Monthly Archives: May 2010

An Argument Against The Soda Tax

Back before health reform became law, one of the biggest problems Congress had to solve was how to pay for it. They came up with lots of ideas, some of which are now law, some of which were discarded entirely, and others which didn’t make it into the law, but are still garnering a lot of interest and support from a variety of stakeholders. One of the ideas in this last category is a proposal to levy a tax on the manufacturers of soft drinks like Coca-Cola and Pepsi.

The thinking is fairly straightforward: Overconsumption of sugary soft drinks plays a major role in the obesity epidemic. So, a tax on the product has the potential to raise significant revenue while combating one of our society’s most plaguing health problems. If you want to get a better look at the data behind this argument, you should check out David Leonhardt’s piece in the New York Times. The “public good” argument–and let’s face it, I live in a School of Public Health–is a convincing one.

As for the soft drink industry, it is fighting hard against such a tax for the obvious reason that it stands to cut into corporate profits. This won’t be because the companies have to pay a tax–they’ll pass those costs on to consumers–but because the consumers will end up purchasing less of the companies’ products. From the perspective of shareholders–and I should go on record as saying that I (as a proud Georgian) own a bit of Coca-Cola stock–reduced profits are a bad thing.

So, given my own personal competing interests in this issue, you might be asking where I stand. In that case, I suggest you revisit this post’s title. I think the soda tax is a bad thing and here’s why:

Unlike traditional sin taxes on products like alcohol and cigarettes, a soda tax would apply to a product for which there is no surgeon general’s warning nor legal restrictions regarding its purchase. In effect, a soda tax would affect an overwhelming number of people. This is one of the reasons why groceries are taxed at a much lower rate than other goods. Of course, one might then argue that soft drinks are not like other groceries in that they are not essential for life. Food and water are really all we need if you get down to it, and the reduced grocery tax should apply only to those items.

I can think of a great number of things one buys at a grocery store that ought also to be taxed if we start taxing soft drinks. These would include coffee, tea, certain types of “juice”, potato chips, frozen pizzas, donuts, cookies, and so forth. We do not require any of these things to live, consuming too much of any of them will lead to obesity or other health problems, and thus, they should be subject to additional taxation. In fact, the only things that would perhaps be rightfully excluded from such a tax would be those very essential items–here I am thinking of things that one can buy with food stamps or as part of the WIC program–like eggs, milk, cheese, and bread. You know, all the things southerners buy in droves when severe weather threatens.

Then, too, there’s the issue of what happens to diet soft drinks. Presumably they do not contribute to the obesity epidemic because they are very close to calorie-free. Would they be taxed? If not, I might warm to a soft drink tax just a little more–and hold out hope that they invent a calorie-free Cheeto. Until then, I remain opposed to taxing anything that becomes harmful only through a gross lack of personal responsibility. Having said that, I apologize to my liberal friends, and ask my conservative friends to pick their jaws carefully up off the floor. Have a great weekend!

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Posted by on May 21, 2010 in Uncategorized


Medical Malpractice Premiums

Conservatives seem to think that reforming the medical malpractice system will fix everything that ails the health care system. The logic goes something like this: Doctor X has to pay a bunch of money for his malpractice premiums, so he’s motivated to recoup that money–and moreover, he’s very concerned about what will happen to those premiums should he happen to be subjected to a lawsuit, so he practices “defensive medicine” to make sure that all his bases are covered. (As an aside, no one ever seems to talk about the potential for defensive medicine to produce harm through over-treatment.) Most health policy experts, however, don’t see much potential to lower health care costs through tort reform. What you’re most likely seeing is the GOP–who gets tremendous financial support from the physician lobby–taking a stance that will help that group at the expense of the Democrats who get tremendous financial support from the trial lawyers’ lobby.

I’m not going to go into the various peer reviewed literature on the weak malpractice-health care costs link, because I’ve already done that. Instead, I wanted to share a resource with those of you who might be inclined to look at it, and overwhelm the rest of you with one of the busiest charts you’re likely to encounter. The resource is historical data on medical malpractice insurance premiums for all states for the years 2000 through 2008 and is furnished by the Medical Liability Monitor Survey. You can take a look to see just how much rates vary by geographic location (a lot), physician specialty (a lot more), and time (mixed results).

