Aaron E. Carroll's Blog, page 127

Healthcare Triage: A Brief History of Guns in America: Guns and Public Health Part 1

Firearms have a long and unique history in the United States. They’re controversial, and they have a huge impact on public health and safety. This month’s special Healthcare Triage series will look at firearms as a public health issue in the United States. This week, we’ll be looking at the history of guns in the US, and how gun legislation has changed over the last couple of hundred years, and how courts’ interpretations of the second amendment have changed. In the next few weeks, we’ll look at gun homicides, gun suicides, and firearm policy.

This series was produced with support from the NIHCM Foundation.

Further reading:

The Second Amendment & the Right to Bear Arms
The Secret History of Guns
The History and Evolution of Guns as Told Through Pictures
A Brief History of Firearms
Why millions of Americans — including me — own the AR-15
Why Do Democrats Keep Trying to Ban Guns That Look Scary, Not the Guns That Kill the Most People?

@aaronecarroll

Healthcare Triage News: Republicans Didn’t Quite Repeal Obamacare…Yet

I assume regular readers of the blog are up to date on Repeal and Replace news. But if not, Healthcare Triage has got you covered!

@aaronecarroll

Maternal deaths are a national tragedy that deserve a national response

Katy Kozhimannil, PhD, MPA is Director of Research at the University of Minnesota Rural Health Research Center and an Associate Professor in the Division of Health Policy and Management, University of Minnesota School of Public Health. You can follow her on Twitter at @katybkoz.

In a recent column, aptly titled “If Americans Love Moms, Why Do We Let Them Die?” New York Times columnist Nick Kristof states that “we’ve structured health care so that motherhood is far more deadly in the United States than in other advanced countries,” and cites data showing that an American woman is five times as likely as a British woman to die around the time of childbirth.

In the U.S., maternal mortality has doubled over the past two decades. This has occurred during a time when almost all other developed and developing countries in the world have seen declines.  Our high rates of maternal mortality and recent increasing trends have been called a national embarrassment. What’s more troubling still is the staggering racial inequities in maternal mortality. The CDC’s data show pregnancy-related mortality of 12.7 deaths per 100,000 live births for white women, which is shockingly high compared with other countries.  Black women have nearly four times the risk of death around the time of childbirth.  The pregnancy-related mortality rate is 43.5 deaths per 100,000 live births for black women in the US.

The top journal for obstetricians, Obstetrics and Gynecology, recently published a perspective article by Dr. Steven Clark and Dr. Michael Belfort. These two highly respected obstetricians and seasoned researchers have spent their careers studying maternal mortality, and they argue the case for establishing a national maternal mortality review committee in the United States. It is both a public health and equity imperative to establish such a committee.

The authors point to examples from other developed countries, including a recent surveillance report from the UK’s national maternal mortality tracking system, which have helpfully informed public health and clinical efforts to reduce maternal mortality. The call by Drs. Clark and Belfort builds upon CDC efforts and a recent Health Affairs Blog by Assistant Surgeon General Dr. Wanda Barfield highlights the many efforts underway, but these efforts need greater structure, resources, and consistency across settings.

About half of all states have maternal mortality review committees.  I have served on Minnesota’s committee since 2012.  We spend hours and hours reviewing each maternal death, assessing preventability and making recommendations. To my knowledge the data from our work has never been publicly released, and our numbers are too small for meaningful statistical estimates.  Serving on this committee is emotionally difficult, to be sure, but it’s frankly heartbreaking to know that our work (and the tragedies we review) have little influence on the rising tide of maternal mortality.

As a member of Minnesota’s maternal mortality review committee, I am familiar with the CDC’s newly-launched MMRIA data system, and while this is a step in the right direction, it still falls short: data are not collected across all states, are not collated or integrated for analysis, and are not easily available for states or researchers to study patterns.

The Obstetrics and Gynecology article notes the need for federal guidance and support in creating a functional national maternal mortality review committee, as infrastructure and data differ dramatically across states.  Drs. Clark and Belfort state: “The establishment of such a committee would in fact probably quite literally take an act of Congress to effectively deal with issues of funding, privacy, and legal liability. However, unless we are to be satisfied with another decade of hand-wringing and strident calls to action, we cannot imagine anything more likely to be actually effective than the establishment of such a committee.”

