Aaron E. Carroll's Blog, page 114

Upshot extra: Medicaid work requirements edition

My Upshot post today is about health and financial literacy courses in Kentucky’s new Medicaid program. An earlier draft had more content about its work requirements. Those paragraphs were cut to focus the piece. Here they are:

Proponents of Kentucky’s approach say work requirements will help Medicaid enrollees. By analogy with food stamps and cash assistance programs that have included work requirements in some states, they argue that encouraging work will reduce Medicaid enrollment. Another advantage they cite is that it would combat needless idleness among adults capable of working. It may also address a perceived inequity, whereby working individuals who make just enough not to qualify for Medicaid have to pay more for health insurance than do Medicaid enrollees who need not work at all.

Ron Haskins, a senior fellow for economic studies and co-director of the Center on Children and Families at the Brookings Institution, advocates affording states flexibility to reform public policies, including Medicaid, to include requirements to work for those who are capable of doing it. “Labor force participation among 25-54 year old men has been declining for decades,” he said. “It has plateaued for other groups more recently, with important consequences for personal finances as well as identity.”

But many health policy experts are not enthused with Kentucky’s program. Some worry it will drown Medicaid enrollees in paperwork, causing many to lose coverage if they get wrapped up in red tape. It would take considerable effort for modest potential gains. Only about one-quarter of Medicaid enrollees in states that have expanded the program under the Affordable Care Act are not working but are capable of working.

“Anger about Medicaid is not surprising. We have taxpayers with jobs that provide no health coverage paying for poorer people to have coverage they couldn’t dream of — with no premiums, copays, or deductibles,” said Atul Gawande, a surgeon and professor with the Harvard T.H. Chan School of Public Health. “This is bound to create bitterness about who is deserving and who is not. The solution isn’t to cut more people off.  That won’t soften the anger. What would is opening up Medicaid more widely, like Medicare. We don’t have these debates about Medicare because everyone contributes as they are able and everyone benefits.”

“Work is an important goal. Health care is an important way to ensure that people can be well enough to work. Refusing health coverage to people unless they work is a proven recipe for more sick people, not more work,” Dr. Gawande said.

The piece is far better with these left out. Go read it!

@afrakt

Help me learn new things in 2018 – the schedule!

After my post asking for your recommendations for books/topics I should learn about in 2018, I got a lot of great responses. If I didn’t choose yours, it’s likely because I already felt like I knew something about the subject (like programming) or because I liked something else just a little bit more. There’s always 2019.

Here’s my proposal. I think I’ll go from past to present. January isn’t happening.

February – Rome
March – The Fall of Rome/The Dark Ages
April – The Revolutionary War
May – The Civil War, part I
June/July – Cocktails
August – The Civil War, part II
September – World War I
October – Nazi Germany
November – World War II
December – TBD/Overflow

Some things to note. I gave The Civil War two months because there were so many books to read. And, I think it deserves it. I also left December open. If I fall behind, this will allow me to push things back. If I stay on schedule, we’ll add something on the fly.

The summer will be for cocktails. Well, the whole year is for cocktails, but I’ll learn a lot this summer. I also want to try and knit more then. We’ll see how I fare. I also need to get back into meditation.

One week before each new month, I will post a query for book suggestions. I have a lot, but there could always be more. I’ll list what I have and ask for more. That will give me time to order them and get going on the first of the month.

I’m excited.

@aaronecarroll

Healthcare Triage News: Get Your Flu Shot! It’s Not About You, OK?

It’s not too late to get a flu shot! You may have heard that the flu shot this year is “less effective” than in earlier years. That may not mean what you think it means. Less effective is a relative relationship, and in absolute terms, the shot is still pretty useful.



This episode was based on a column I wrote for the Upshot. Links and resources found there.

@aaronecarroll

Still Not Convinced You Need a Flu Shot? First, It’s Not All About You

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

One of the biggest problems in trying to convince people that they need to immunize against things like the flu is that they don’t really feel the pressure. After all, for most people, the flu shot is an inconvenience, and they’re unlikely to get the flu in a given year. So why bother? Quite a few readers expressed this view after my article “Why It’s Still Worth Getting a Flu Shot” on Thursday, including this one.

I promise this is an honest question: Are people routinely being destroyed by the flu or something? (I mean, first I’d ask, ‘Is everyone but me simply vaccinated, and thus gifting me with herd immunity?’ And so I did. My first Google search brought me to yearly C.D.C. flu-vaccine coverage statistics, and for the last four years, the percentage of flu-vaccinated adults has been in the low 40s. So… nope.)

