Topic: Health Care & Welfare

Large Majorities Support Key Obamacare Provisions, Unless They Cost Something

Support for the ACA’s community-rating provisions flips from 63%-33% support to 60%-31% opposed if it harms the quality of health care. 55% say more free-market competition not government management would best deliver high-quality affordable health care. FULL RESULTS (PDF)

Most polling of the Affordable Care Act finds popular support for many of its benefits when no costs are mentioned. However, a new Cato Institute/YouGov survey finds that support plummets, even among Democrats, if its popular provisions harm the quality of health care. The poll finds that risks of higher premiums, higher taxes, or subsidies to insurers are less concerning to Americans than harm to the quality of care. 

By a margin of 63% to 33%, Americans support the ACA’s community-rating provision that prevents health insurers from charging some customers higher rates based on their medical history. However, support flips with a majority opposed 60%-31% if the provision caused the quality of health care to get worse.

Majorities also come to oppose the ACA’s community-rating provision if it increased premiums (55% oppose, 39% favor), or raised taxes (53% oppose, 40% favor). However, threats to the to quality of care appear to be a pressure point for most Americans.

WSJ: How ObamaCare Punishes the Sick

In today’s Wall Street Journal, I discuss new economic research showing ObamaCare is making health insurance worse for patients with high-cost medical conditions.

Republicans are nervous about repealing ObamaCare’s supposed ban on discrimination against patients with pre-existing conditions. But a new study by Harvard and the University of Texas-Austin finds those rules penalize high-quality coverage for the sick, reward insurers who slash coverage for the sick, and leave patients unable to obtain adequate insurance…

If anything, Republicans should fear not repealing ObamaCare’s pre-existing-conditions rules. The Congressional Budget Office predicts a partial repeal would wipe out the individual market and cause nine million to lose coverage unnecessarily. And contrary to conventional wisdom, the consequences of those rules are wildly unpopular. In a new Cato Institute/YouGov poll, 63% of respondents initially supported ObamaCare’s pre-existing-condition rules. That dropped to 31%—with 60% opposition—when they were told of the impact on quality.

Republicans can’t keep their promise to repeal ObamaCare and improve access for the sick without repealing the ACA’s penalties on high-quality coverage.

The lesson is clear. To repeal ObamaCare, opponents need to talk to voters about how the law is reducing the quality of health insurance and medical care for the sick.

Read the whole thing.

SNAP: $15 Billion on Junk Food

The Supplemental Nutrition Assistance Program (SNAP) aims for recipients to “make healthy food choices within a limited budget.” SNAP is supposed to “permit low-income households to obtain a more nutritious diet.”

However, the lofty goals of federal programs often differ from the actual results. It turns out that about $15 billion of SNAP benefits are for junk food. Apparently, recipients are not making the nutritious and healthy choices that the government promised.

SNAP, or food stamp, benefits totaled $67 billion in 2016. Food stamps can be used to buy just about any edible item in grocery stores other than alcohol, vitamins, and hot food. But exactly what is being purchased by the program’s 44 million recipients has been mainly shrouded in secrecy—until now.

A November study by the U.S. Department of Agriculture finally shed light on food stamp purchases. The study examined detailed data for SNAP and non-SNAP shoppers for one large food retailer over a one-year period.

The study found that SNAP shoppers bought slightly more junk food than non-SNAP shoppers. For example, 9.25 percent of total purchases by SNAP shoppers were for “sweetened beverages” such as cola, which compared to 7.1 percent for non-SNAP shoppers. At the same time, SNAP shoppers spent relatively less on nutritious foods such as fruits and vegetables.

For SNAP shoppers, “sweetened beverages,” “prepared desserts,” “salty snacks,” “candy,” and “sugar” accounted for 22.6 percent of purchases. These junk food items thus accounted for $15 billion of SNAP purchases in 2016, if the study is representative of all SNAP purchases.

SNAP is a bloated program, and cutting out junk food would be one way to reduce costs. The program was created to tackle hunger, but Harvard University’s Robert Paarlberg noted that on a typical day less than 1 percent of households now face “very low food security.” That low figure contrasts with the 17 percent of U.S. households that currently receive food stamps.

The main food-related health problem for low-income households today is not hunger, but obesity. CDC data show that people with low incomes are more obese than people with high incomes, on average. In general, low-income Americans are suffering not from too little food, but from too much of the wrong kinds of food.