But, because many of you won’t explore the site, I created a chart that shows the highest and lowest malpractice premiums reported for internists, general surgeons, and OBGYNs in the state of North Carolina. You’ll see a few things: First, there’s often (but not always) quite a range between the lowest and highest premiums within a specialty. It kind of makes you wonder if the actuaries just pick numbers out of a hat. Second, there is a clear difference in premiums according to specialty. This difference makes sense for the most part, with internists facing much lower premiums than general surgeons, and OBGYNs paying more than either group. The more likely you are to encounter an adverse outcome in your field, the more you can expect to pay. Awards are often higher when the birth of a child is involved, because juries take into account the resultant damages, and a newborn has more to lose over their remaining lifetime than a 50-year old. Finally, you’ll note that premiums haven’t just climbed onward and upward. I think this is interesting. It’s probably the result of new insurers entering and exiting certain markets, and may well be affected by certain insurers paying out large claims in a given year, but what it doesn’t do is show the same steady rise as health care expenditures. That doesn’t mean defensive medicine plays no role in rising health care costs, but it is a bit curious. Anyway, enough of my rambling…’s the eye-popping chart, which you may need to click to see entirely. (Advil recommended immediately after viewing).

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Posted by on May 20, 2010 in Uncategorized


Lacking Insurance in the ICU

Dr. Sarah Lyon and colleagues of the University of Pennsylvania published a study Monday comparing the experiences of insured versus uninsured patients in intensive care units across the state of Pennsylvania. What they found is just more evidence that lacking health insurance can mean worse health outcomes. Obviously the mechanism by which being uninsured leads to poorer health would have to do with differences in health care utilization between the insured and the uninsured, but how much of that difference is driven by the patients and how much is driven by the providers isn’t entirely clear.

The study was based on nearly 167,000 non-elderly patients admitted to an ICU in Pennsylvania from 2005 to 2006. Dr. Lyon’s group found that uninsured ICU patients were 21 percent more likely to die within 30-days post-admission than their insured counterparts. Of course, it’s possible that the uninsured arrive at the ICU in worse condition than the insured–the result of persistent financial barriers to care–or that the uninsured differ from the insured in other important ways. The study isn’t able to control for every conceivable factor.

What’s more concerning, though, is that health care providers may go about treating uninsured patients differently than they treat insured patients. You might hope that such things wouldn’t happen, but we have ample evidence that physicians who deny having any racial prejudices do demonstrate different courses of treatment based on the patient’s race. So, it’s plausible that physicians might pursue different treatments for the two groups. This would also help to explain why the disparity in mortality was observed within the same hospital. In other words, it isn’t because the uninsured get sent to the worst hospitals while the insured get sent to the best hospitals. On the contrary, the difference seems to be taking place either before the patient gets to the hospital or after they’re admitted. The authors carefully couch their discussion to avoid placing blame on providers by using the standard academic conclusion “more research is needed.” But, if I had to guess, I think it’s probably a combination of both patient and provider factors. Uninsured patients probably have more comorbid conditions than insured patients, and providers probably treat insured patients more aggressively because they and the hospital know that they will be paid for those services. I suppose everything really does have a price.

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Posted by on May 19, 2010 in Uncategorized


Physician Training In China and France

I’ve recently been introduced to the blog of Dr. Kevin Pho “KevinMD.” It’s a top-notch site and I’ll be working on a link-exchange soon. In the meantime, I thought you might enjoy reading a couple of entries from the blog that give a quick introduction to how physicians are trained in China and France. You’ll learn, for instance, that the Chinese head to medical school straight after high school, and that they aren’t required to complete residency training. You’ll also learn that the French complete medical training in three cycles spanning roughly 8 to 10 years (depending on specialty) and that they do so while amassing almost zero debt, because the government heavily subsidizes medical education. This means French physicians don’t face the same financial incentives that American physicians do when they decide between primary care and other specialties.

We talk a lot about technology, insurance, payment of physicians, and other elements of the health care system when we talk about reform, but I think we often don’t back up far enough. Health care providers are the building blocks of the health care system, and they are created through health professional education. If we keep churning out doctors the same way we always have, the basic infrastructure of our health care system will remain unchanged. Translation: Real health reform is likely to require new approaches to medical education.

