Monthly Archives: October 2013

Getting your teeth into health care

Posted by on October 27, 2013 Comments Off on Getting your teeth into health care

We all know the reasons for going to the dentist regularly:

  1. Early detection (cavities, gum disease, oral cancer, bruxism)
  2. Checking existing fillings for structural weakness or peripheral decay
  3. Review of oral health practices

These are dental reasons, but there are other reasons as well.

The relationship between dental health and other medical health is not a new concept, with studies going back to the 1980’s. For example, the statistical relationship between heart attacks and poor dental health was noted in a 1989 Finnish study.

Managed care organizations have a strong financial incentive to lower health care costs. Healthier members have lower medical costs, so improving the health of members is an attractive alternative to cutting benefits in order to lower costs.

Aetna has been a leader in “Dental-Medical Integration” (DMI) as an approach to that end.

A study in 2006 found significant relationships between treatment for gum disease ( a proxy for having gum disease) and higher medical costs for cardiovascular, cerebrovascular, and diabetic conditions, heart, stroke, and diabetes, respectively.

In 2009, Aetna reported considerable success in getting dental care for at risk members:

In 2008, nearly 67,000 medically at-risk members sought dental care after being enrolled in Aetna’s Dental Medical Integration program. At-risk members are identified as those with diabetes, heart disease and pregnant women who have not seen a dentist in 12 months or more.

A 2011 University of Pennsylvania study in collaboration with Cigna Dental established lower medical costs two years after periodontal (gum) treatment:

2011_UPa_Dental

Earlier this month Aetna reported:

  • Lowered their medical claim costs by an average of 17 percent
  • Improved diabetes control by 45 percent
  • Used 42 percent less major and basic dental services
  • Required 3.5 percent fewer hospital admissions year-over-year compared to a 5.4 percent increase for non-members

With the caveat that the Aetna programmed targeted individuals with particular diagnoses who had not seen a dentist in a year, we are nonetheless facing an important question:

Is it time to end the division between dental and medical insurance, treating health care for the mouth as a medical specialty like others, and dentists as medical specialists like others?

Competition, Cooperation, and Health Care

Posted by on October 14, 2013 Comments Off on Competition, Cooperation, and Health Care

Maybe it’s the days of endless government shutdown. Maybe it’s the days of endless rain.

Writing about any of it comes hard to me. I am uncharacteristically quiet and reflective.

We live in a society built on competition. The economic system creates wealth and rations scarce resources through competition. Democracy is a competition for the support of voters. And, no society is more sports-minded than we are, with giant arenas and stadiums for a variety of sports, each with millions of followers.

However, all of this competition occurs in the context of a society. A society implies certain shared values, a modicum of cooperation, and concern for other members of the society, if not for their own sakes, then for the sake of the society.

Consequently, a competitive society is one with built-in contradictions. At the extreme, economic competition results in great wealth, poorly distributed, and concentrated in the hands of the few. At the extreme, political competition, like sports competition, requires that victory trumps all ethical considerations, including the needs of the society or sport.

On the other extreme, a completely cooperative society, devoid of competition, sharing things equally, is unlikely to thrive. As our conservative friends point out, the incentives for wealth creation and technological progress based on expenditure are likely to be lacking. In addition, there will be free riders, people who wish to partake without producing.

The political and social pendulum in the United States often swings between competition and cooperation, between liberty and equality. At this point in time, it seems to me that we have swung a bit too far toward competition. We have a Congress that cares more about the next election and scoring political points than public policy; we have a Speaker, who should know better, but is more concerned about the challenge to his leadership than the American economy.