I’m not a particularly healthy person — I get colds, sinus infections, etc. — but I just can’t recall ever having had the flu, or at least *knowing* I had it. This seems to indicate that the flu is either 1) rare enough that it’s possible for me to have been lucky forever (in which case it’s fairly rare, apparently), or 2) not severe enough of an illness for me to have noticed experiencing it.

Both lead me to conclude that skipping the vaccine is fine.

I’m just a regular idiot, presumably representing other regular idiots, amenable to changing their habits, but who haven’t done so — not due to obstinance or contrarianism, but due to signals so mixed as to inspire ambivalence — and if this article can be said to have provided the ‘why’ its headline promises, unfortunately it hasn’t provided the ‘why’ idiots like me need to hear:

Why is the flu a big deal literally at all? — Chrystie, Los Angeles

Although I devote some of my articles to telling you not to worry so much about some diseases or other risks, influenza is one thing you actually should worry about. It’s terrible; it’s also far too common.

Influenza, commonly called the flu, spreads easily. You can catch it from someone who coughs, sneezes or even talks to you from up to six feet away. You can infect others a day before you show any symptoms, and up to a week after becoming sick. Children can pass along the virus for even longer than that.

Influenza is not a reportable disease, so its prevalence must be estimated. The Centers for Disease Control and Prevention believes that, since 2010, between 9.2 million and 35.6 million people have come down with the flu in the United States each year. That means that in a bad year, more than one in every 10 people in the United States might get it.

Many of those people end up in the hospital. In a good year, we might see as few as 114,000 people hospitalized with flu-associated illnesses. In a bad year, that number rises to more than 700,000.

In 2014, more than 57,000 people died of influenza/pneumonia. It was the eighth-most common cause of death, behind diabetes (just under 80,000 deaths). It’s also the only cause of death in the top 10 that could be significantly reduced by a vaccine. Lowering risks of heart disease, cancer or Alzheimer’s are much, much harder to do.

In 1995, the worst year of the AIDS epidemic in the United States, fewer than 51,000 people died of it. In 2014, just over 6,700 deaths were attributable directly to H.I.V. Yet it is H.I.V., not the flu, that people dread far more.

Because the flu is so common, we tend to minimize its importance. Consider the contrast with how the United States responded to Ebola a few years ago. We had a handful of infections, almost none of them contracted here. One person died. Yet some states considered travel bans, and others started quarantining people.

Worldwide, just over 10,000 people died in the 2014-15 West African outbreak of Ebola: a relatively new, frighteningly contagious illness that people feared could become a global pandemic. It’s not surprising that it got a lot of attention. Yet the tens of thousands who died of influenza in the United States the same year barely made the news.

It’s possible that so many adults ignore the danger because it seldom affects them directly. Most of the hospitalizations and deaths occur among children and older people. The rates of hospitalization of those less than 5 years of age are twice that of adults under 50. The rates among those 65 or older can be 10 times that of other adults. Almost two-thirds of deaths are among older people.

So much of this is preventable. The C.D.C. estimated that in the 2015-2016 flu season, the flu shot prevented more than five million cases of the flu, about 2.5 million medical visits and more than 70,000 hospitalizations. It was also estimated that it prevented 3,000 deaths.

If just 5 percent more people had been immunized, we could have probably avoided 500,000 illnesses, 230,000 medical visits and 6,000 hospitalizations.

We should also note that the 2015-2016 flu season was also mild. More worrisome is something like what happened with the Spanish flu in 1918-1919. One third of the world population was infected, and about 675,000 Americans died.

They died from the flu.

If you fall into one of the lower-risk groups (i.e., adults age 18-50), you might still think that the flu isn’t such a big deal, and that you don’t need to worry much. I could argue that there’s evidence that even if the shot doesn’t prevent you from getting the flu, it could make your illness less severe. But even this misses a huge point. You don’t get immunized just to protect yourself. You also get immunized to protect those who can’t protect themselves.

Chickenpox — and the varicella virus that causes it — had long been considered a “nuisance” by many. When a vaccine was introduced in 1995, some questioned whether it was necessary for children, since most who got the disease were fine. Pediatricians disagreed; they had cared for the many young children who were hospitalized by the illness, and the surprising number who died — mostly infants.

A study published in Pediatrics in 2011 made the case for why thinking about only yourself is the wrong way to look at varicella vaccination. The first thing it showed was that from 2001 through 2007, as rates of vaccination rose, the rates of death from varicella were low, with just a few children dying from chickenpox nationally each year. But more significant, from 2004 through 2007, not one child younger than 1 year old died in the United States from chickenpox.