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Posted by on May 18, 2010 in Uncategorized


Latest Health Wonk Review

Henry Stern of the InsureBlog hosts the most recent edition of the Health Wonk Review in which he strives to trim the fat and return to the original founding purpose of the HWR. His is a very bare bones approach–but the links are there and are, as always, worth a read.

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Posted by on May 17, 2010 in Uncategorized


Cancer: Just What Are Your Odds?

I did a piece on the potentially misleading nature of rankings last week, and now Maggie Mahar of Health Beat has written a piece on cancer incidence in which she takes issue with a finding reported in the New York Times that claims that nearly 1 in 4 Americans will die of the disease. Along  with heart disease, cancer is certainly one of our major causes of mortality. But, as with rankings, disease incidence–averaged across an entire national population–can actually be fairly misleading.

As she explains in her post, cancer risk varies substantially according to other factors like smoking, gender, age, and income. I assume that income is actually a proxy for other health behaviors like diet, exercise, and regular medical checkups. What Mahar reports isn’t really news. I mean, it’s fairly intuitive that the longer you live the more likely you are to die of cancer, as most forms of the disease arise from mutations that become more prevalent over the cumulative course of the lifespan. The interesting thing is why the Times piece would be so quick to overgeneralize in its piece. The obvious answer is that it sells newspapers, but Mahar has other explanations as well.

I’ll be back next week, but until then, why don’t you give her piece a read?

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Posted by on May 14, 2010 in Uncategorized


The Role of Government: Some Thoughts

Sometimes a health policy blogger decides to blog about something other than health policy. Today is one of those days. I’ve been hearing so much of the political back-and-forth over the oil spill in the Gulf of Mexico that I finally decided to weigh in. At issue, as I see it, is the proper role of government in responding to the disaster.

Of course, we have to back up to Hurricane Katrina and the way in which the Bush administration mishandled the federal response to that disaster. With perhaps the exception of the 30% who consistently approved of Bush’s presidency, most would agree that this was a screw up primarily because the response was delayed by several days and even then seemed somewhat inadequate. At the time, of course, the largest outcry came from liberals. After all, when the other team’s batting, you definitely want to highlight every time they strike out.

Fast forward to today, and many on the right are similarly accusing the Obama administration of dropping the ball with the BP oil spill in the gulf. In fact, some are getting really political about it, claiming that either it was an inside job (similar to the conspiracy theorists that think Bush plotted 9/11) or–a bit less extreme–that Obama wants the situation to get pretty bad (check) to support his position against expanding offshore drilling. I can sort of believe in the latter.

But, as I already said, the real question is what the role of government should be (or have been) in both cases. On the one hand, there will be those who think that the government should never be involved–but I think there numbers are few. Then, conversely, there will be those who think that government should always be involved whenever a large catastrophe threatens the nation. I think that there are probably a lot more of those folks. Then there are people who just play politics. When the federal government failed to respond to Katrina in time, it was the people’s fault for not evacuating–never mind that they lacked the means to do so in most cases. Now that someone from the other party is in charge, though, it’s okay to blame government. It almost makes me wonder, if McCain had won the election, if the response would have been–well, those people chose to live down there, so they should move or learn to deal with it. I hope not, but you never know.

After much thought, here’s the distinction I see. Katrina was a natural disaster. Since it’s not really feasible for us to hold Mother Nature accountable for her actions, we have to respond somehow. Who takes the lead in that case? Some would say government, some a coalition of private non-profits. What we saw was a lot of both, and I think that’s appropriate. I do think that government should have stepped in earlier. The oil spill is the result of an accident, but it falls squarely under the authority of BP. In this case, I don’t necessarily think that it is the government’s responsibility to fix the problem. Sure, if BP asks for federal assistance, they should step in, but otherwise, I think this is BP’s mess. They shouldn’t be insulated from the risks of their enterprise. Long story short, I firmly believe that the oil spill and Hurricane Katrina are like apples and oranges. BP should be taking the lead (as they largely are) in containing and cleaning the spill with the assistance of the Coast Guard and other branches of the federal government. Attacks on the administration for failing to do a job that a private corporation should be doing is, however, nothing more than petty political pandering.

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Posted by on May 13, 2010 in Uncategorized

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