Behind it all are two ideologies that seem singularly unconcerned about any impact, other than how a position is measured against the yardstick of a belief system, a non-religious libertarianism allied with a particularly narrow version of Christianity, aligned together in opposition to government initiatives, despite their obvious contradictions. It is a characteristic of ideology and utopia, as Karl Mannheim called the narrow beliefs of the present and the future, that purity of belief surpasses any human need.
ideology and utopia

Combining these strong ideological commitments with the political system results in the political impasse we are experiencing. Closed belief systems can rationalize economic collapse as a necessary, ultimate good, so compromise is not only unnecessary from that perspective, but traitorous. As Eric Hoffer put it,

It is the true believer’s ability to “shut his eyes and stop his ears” to facts that do not deserve to be either seen or heard which is the source of his unequaled fortitude and constancy. He cannot be frightened by danger nor disheartened by obstacle nor baffled by contradictions because he denies their existence

So, the campaign against the program of our current President can pivot from health care to spending to entitlements, but is consistently against the President and his positions. When the economic consequences of the shutdown and the debt limit crisis are tallied, they will say, “See, we told you that the Affordable Care Act would destroy the economy.”

Politicians of all wings, parties and beliefs routinely employ spin–stretching the truth to make their points; however, at some point the distance from the truth is sufficient to call “spin” an outright falsehood. An example, in health care, was the charge that Obamacare mandated “death panels.” (Physicians routinely discuss end-of-life issues with their patients. The proposal was that they be reimbursed for the time so spent.)

As Mark Twain put it, “A lie can travel half way around the world while the truth is putting on its shoes.”

When confronted with an obvious falsehood or exaggeration, the honest person faces a dilemma: does the speaker/writer truly believe what is written, or is that person cynically exploiting the ignorance of others?

Here are some of the arguments about the Affordable Care Act that have been dragged into debate about fiscal policy, the Federal budget, and the US statutory debt limit.

  1. Congress has exempted itself from Obamacare.
    The fact is that Congressional employees will be shopping for health care on the exchanges rather than receiving employer-provided health care as would most businesses with a comparable number of employees. As employees, they will receive an employer contribution that reduces the monthly premium cost.
  2. Large enterprises have been made exempt from the mandate to provide coverage so individuals should be exempt as well.
    Large enterprises are still required to provide health insurance coverage for their employees as scheduled; however the Justice Department will not be imposing penalties immediately. Furthermore, the individual mandate is an entirely separate issue–it is the linchpin of eliminating denial of coverage for pre-existing conditions. Without it, no one would buy health insurance until they needed it, with the assurance that their health condition could not be denied.
  3. Health insurance premiums are going up because of Obamacare.
    With the exception of the past 3 years, health insurance premiums have been rising by double digit percentages each year. The rise slowed because of the deep recession we are emerging from. Health insurance premiums will continue to rise, largely driven by technology (MRIs are expensive), now that the recession is almost over. Furthermore, premiums may seem very high to individuals who have not been able to or been interested in purchasing insurance until now. Health insurance is expensive.
  4. Companies are letting full-time workers go and hiring part-time workers in their place.
    1. Many individuals choose part-time employment over full-time employment. So, the only concern should be involuntary part-time employment rather than all part-timers.
    2. There has generally been a rise in part-time employment during economic recessions. The recent recession is no different.
    3. Many new jobs are coming into the economy to help with Obamacare, as well as new hires in the private sector to meet the needs of the health care law mandates for preventive care and individual coverage.

      4. [It should be noted that individuals concerned about employment issues would never close the Federal government or permit it to be closed, since the loss of spending by Federal workers ripples through the labor market as business owners determine whether to take on new hires, and the lack of Federal issuance of permits in several areas e.g. a Vermont micro-brewery, adversely impacts employment.]