Ending SNAP’s junk food subsidies would likely cut demand for the program and reduce taxpayer costs. If policymakers decided that food stamps could only be used for items such as fruits and vegetables, fewer people would use the program, which would be a good thing.

An even better reform would be to end federal involvement in food stamps. Each state could then decide on the overall level of benefits it wanted, and on whether taxpayers should be subsidizing cola, candy, crackers, and cookies.

For more on food stamps, see here and here.

Do Opioid Restrictions Reduce Opioid Poisonings?

In a recent working paper, economists Thomas Buchmueller and Colleen Cary find that one particular kind of restriction does reduce opioid misuse among Medicare beneficiaries:

The misuse of prescription opioids has become a serious epidemic in the US. In response, states have implemented Prescription Drug Monitoring Programs (PDMPs), which record a patient’s opioid prescribing history. While few providers participated in early systems, states have recently begun to require providers to access the PDMP under certain circumstances. We find that “must access” PDMPs significantly reduce measures of misuse in Medicare Part D.

Yet, they also find

no statistically significant effect [of must access PDMP’s] on a key medical outcome: opioid poisoning incidents.

How is this possible?

Socialized Medicine: From Anecdote to Data

Last night’s CNN duel between Senators Bernie Sanders and Ted Cruz on the future of Obamacare was pretty illuminating for a recent arrival to the United States, with Senator Sanders’ playbook all-too-familiar to those of us from the UK.

Sanders wants a single-payer socialized healthcare system in the United States, just as we have in Britain. Any objection to that is met with the claim that you are “leaving people to die.” The only alternatives on offer, you would think, are the U.S. system as it exists now, or the UK system. Sanders did not once acknowledge that the UK structure, which is free at the point of use, inevitably means rationed care, with a lack of pre-screening. He also failed to acknowledge that lower health spending levels (indeed, even public spending on health is lower in the UK than the United States now) are not the same as efficiency—which is about outputs per input.

In the face of anecdote after anecdote about those saved by Obamacare and the virtues of a government-run health system, Cruz countered with some anecdotes from the UK showing the consequences of rationed care: a Scottish hospital turning away pregnant women, a woman in Wales waiting eight hours on the floor for an ambulance to arrive after a fall, and a hospital in Essex canceling life-saving cancer treatment because there were no free beds in intensive care. He could also have talked about the Mid-Staffs scandal, or a recent documentary showing doctors deciding between saving a cancer patient or a pensioner bleeding to death.

Anecdotes are powerful in helping to persuade people, and there are good reasons to use them in debates. Yet they are always susceptible to the charge that all health systems have extreme failures. Perhaps more powerfully then, the inadequacies of the UK system show up systematically in the data about how well conditions are dealt with (data from my former colleague Kristian Niemietz’s reports here and here):

  • In the United States, the age-adjusted breast cancer 5-year survival rate is 88.9 percent, compared with just 81.1 percent in the UK
  • The United States leads the world on the equivalent stat for prostate cancer (97.2 per cent) vs. 83.2 percent in the UK
  • Lung cancer: 18.7 percent in the United States vs. 9.6 percent in the UK; bowel cancer: 64.2 percent vs. 56.1 percent
  • Just in case you think I am cherry picking: U.S. survival rates are also better for leukemia, ovarian cancer, stomach cancer, and liver cancer—all of those for which I can find comparisons
  • The age- and sex-standardized 30-day mortality rate for ischaemic stroke is just 3.6 per cent in the United States vs. 9.2 per cent in the UK; for haemorrhagic stroke, the figures are 22 percent vs. 26.5 percent

I could go on. All of which is to show that your probability of dying from a range of common conditions is much higher in the UK than here. Perhaps that’s why (with no hint of irony) The Guardian’s write-up of a Commonwealth Fund Report suggesting the UK’s health system was “the best in the world” said “the only serious black mark against the NHS was its poor record on keeping people alive.”

For Women, Cultural Pressures Remain Paramount

A fascinating new field experiment may cast light on the effectiveness of Ivanka Trump’s prospective mandated paid leave and child care initiatives.

In the Acting Wife study, researchers asked elite Masters in Business Administration (MBA) students questions about their job preferences. Students were told that the answers would be provided to the school’s career center and used to place the students in internship roles.