In July 2017, I wrote to the CDC’s Division of Reproductive Health about this issue, and I received a prompt response highlighting the importance of state and local efforts, as well as the CDC’s efforts to support regional approaches for rural and smaller states to work together. The response also noted the crucial role of data availability on maternal deaths in the US, citing the “ultimate aim of having robust, national data to improve maternal outcomes and eliminate preventable maternal deaths.”

Yet, it stopped short of offering support for a national maternal mortality review committee.  Perhaps the current political climate hampers feasibility, with a focus on greater local control and flexibility.  But our current trajectory makes it clear that’s not enough.

Recent media attention, including an amazing in-depth investigation of maternal deaths by Pro-Publica and NPR and a Vox.com series by Julia Belluz focusing on successes in California and North Carolina, are bringing new light to maternal mortality.

The time is right to take national action to address this national crisis, by structuring and resourcing a federal maternal mortality review committee.

More about cost-sharing reductions, now in podcast format

I had the good fortune yesterday to be a guest on Dan Diamond’s terrific podcast, POLITICO’s Pulse Check.

The central fight over the ACA has (for now) moved from Congress to the White House, where President Donald Trump is debating whether to yank key payments for insurers. But some senators are hinting that a bipartisan compromise on Obamacare is coming — as long as Trump doesn’t blow up their efforts, that is.

First, POLITICO’s Jennifer Haberkorn and Paul Demko join Dan Diamond to talk about what’s next in the Senate, the legal case that gives Trump the power to nix the payments, and what it was like to watch the dramatic vote early Friday morning. (Starts at 1:30.)

Then after the break, Nicholas Bagley, a University of Michigan law professor who’s a leading voice on the ACA’s legal issues, explains the theory behind the current case, what happens in the courts if Trump yanks the payments, and the series of legal attacks on Obamacare over the years. (Starts at the 22:45 mark).

The podcast was really fun to do, and Dan is a wonderful interviewer. Give it a listen!

@nicholas_bagley

When Children Lose Siblings, They Face an Increased Risk of Death

The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

Of all the possible tragedies of childhood, losing a sister or brother to early death is almost too awful to contemplate. Yet it is startlingly common. In the United States, 5 to 8 percent of children with siblings experience such a loss.

The immediate effects of a sibling’s death, and the grief that follows, are obvious to all. But the consequences are more than emotional and can last for decades. They are even associated with an increased risk of death in those who remain.

A recent study in JAMA Pediatrics followed all children in Denmark and Sweden from 1973 through 2013. More than 55,000 of these children experienced the death of a sibling before they turned 18. In the 37 years of follow-up, these children were more than 70 percent more likely to die as well. Although the overall risk of death remained low throughout these years, it was highest in the first year after a sibling’s death. During that period, children who lost a sibling have a mortality rate two and a half times that of other children.

Why are children who lose siblings more likely to die, even decades later? One of the reasons is probably genetic. In the study, many of the children who died later, even those who died within a year of each other, died of the same disease as their sibling.

Another factor could be the emotional impact and its effects on mental health, especially in the short term. Children who lose their parents are more likely to engage in alcohol and substance abuse not long after, often because of greater functional impairment, or to experience depression or post-traumatic stress disorder.

That emotional damage can linger. A study of young adults who lost siblings to cancer found that most still had not worked through their grief, even nine years later.

A case control study of children in Scandinavia found that children who experience the death of a parent had twice the chance of committing suicide. That increased risk lasted at least 25 years.

The risk of suicide in children who had lost a parent was 4 in 1,000 for boys and 2 in 1,000 for girls.

Emotional damage can have a physical impact as well. In 2013, researchers published work in PLoS One that showed that both men and women who had lost a sibling in adulthood had an elevated risk of death from stroke, potentially stress related, in the 18 months after the sibling’s death. For women, that increased risk got worse over time, still increasing 18 years later. Sibling death from external causes (mostly accidents and suicides) was also associated with an increased risk of death from heart attacks in women years later.

Families who lose a child are more likely to show problems that already existed, like evidence of social deprivation and poor health. Health care professionals may want to consider that the death of a child can exacerbate problems, and signify long-term social, behavioral and environmental risks for the survivors.