    And as I was reflecting upon the original conundrum, how to reconcile cooperation and competition, liberty and equality, while retaining the best of both, I came across a quotation from Milan Kundera,

    kundera

    “Too much faith is the worst ally. When you believe in something literally, through your faith you’ll turn it into something absurd. One who is a genuine adherent, if you like, of some political outlook, never takes its sophistries seriously, but only its practical aims, which are concealed beneath these sophistries. Political rhetoric and sophistries do not exist, after all, in order that they be believed; rather, they have to serve as a common and agreed upon alibi. Foolish people who take them in earnest sooner or later discover inconsistencies in them, begin to protest, and finish finally and infamously as heretics and apostates. No, too much faith never brings anything good…”

    The Roman playwright Terence wrote “Ne quid nimis,” alternatively translated as “Nothing in excess,” or “All things in moderation.”
    Terence

    Moderation isn’t sexy or attractive. It doesn’t cause the adrenaline rush of ideological combat. But, I think it is the medicine we need now.

    Moderation in politics, moderation in spending, moderation in punditry. Here’s to moderation!!

The US health care debate

Posted by on October 3, 2013 Comments Off on The US health care debate

Writing about the political dance in Washington, DC is not a pleasant task. I intend to skirt around the edges of it. It is marginally about health care and largely about the relative power of the two major US political parties.US_capitol

Nonetheless, since it has brought the Obama health care plan back to the top of the national political agenda, it is worth recalling some basics.

First, the principle of insurance is that a catastrophic risk is spread across as many people as possible making advanced contributions so that funds are pooled and available to any individual suffering that risk. For example, individuals buying life insurance at a young age receive a favorable premium rate and are likely to contribute for a long time, much longer than the time it would take to accumulate the death benefit, but for those individuals not so fortunate, the monies are there in a pooled risk fund to be distributed to the family of someone who dies prematurely. The risk of an expensive illness with accompanying medical costs is similar.

Second, millions of Americans have not had health insurance. Some of those are young, feel invulnerable and do not want health insurance. Others have pre-existing health impairments and have been refused health insurance. Still others do not receive insurance through their employers and cannot afford it on their own.

Third, there are negative consequences to our society for these uninsured:

  1. Those without insurance still must be treated when they get ill or have a motor vehicle accident.
  2. The young, less likely to be net expenses to a pooled risk fund, need to be part of the contributors under the principle of insurance
  3. Those denied insurance because of pre-existing conditions need to be saved from bankruptcy, and the hospitals need to be protected from having to serve them at no cost.
  4. Those who do not have insurance through their employers, who could not afford individual insurance policies, require a means to participate.

Fourth, the Patient Protection and Affordable Care Act (PPACA), commonly known as “Obamacare,” is an honest attempt to address those concerns, as well as reining in the ever-rising costs of medical care.

Fifth, the term “socialized medicine” is easily bandied by politicians, but there are two distinct areas of government involvement in health delivery that can more accurately be called “socialized medicine,” and “socialized insurance.” The US has both. Socialized medicine occurs when the government provides access to healthcare either directly through government clinics or through social insurance used in government health facilities. In that case, the health care providers are government employees. Foreign examples are the National Health Service of the United Kingdom. NHS-logoIn the US the system of hospitals under the Department of Veterans Affairs (VA). Socialized insurance is when the government supplies health insurance but the healthcare practitioners are not government employees. Medicare is socialized insurance, as are the national health systems of Canada, France, Italy, and Germany. There are advocates for socialized insurance in the United States, under the banners “Medicare for All” and “Single-Payer.” There is no recognizable group that favors socialized medicine in the US–NONE.

Sixth, Obamacare is neither socialized medicine nor socialized insurance, because all of the providers are private, and all of the insurers are private. An early proposal to include a “public option” form of insurance was dropped. It is not surprising that Obamacare is completely privatized–it is a proposal in concept by that most conservative think tank, the Heritage Foundation. (More recently, it has taken a further turn to the Right by engaging former SC Senator Jim DeMint as President; however, it has always been quite conservative.) Its proposal was adopted, supported, and implemented by the Republican governor of Massachusetts Mitt Romney. The theory was that the accelerating costs of healthcare could be addressed by a market system, and the government assumed the role of creating the market or even playing field for the insurance companies to compete for business.

