researcher in court, in an attempt to discredit the scientists, stop the research, and protect profits. This has happened with lead, it’s happened with guns, and it has happened with synthetic amphetamines in dietary supplements. Unbelievable, but true.



This episode was adapted from a column I wrote for the Upshot. Links to sources and further reading can be found there.

@aaronecarroll

Help me learn new things in 2018 – Rome! (What should I read?) – Updated

I’m going to spend February learning about the history of Rome. You’ve already given me some great ideas. I want to post them here, so you can help me prioritize what to read. If you think I’m missing something, please go tell me. I’m opening comments, or you can tweet me.

The Storm Before the Storm by Mike Duncan
The History of Rome: The Republic by Mike Duncan
Decline and Fall of the Roman Empire by Edward Gibbon
SPQR by Mary Beard
Rome: An Empire’s Story by Greg Woolf
The Fall of the Roman Empire: A New History of Rome and the Barbarians by Peter Heather

Some also suggested Anthony Everitt’s biographies of Cicero, Augustus, Hadrian. What do you all think? Any thoughts on the order?

@aaronecarroll

I updated the list as more recommendations came in. (AC)