These warning signs exist in other familial relationships. Research has shown that losing a child increases the mortality rate in mothers more than a decade later, both from natural and unnatural causes. It increases the mortality rate in fathers, too, but only from unnatural causes. Losing a parent does the same.

But death may be harder for children. As a parent, I can imagine nothing worse than the loss of a child. But as I watch my children grow up together, I’m struck by the fact that their bond is, at times, stronger than their bonds to my wife and me. They’re together at school. They’re together at camp. They’re together when they play. They have secrets and shared experiences as they grow and develop together. They also have known almost no life without each other.

They are also far less capable of handling a loss than I or my wife would be. A study in the late 1990s examined how children responded to the loss of a parent versus a sibling. Girls, in general, were more affected by the loss of a sibling — especially a sister. Preteens showed higher levels of depression and anxiety, and adolescents had more attention problems and anger.

Given all these data, it may be time for us to pay more attention to the long-term effects of a child’s death. We can take hope from research showing that most children do thrive and overcome adversity, even after such a loss. Too many do not, though. We ought to monitor those who lost siblings as children for possible health consequences for many years to come.

@aaronecarroll

The D.C. Circuit just made it harder for Trump to stop the cost-sharing payments

This afternoon, the D.C. Circuit granted a motion from a group of fifteen states, led by California, to intervene in the pending appeal in House v. Price. As I explained when the motion was filed, allowing the states to intervene will prevent the Trump administration from unilaterally dismissing its appeal in the case.

That’s a big deal. If the Trump administration wanted to stop making cost-sharing payments, the easiest way to do so would be to dismiss the appeal. The lower court entered an injunction to stop those payments, but put its injunction on hold to allow for an appeal. If Trump were to order the appeal’s dismissal, the injunction would spring into force, and the payments would end.

Now the states can keep the appeal alive, even if Trump wants to get rid of it.

When the states asked to intervene, it wasn’t totally clear they should be allowed to do so. Intervening in a case that’s already on appeal is strongly disfavored. I nonetheless thought the states had a good case—and so did the D.C. Circuit, for the same reasons:

[T]he States have raised sufficient doubt concerning the adequacy of theDepartment’s representation of their interests. Indeed, the Department nowhere argues in its intervention papers that it will adequately protect the States’ interests or even continue to prosecute the appeal. Such “equivocat[ion] about whether” the Department will continue to “appeal the adverse ruling of the district court” or will otherwise protect the intervenors’ interests, Smoke v. Norton, 252 F.3d 468, 471 (D.C. Cir. 2001), constitutes at least the requisite “minimal” showing that the Department’s “representation of [the States’] interest ‘may be’ inadequate.” Trbovich v. United Mine Workers of Am., 404 U.S. 528, 538 n.10 (1972) (emphasis added). …

… [T]he States’ motion is [also] timely. … Where, as here, substantial doubts about the inadequacy of representation develop after the case has begun, timeliness is measured from when the potential inadequacy of representation develops. … The States have filed within a reasonable time from when their doubts about adequate representation arose due to accumulating public statements by high-level officials both about a potential change in position and the Department’s joinder with the House in an effort to terminate the appeal.

In other words, President Trump’s loose lips have once again created problems for his lawyers. Go figure.

Now, the Trump administration could probably stop the payments, with or without the pending appeal. The administration could simply announce that, after a thorough review, the Justice Department has concluded that no appropriation exists to continue making the payments. Although there’s a regulation on the books requiring payments to be made, the absence of an appropriation would likely prevent the administration from following through.

Politically, however, it’d be awfully convenient to blame the courts. The D.C. Circuit’s decision takes that approach off the table. If Trump wants to end the payments, it’ll be on his head.

@nicholas_bagley

Here’s how Trump could sabotage Obamacare

I’ve got a new op-ed under that headline in the L.A. Times. Here’s an excerpt:

The private insurance market is much more vulnerable. And the biggest problem may not be what the Trump administration does. It may be what it doesn’t do. The exchanges depend on complicated information technology, and maintaining them requires competent day-to-day management. What if Trump doesn’t bother?