Seventh, the individual mandate, which draws a lot of the political fire, was part of the original Heritage plan by Stuart Butler in a 1989 paper, and of the Romney plan. It is essential to the effectiveness of the system in two major ways:

  1. It makes the younger, healthier citizens participants, with the benefit of their consuming less than they contribute but not being a burden when struck by accidents or rare illness.
  2. More importantly, it makes possible the elimination of pre-existing conditions. If pre-existing conditions could not prevent obtaining insurance, no one would buy insurance until contracting an illness, and would then be assured of acceptance. Because the insurance would have to cover the illness, with no reserve built up, with no spreading of risk across the entire population per the insurance principle, the insurance would be nearly unaffordable with the premiums set at the level of the average illness since it would have to cover the risk. Pregnancy benefits are often rated that way in insurance policies since the benefits being paid are nearly assured.

Eighth, there is the issue of affordability. Enterprises with over 50 employees are required to provide insurance. Most already do, but these employers are a very small segment of the workforce, perhaps 10 percent. The rest of us are self-employed or employed by smaller enterprises. If they already provide health insurance that is fine, but under the individual mandate, if they do not, then anyone working there including the executives will have to fulfill the mandate by finding insurance on the exchanges, and by shopping for the level of coverage at a premium they can afford. Both affordability and insuring the young are addressed in part by requiring adults to be eligible until age 26 for insurance under their parents’ plan.

For those at the bottom of the pay scale, those who do not qualify for Medicaid, which can have very stringent asset limitations (in California, for example, having funds over $2,000 disqualifies one from Medi-Cal), those often called “the working poor” may be eligible for government subsidies. In addition, the federal government is offering states financial incentives to expand the Medicaid program to cover more of the working poor.

Finally, there is the issue of what is health insurance coverage? If we want to require people to buy it, we need to be able to say what is and what is not acceptable coverage, to avoid individuals and businesses buying something so minimal that it complies with the law but does not address the problem of access to health care. An individual buying a policy hat pays $100 daily for hospital care has not really bought insurance. So, the government through implementing regulations has stipulated what a minimum policy contains. This has raised issues of conscience for those who do not believe in one or more aspects of medical science as applied to health care.

The religious reservations are well-known in the United States. Among them are a preference for Christian Science practitioners among Christian Scientists, an avoidance of blood transfusions among Jehovah’s Witnesses, rejection of birth control measures among Catholics, as well as rejection of pharmaceutical and surgical interventions to prevent or abort a pregnancy among numerous denominations. The law has allowed a religious exemption for churches. The point of contention has been for practitioners who participate in commerce and do not wish to compromise their religious beliefs by providing the means for something they consider murder. From a public policy view, the problem is multiple:

  1. Recognizing that right by owners of businesses and organizations may deny access to some of their employees who feel equally strongly that obtaining those treatments is their right.
  2. Recognizing those rights by one group implies, under equal protection, recognizing such objections by all groups and individuals. That places the government in the powerful and unwelcome position of determining which religious beliefs are legitimate and entitled to protection, an intrusion into religion that most Americans would find offensive.
  3. Recognizing that right with respect to abortion, would open the possibility of recognizing objections to all forms of insurance. A business owner might claim religious exemption to providing any insurance, undermining the public purpose of the law.

In order to address these concerns, the law limits religious exemptions to religious institutions, such as places of worship. There are pending court cases that may change the way this challenge is addressed in order to comply with First Amendment considerations.

One theory of American government is that the states act as laboratories for the society and the nation, trying approaches, which, if successful, can be generalized. That has occurred here, with Massachusetts providing the laboratory. As the national experiment is just beginning, it is too early to tell whether the proponents or opponents of Obamacare have correctly analyzed its impact and future. Five years from now, it will be much clearer. I look forward to seeing that day and looking around to see what worked and what did not, what needs changing, what has been correctly changed, and what has not. I have often thought that politics is America’s most engaging indoor sport, and, at this moment, Obamacare is at center court.