“We are about to witness, for the first time, the power of a fully operational Affordable Care Act (ACA).
The American Rescue Plan made 3.7 million more people eligible for the ACA’s premium subsidies. The Biden administration had already opened up enrollment after taking office, and 200,000 Americans signed up in the first two weeks. Now the administration is extending enrollment until August 15, backed by millions of dollars in advertising.
Insurers are expanding into new markets, and some who abandoned it long ago in the law’s fraught early years are now reentering. The individual mandate is gone, but, as it turns out, it may not be as important to the law’s long-term viability as originally thought. The law had been weakened since its passage by the Supreme Court and Republican opposition. So this is a new beginning of sorts.
“The ACA is right now much closer to what its advocates hoped it would be from the start,” Larry Levitt, executive vice president at the Kaiser Family Foundation (KFF), told me. “This is a true test of how effective a juiced-up ACA can be at getting us closer to universal coverage.
Taken together, come Labor Day, the country should have the clearest idea yet of how the ACA functions at full strength — and where holes in the US health system remain.”
“Nowadays, doctors recommend taking a humane and affirming approach when a child expresses that their gender may not match their assigned sex at birth. This affirmation includes allowing trans kids to socially transition (i.e., use whichever name, pronouns, and clothing make them comfortable). Medical interventions — like puberty suppression or gender-affirming hormones like estrogen or testosterone — are only recommended for adolescents who have been insistent, persistent, and consistent in their gender identity over long periods.
The affirming model has been recommended by nearly every major American medical association, including the American Academy of Pediatrics, the American Medical Association, the American Psychological Association, the Endocrine Society, the World Professional Association for Transgender Health, the American College of Obstetricians and Gynecologists, and many others.
While the affirming model is often willfully misconstrued as instructing parents to accept a child’s gender identity and rush them off into medical interventions, it’s really more about creating a space for trans kids to explore their own gender expression and more thoroughly understand their dysphoria before deciding on whether to transition or not. Allowing a trans adolescent to go on puberty blockers is a decision most parents don’t take lightly. Transitioning is a slow, deliberative process for minors.
Puberty blockers merely act as a pause on an adolescent’s natal puberty, so that adolescents ages 9 to 14 can be more mentally mature before deciding on the course of their permanent treatment when the time comes”
“puberty… brings along its own permanent changes, which could only partially be reversed through painful and expensive medical treatments in adulthood. Trans women forced through male puberty would then have to undergo painful and expensive electrolysis to remove facial hair and may be left with a body frame (shoulder and hip width) that would be unchangeable by any surgeries. Trans men would have to have surgery to remove their breasts and, like their trans female counterparts, be forced to live in an unwanted body frame for their entire lives.”
“examining how the rollout of Medicaid in the late 1960s affected people who were children at the time.
If you got health insurance through the program as a child, he found, you were less likely to die young; you were likelier to be employed and less likely to have a disability as an adult; and all these benefits actually wound up saving the government money.”
“When private equity firms acquire nursing homes, patients start to die more often, according to a new working paper published by the National Bureau of Economic Research.
Private equity acquisitions of nursing homes is a pressing topic: Total private equity investment in nursing homes exploded, going from $5 billion in 2000 to more than $100 billion in 2018. Many nursing homes have long been run on a for-profit basis. But private equity firms, which generally take on debt to buy a company and then put that debt on the newly acquired company’s books, have purchased a mix of large chains and independent facilities — making it easier to isolate the specific effect of private equity acquisitions, rather than just a profit motive, on patient welfare.
Researchers from Penn, NYU, and the University of Chicago studied Medicare data that covers more than 18,000 nursing home facilities, about 1,700 of which were bought by private equity from 2000 to 2017.
Their findings are sobering.
The researchers studied patients who stayed at a skilled nursing facility after an acute episode at a hospital, looking at deaths that fell within the 90-day period after they left the nursing home. They found that going to a private equity-owned nursing home increased mortality for patients by 10 percent against the overall average.”
“the increased mortality is concentrated among patients who are relatively healthier. As counterintuitive as that may sound, there may be a good reason for it: Sicker patients have more regimented treatment that will be adhered to no matter who owns the facility, whereas healthier people may be more susceptible by the changes made under private equity ownership.
Those changes include a reduction in staffing, which prior research has found is the most important factor in quality of care. Overall staffing shrinks by 1.4 percent, the study found, but more directly, private equity acquisitions lead to cuts in the number of hours that front-line nurses spend per day providing basic services to patients. Those services, such as bed turning or infection prevention, aren’t medically intensive, but they can be critical to health outcomes.”
“The combination of fewer nurses and more antipsychotic drugs could explain a significant portion of the disconcerting mortality effect measured by the study. Private equity firms were also found to spend more money on things not related to patient care in order to make money — such as monitoring fees to medical alert companies owned by the same firm — which drains still more resources away from patients.”
“The researchers make a point in their opening to stipulate that private equity may prove successful in other industries. But, they warn, it may be dangerous in health care, where the profit motive of private firms and the welfare of patients may not be aligned”
“Researchers at Harvard University and the University of California Berkeley examined what happened when Medicare beneficiaries faced an increase in their out-of-pocket costs for prescription drugs. They found that a 34 percent increase (a $10.40 increase per drug) led to a significant decrease in patients filling their prescriptions — and, eventually, a 33 percent increase in mortality.
The rise in deaths resulted from people indiscriminately cutting back on medications when they had to pay more for them, including drugs for heart disease, hypertension, asthma, and diabetes.