The problem is most acute for the 38 states that rely on HealthCare.gov, the federally administered exchange. But it’s also a concern for the states, including California, that run their own exchanges. To calculate a customer’s subsidized premiums, for example, the state exchanges need to know that customer’s income — which requires rapid communication with databases at the Internal Revenue Service. If that communication channel goes down and no one repairs it, the state exchanges can’t work.

For Obamacare to falter, in other words, Trump doesn’t need to burn down the exchanges. He just needs to let their gears turn to rust.

This sort of malign neglect would violate the president’s constitutional duty to “take Care that the Laws be faithfully executed.” But don’t expect the courts to save the day. Courts are pretty good at stopping presidents from doing unlawful things, but they can’t thwart a campaign of mismanagement.

Read the whole thing!  Also, if you’re very curious, Adrianna and I have compiled a longer list of the executive actions that the Trump administration might consider in connection with the ACA.

@nicholas_bagley

Health plan choices: less is more

Whether through an employer, Medicare, or an Affordable Care Act marketplace, many Americans have choices of health care plans — sometimes from among dozens of possibilities. I’ve written a lot on the AcademyHealth blog and The Upshot about how hard it is for people to make good plan choices from such a bounty of options. They often end up paying more than they should, either because they actively choose a suboptimal product or because they passively remain in a product that drifts away from optimality over time.

Some studies indicate that with reminders and assistance — provision of calculating tools, better ways of comparing and viewing options, and other guidance — people can be encouraged to make active choices and, moreover, make better ones. Availability of such things is not widespread, but it is growing.

But is encouraging annual plan shopping, providing selection aids, and improving choice architecture just treating the symptom of the real problem? Maybe more choices isn’t better? What if helping consumers navigate them is merely second best to reducing the number of choices in the first place?

It sounds a bit crazy, because a premise of an ideal market is that there are so many choices, everybody can find a product to perfectly match his or her preferences. No market achieves that ideal, but clearly fewer choices moves in the wrong directly, theoretically.

Theory is useless if it is wrong. It must be tested.

In a study published as an NBER working paper, Jason Abaluck, Jonathan Gruber did so. They compared people’s choices of health plans under various interventions: (1) promotion of active choices, (2) assistance with choice support software, and (3) reduction in plan choices. According to their analysis, across these intervention types, consumers achieved the best outcomes when choices were restricted. Less is more!

These interventions were implemented across school districts in Oregon between 2008 and 2013 where, according to the analysis, only 36% of covered employees had made the cost-minimizing choice. On average, employees spent about $1,000 more on coverage per year than they could have. The number of plan choices varied across district and time. Through 2011, the vast majority of employees had four choices. After 2011, some had as many as ten. Choices ranged in plan style — closed panel HMOs (e.g., Kaiser) and broader network PPOs — as did employer contributions to premiums and cost sharing, all of which was controlled for in analysis.

The authors analyzed nearly 400,000 employee-year observations in several ways. One analysis exploited the fact that 12% of employee-year observations were forced to switch plans when their current plan was dropped in their district. Did forcing people to switch cause them to choose better plans, compared to people who did not switch? Nope. Forced switchers actually spent even more than they could have, compared to non-switchers.

Another analysis exploited the randomization of enrollees to access to a tool that used each individual’s claims history to provided the total cost of each available plan. Based on this information, it also displayed plans in order of total cost and stared the lowest cost plan. In other words, it relieved consumers of most of the cognitive effort of comparing plan costs — just look for the star and done!

The authors estimated that users that received the tool’s recommendations were only 8% more likely to choose the best plan, relative to those that did not have access to the tool. Unfortunately, the tool’s recommendations were not always in alignment with true plan costs, because the tool had to make some assumptions and also due to user input error. The authors estimated that a perfect tool fed perfect information — which is essentially impossible to achieve — would induce 17% of users to choose the lowest cost plan, reducing foregone savings, coincidentally, by only 17% as well.

Finally, the authors examined forgone savings as a function of choice sets. Foregone savings are almost twice as large when employees face a choice of eight plans versus only four plans. Now, this result could occur if what’s going on is that as additional choices include better ones, but that enrollees don’t pick better ones. That is, they could do better with more choices, but they don’t know how to make the right ones.