What was amazing about this finding was that we don’t vaccinate children that young for chickenpox — therefore, those babies’ deaths were not prevented because they were vaccinated. Their deaths were prevented because we vaccinated their older siblings. That achieved the herd immunity necessary to slow or prevent the rates of infection significantly.

Adults need to get vaccinated to protect children and babies. They need to get vaccinated to protect older people and the immuno-compromised. This is true for almost all diseases, including the flu. Less than 50 percent of children are immunized against the flu. About two-thirds of people 65 and older are.

But only a third of adults 18 to 49 are.

They can do better. If not for themselves, then for those they love.

@aaronecarroll

I’m the new Web and Social Media Editor at JAMA Pediatrics! We’ve got a podcast you might like.

So first off, the news if you missed the headline: I’m the new Web and Social Media Editor at JAMA Pediatrics. I’ve been on the editorial board there for years, and it’s a privilege to serve in this new role.

One thing I’m going to try and do is change up their audio stream. We’re going more podcast. As close-to-every-week as I can manage, I’m going to make a less-than-ten-minute episode talking about a paper being released this week. We’ll try and pick a good one. As often as we can, we’ll make that paper free to read.

You can listen to the first episode here. You can subscribe to the podcast at the bottom of the page here.

@aaronecarroll

Healthcare Triage News: New Year, New News: CHIP, taxes, and Obamacare

We’re back, and it’s 2018, y’all. Let’s talk about what’s happeing with CHiP, taxes and the individual mandate, and the Obamacare exchanges.

@aaronecarroll

Why the U.S. Spends So Much More Than Other Nations on Health Care

The following, jointly authored by Austin Frakt and Aaron Carroll, originally appeared on The Upshot (copyright 2018, The New York Times Company). It also appeared on page B1 of the January 2, 2018 print edition.

The United States spends almost twice as much on health care, as a percentage of its economy, as other advanced industrialized countries — totaling $3.3 trillion, or 17.9 percent of gross domestic product in 2016.

But a few decades ago American health care spending was much closer to that of peer nations.

What happened?

A large part of the answer can be found in the title of a 2003 paper in Health Affairs by the Princeton University health economist Uwe Reinhardt: “It’s the prices, stupid.”

The study, also written by Gerard Anderson, Peter Hussey and Varduhi Petrosyan, found that people in the United States typically use about the same amount of health care as people in other wealthy countries do, but pay a lot more for it.

Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute, studies how health systems from various countries compare in terms of prices and health care use. “What was true in 2003 remains so today,” he said. “The U.S. just isn’t that different from other developed countries in how much health care we use. It is very different in how much we pay for it.”

A recent study in JAMA by scholars from the Institute for Health Metrics and Evaluation in Seattle and the U.C.L.A. David Geffen School of Medicine also points to prices as a likely culprit. Their study spanned 1996 to 2013 and analyzed U.S. personal health spending by the size of the population; its age; and the amount of disease present in it.

They also examined how much health care we use in terms of such things as doctor visits, days in the hospital and prescriptions. They looked at what happens during those visits and hospital stays (called care intensity), combined with the price of that care.

The researchers looked at the breakdown for 155 different health conditions separately. Since their data included only personal health care spending, it did not account for spending in the health sector not directly attributed to care of patients, like hospital construction and administrative costs connected to running Medicaid and Medicaid.

Over all, the researchers found that American personal health spending grew by about $930 billion between 1996 and 2013, from $1.2 trillion to $2.1 trillion (amounts adjusted for inflation). This was a huge increase, far outpacing overall economic growth. The health sector grew at a 4 percent annual rate, while the overall economy grew at a 2.4 percent rate.

You’d expect some growth in health care spending over this span from the increase in population size and the aging of the population. But that explains less than half of the spending growth. After accounting for those kinds of demographic factors, which we can do very little about, health spending still grew by about $574 billion from 1996 to 2013.

Did the increasing sickness in the American population explain much of the rest of the growth in spending? Nope. Measured by how much we spend, we’ve actually gotten a bit healthier. Change in health status was associated with a decrease in health spending — 2.4 percent — not an increase. A great deal of this decrease can be attributed to factors related to cardiovascular diseases, which were associated with about a 20 percent reduction in spending.

This could be a result of greater use of statins for cholesterol or reduced smoking rates, though the study didn’t point to specific causes. On the other hand, increases in diabetes and low back and neck pain were associated with spending growth, but not enough to offset the decrease from cardiovascular and other diseases.