When single women thought that their responses would be public to their peers, they answered the career center’s questions differently – for example, by indicating they desire $18,000 less in annual compensation, are willing to travel 7 days less per month, and are willing to work four hours less per week than the control group. They also reported lower levels of career ambition and less leadership ability when they knew that peers could access the information.[1]

Chart 1

Chart 2

Chart 3

In the observational portion of the study, 73% of single women and 61% of non-single[2] women reported that they had avoided behaviors that they believed would help their career – like speaking up in meetings or asking for a raise or promotion – because they were worried about looking too ambitious. In other words, women are wary of sending signals that damage their social image.

Chart 4

According to the researchers, the results 

“…suggest that single women avoid actions that would help their careers because of marriage market concerns. Many schooling and initial career decisions – such as whether to take advanced math in high school, major in engineering, or become an entrepreneur – occur early in life when most women are single. These decisions can have labor market consequences that last long after these women get married.

Though not addressed directly in the study, it seems probable that women that signal faux professional apathy to male peers in the marriage market may have difficulty renegotiating when domestic responsibilities become material later in the relationship. This may partially help explain why 43% of highly-qualified women with children leave their careers or off-ramp for a period of time.[3]

Although Ivanka’s $300 billion solution to women’s professional dilemmas are well-intentioned, mandated paid leave and tax deductions for child care are not a panacea. In fact, short of re-programming women and their prospective mates, the most consequential barriers to women’s professional success appear difficult to overcome through government policy.

 


[1] Study results were statistically significant, and single male counterparts and married women did not behave this way.

[2] Where “non-single” indicates a woman who is in a relationship, cohabiting, engaged, or married.

[3] According to Sheryl Sandberg’s Lean In.

Fair Housing or Federal Agency Running Riot?

In case you missed it, Ben Carson has been labeled as being “at odds with fair housing.” During his senate confirmation hearing last week, Carson was required to defend his position on Affirmatively Furthering Fair Housing (AFFH), the Department of Housing and Urban Development’s (HUD’s) controversial 100-page-plus contemporary interpretation of the Fair Housing Act.

It may sound appalling that anyone anywhere would be against fair housing. Still, there are sane reasons to object to the rule. Carson suggested a couple of possibilities; for example, he worries about Washington, D.C. administrators demanding that local communities “go looking for a [racial] problem” when no evidence of such a problem exists a priori.

If you don’t like intemperate federal agencies running riot, there is another process-related objection that Carson missed: AFFH may insert the federal agency into policy areas not even remotely authorized by the legislation it purportedly interprets.

The table below provides a comparison of the original Fair Housing Act language and AFFH language, so that you can decide for yourself:

Fair Housing Act of 1968 (original legislation) Affirmatively Furthering Fair Housing of 2015 (HUD’s re-interpretation)
1)    Prohibits landlords from discriminating against minority tenants. 1)    Stated objective is to “replace segregated living patterns with truly integrated and balanced living patterns [within cities].” 
2)    Uses the word “segregated” or “segregation” a total of 0 times. 2)     Uses the word “segregated” or “segregation” a total of 126 times and urges“overcoming historic [geospatial] patterns of segregation.”
3)    The original FHA law uses the word “zoning” just 1 time, wherein it instructs the HUD Secretary to refer discriminatory local zoning or land use laws to the Attorney General so that he/she can file a lawsuit. 3)    The AFFH mentions “zoning” 53 times, wherein it suggests that communities change their zoning to improve racial integration (not a bad suggestion, but a departure from the original law).
4) The original FHA law uses the word “affirmatively” 2 times. Each time, it asks executive departments and agencies to administer their programs and activities in a way that affirmatively furthers “the purposes of this subchapter,” where the subchapter focuses on prohibiting a discriminatory relationship between landlord/seller and tenant/buyer. 4) The AFFH rule uses the word “affirmatively” 423 times, wherein it redefines the term to mean “replacing segregated living patterns with truly integrated and balanced living patterns” and “transforming racially and ethnically concentrated areas.”
5) The original FHA law uses the word “concentration,” referring to the concentration of poverty or concentration of minorities in cities, 0 times. 5) The AFFH rule uses the word “concentration” 56 times and urges “reducing racial or ethnic concentrations of poverty.”

HUD believes the rule merely implements the Fair Housing Act’s intent.  You can form your own view.