That’s not what’s going on. The authors wrote,

[S]maller choice sets lead to beneficiaries being enrolled in lower cost plans because larger choice sets have more plans which are higher cost on average – and individual choices do little to offset this “more dangerous” choice environment.

In other words, when choice sets are small, plan administrators have made relatively good selections already. But as administrators expand the choice set, they add worse (more expensive) plans. Because consumers have a hard time picking the best plan, they are more likely to end up in a more expensive one as choices grow.

The conclusion is that consumers may save far more if they are presented with fewer choices than they save by either being induced to shop or by provision of output from a plan cost estimator. Yes, we can help some people make modestly better choices with cost calculators and better choice architecture — and we should provide such things. However, according to this study, people are so bad at choosing plans that they are even better served by simplifying their choices.

@afrakt

Healthcare Triage: Hay Fever and Allergies Can Lower Student Test Scores

Health issues can negatively affect people’s lives in an astoundingly wide array of ways. Recent studies indicate that students who suffer from allergies may perform worse on tests when testing occurs on high pollen count days. So how can we help all these students who are sneezing their way into remedial courses? Healthcare Triage has a few ideas about that.

Special thanks to Austin, from whose Upshot column this episode was adapted.

@aaronecarroll

Waivers are dead, long live waivers

At 10pm on Thursday, the Senate finally released a “repeal” bill—the Health Care Freedom Act—that may have the votes to pass. If you’ve been following the reporting, it’s mostly as expected. The bill repeals the individual mandate, delays the employer mandate until 2025, delays the implementation of the medical device tax until 2021, and defunds Planned Parenthood for one year.

But there’s one big surprise. Reports earlier in the day said that the Senate parliamentarian had ruled out the changes to the ACA’s waiver provision contained in the Better Care Reconciliation Act. (I wrote about BCRA’s waiver provision here.) The Senate went back to the drawing board, however, and the so-called skinny bill contains a slimmed down waiver provision.

Under the ACA, a state can get a waiver from most of the ACA’s rules only if it adheres to certain guardrails: a state has to cover as many people as comprehensively without increasing federal spending. Even then, the ACA says only that a waiver “may” be granted if those conditions are met.

The original version of BCRA would have wiped out those guardrails. All a state had to do was promise not to increase federal spending. If it did, BCRA said that the Secretary of HHS “shall” grant it—even if the state wanted to use the money to fund its public schools or a new stadium. A revised version of BCRA was mildly better on this front, but it retained the “shall” directive.

So too does the Health Care Freedom Act. Presumably because of the Senate parliamentarian’s involvement, however, the guardrails remain intact. The Secretary must therefore approve waivers if they adhere to the guardrails; if they don’t, he can’t.

But here’s the rub. The waivers are presumptively approved for 8 years—and they “may not be cancelled by the Secretary before the expiration of the 8-year period.” This 8-year lockout was also in BCRA, and here’s what I wrote about it at the time.

And once a waiver is granted, the Senate bill says that the federal government cannot terminate the waiver, no matter what. It is hard to overstate how unusual—even unique—this is. When the federal government offers money to states, it places conditions on how the states are to use that money—and reserves the right to cut off the states if they fail to adhere to those conditions. The cutoff threat is essential to prevent state abuse of federal funds.

The Senate bill removes that threat. It says that a waiver “may not be cancelled” before its expiration. If state officials blow the Obamacare money on cocaine and hookers, there’s apparently nothing the federal government can do about it. At the same time, the bill expands the duration of waivers from five years to eight years. The upshot, then, is that the next president won’t be able to renegotiate any waivers granted during the Trump administration, no matter how badly a given state might have abused its waiver.

So while the ACA’s guardrails are still in place, states can ignore them once a waiver has been granted. And there’s not a thing the federal government can do about it.

To my eyes, the legislation looks like an open invitation to states to submit farfetched waivers that purport to achieve the ACA’s objectives, knowing full well that, once a waiver is granted, they can’t be held to account if their residents lose coverage.

How the 8-year lockout made it past the Parliamentarian is beyond me. It has nothing to do with protecting the federal budget. It has everything to do, instead, with a Republican effort to prevent a future president from undoing waivers. And it may provide a backdoor way for states to undo some of the ACA’s most significant protections.

@nicholas_bagley