Did we spend more time in the hospital? No, though we did have more doctor visits and used more prescription drugs. These tend to be less costly than hospital stays, so, on balance, changes in health care use were associated with a minor reduction (2.5 percent) in health care spending.

That leaves what happens during health care visits and hospital stays (care intensity) and the price of those services and procedures.

Did we do more for patients in each health visit or inpatient stay? Did we charge more? The JAMA study found that, together, these accounted for 63 percent of the increase in spending from 1996 to 2013. In other words, most of the explanation for American health spending growth — and why it has pulled away from health spending in other countries — is that more is done for patients during hospital stays and doctor visits, they’re charged more per service, or both.

Though the JAMA study could not separate care intensity and price, other research blames prices more. For example, one study found that the spending growth for treating patients between 2003 and 2007 is almost entirely because of a growth in prices, with little contribution from growth in the quantity of treatment services provided. Another study found that U.S. hospital prices are 60 percent higher than those in Europe. Other studiesalso point to prices as a major factor in American health care spending growth.

There are ways to combat high health care prices. One is an all-payer system, like that seen in Maryland. This regulates prices so that all insurers and public programs pay the same amount. A single-payer system could also regulate prices. If attempted nationally, or even in a state, either of these would be met with resistance from all those who directly benefit from high prices, including physicians, hospitals, pharmaceutical companies — and pretty much every other provider of health care in the United States.

Higher prices aren’t all bad for consumers. They probably lead to some increased innovation, which confers benefits to patients globally. Though it’s reasonable to push back on high health care prices, there may be a limit to how far we should.

Help me learn new skills! – the Recap

I like learning new things. I think it’s important. It keeps me fresh. It makes me a better person. I decided, last year, that I wanted to dedicate a significant amount of time this year to learning six new skills. I asked for your help in picking them, and in suggesting things I should read or watch. Each month, I wrote up what I learned, and reviewed the materials.

Meditation and knitting were home runs. So was cooking. I’ve continued that better than any other. I’m even sous viding (is that a verb?) hamburgers tonight. Wish me luck. Drawing was a win in that I learned a lot, but I don’t think I will continue it. Hebrew was a good effort, but there’s still a lot of work to do.

I only missed one block (Electronics), which isn’t that bad considering I still had a full-time job, wrote 30 or so columns for the NYT, made a hundred videos for Healthcare Triage, wrote a handful of times for the JAMA Forum, and published a book.

The individual posts are still available from both The Schedule and here. I wanted to collect all of the recommended materials I used in one place, though. As with last year, I’m pretty happy I managed to pull most of this off.

January/February – Meditation.

Read Dan Harris’s book 10% Happier, if you’re inclined.
Headspace is really helpful. 


March/April – Knitting.

Videos like those from ExpressionFiberArts are invaluable.
A nice resource to have is Stitch ‘n Bitch.
Tools you need include: Bamboo needles, Rounded needles (I bought the 5″ set and a 16″ wire), Knitting markers, crochet needles, sewing needles, counters, double pointed needles, and caps for your needles.


May/June – Drawing.

A drawing set
Drawing on the Right Side of the Brain Workbook


July/August – Hebrew.

Rosetta Stone


September/October – Cooking.

The best book by far is Salt, Fat, Acid, Heat. 
The Flavor Bible can be a helpful reference.
And buy my book!


November/December – Electronics.

A good Arduino kit

I hope you enjoyed this as much as I did. I think I might go back to reading/learning in 2018. More on that to come.

@aaronecarroll

Help me learn new skills in 2017 – Electronics!

This post is part of a series in which I’m dedicating two months to learning six new skills this year. The full schedule can be found here. This is month eleven/twelve. 

I failed. I tried my best to get this done, but I couldn’t. I will say this. I bought an Arduino kit from Amazon and began to work with it. It’s fricking incredible. The programming language is pretty simple (if you already know how to program a language like C+, I should say). The components are unbelievable, especially for the money. I’d need more time to play around with them to design something cool, but I can see how you could learn to put these things together to build something pretty amazing. I wish I’d had more time, but November and December crushed me.

I will put this away and save it for some magical month in the future when I have more time. It will be worth it.

@aaronecarroll

Healthcare Triage News: Should You Panic about the Breast Cancer/Birth Control Stories?

No. It turns out, media outlets sometimes sensationalize connections like this. Hormonal birth control is safe, and while it does come with some risks, the benefits very often outweigh the downsides.



This episode was based on a column I wrote for the Upshot. Links and further reading there.

@aaronecarroll