“We find that small increases in cost cause patients to cut back on drugs with large benefits, ultimately causing their death,” the authors — Amitabh Chandra, Evan Flack, and Ziad Obermeyer — wrote. “Cutbacks are widespread, but most striking are those seen in patients with the greatest treatable health risks, in whom they are likely to be particularly destructive.””
“This finding challenges an important assumption embedded in American health care policy. In the 1970s and ’80s, the RAND Health Insurance Experiment concluded that small copays encouraged patients to use fewer health care services without leading to worse health outcomes. That helped establish a new economic argument for insurers to ask their customers to put more “skin in the game”: it would encourage more efficient use of health care services with no downside.
But that premise presumed people would be rational. For example, if they are being asked to pay more money for prescription drugs, they would cut back on less-valuable medications first. The Harvard/Cal study didn’t detect any such rationality. When costs went up, people just stopped filling their prescriptions for statins — high-value drugs that are effective in preventing heart attacks.
The researchers explained it like this: The way patients behaved when faced with higher out-of-pocket costs would suggest that they placed very little value on their lives. They literally stopped taking high-value drugs because of the price.”
“If patients can’t make good value judgments, the economic argument for cost-sharing starts to crumble, and it starts to seem like eliminating cost-sharing — increasing the likelihood patients will continue to take the medications they need to stay alive — would be a cheap way to “buy” people more health. As the researchers wrote, “improving the design of prescription drug insurance offers policy makers the opportunity to purchase large gains in health at extremely low cost per life-year.””
“Eliminating out-of-pocket costs would come with a price: Insurers would likely charge higher premiums to offset the loss of the copays and coinsurance that currently reduce their direct costs. But if the goal is better health outcomes, that is arguably a price worth paying.”
“In 1984, they introduced MediSave, a health savings account that was part of the country’s mandatory savings scheme, called the Central Provident Fund (CPF). Adding the MediSave bucket to the fund (which also has a bucket for housing and a bucket for retirement) forced all Singaporeans to pay something for medical care. This was followed in 1990 by the introduction of a catastrophic insurance policy called MediShield Life that is mandatory for all Singaporeans and permanent residents. Finally, in 1993, Singapore introduced MediFund, a government-managed endowment for Singaporeans who cannot cover their medical bills using the above two funding methods, cash, or family assistance. Interest from the endowment is given to certain health care institutions to underwrite the bills of patients who can’t pay. (The family help aspect is important, as MediSave funds can be used to pay the health bills of an immediate family member.) Although the country also has a supplemental private insurance market, Singaporeans under 55 must contribute 20 percent of their salaries, and their employers another 17 percent, to the CPF.
A network of public hospitals are meant to encourage what Lee Kuan Yew called a “self-administered means test.” Patients can choose any kind of hospital “ward” they like, but the subsidies slide based on consumer income and ward grade. A public hospital’s cheapest ward might sleep four patients to a room and lack air conditioning, while its most expensive wards sleep one person to a room and are cooled. While the vast majority of Singapore’s hospital beds are in public facilities, there are also private hospitals. (The situation for primary care and clinics, where care is cheaper, is the opposite: Most practices are private.)
Singapore has found that making people pay a nominal amount for every type of medical service discourages unnecessary consumption and that the spectrum of service upgrades—from shorter wait times to one-person rooms—allows prices to work as a mechanism for allocating resources. The system is greatly aided by a requirement from the Ministry of Health (MOH) that all public hospitals report to the government what they charge. The MOH then posts facility-specific averages on an easily searchable website where consumers can sort hospitals and wards by how much they charge for specific procedures. Private hospitals aren’t required to submit this information to the MOH, but many do so voluntarily. The differences are stark: The median cost of repairing a one-sided lower abdominal hernia at Singapore’s cheapest public hospital ward in 2018–2019 was $966. The median cost for the same procedure at Singapore’s most expensive private hospital was $15,729.”
“Singapore doesn’t control just the pharmaceutical choices of its residents; it also controls most of their media choices. Consider that Singapore’s buskers—the independent street performers one sees in public transportation systems and parks around the U.S.—not only need a permit (as is the case in Boston and several other American cities) but “are required to attend an audition to ensure consistency in the quality of busking activities,” according to guidelines published by Singapore’s Media Development Authority (MDA). Video games and movies “deemed to undermine public order” or that are “likely to be prejudicial to national interest” are prohibited. Press freedoms are nonexistent.”
“Even people who abhor the draconian policies in Singapore begrudgingly admit that it is a well-put-together place. The science fiction writer William Gibson visited the island for a 1993 Wired article in which he described the airport, streets, and buildings as perfectly maintained and the flora as immaculate. He could find no “wrong side of the tracks” or dilapidated infrastructure. The whole country was safe and polite and advanced. “Only the clouds were feathered with chaos,” Gibson wrote.
Following the publication of the piece, which described the country as “Disneyland with the death penalty,” Singapore banned the distribution of Wired.”
“Singapore is complex, but its core tension comes from the pairing of highly effective public and private institutions that take into account how people respond to incentives while engaging in shocking incursions on personal liberty and bodily autonomy. Imagine for a moment that it were possible for America to import what’s “good” about Singapore—the effective institutions, the economic growth, the tranquility. Could it be done without accidentally importing what’s bad?”
“Singapore is one of the few countries in the world where the public sector outbids the private sector for talent, thanks to the fact that “cabinet level pay may exceed U.S. $800,000, with bonuses attached that can double that sum for excellent performance.” The country’s culture of public service is also bolstered by “complex and overlapping incentives whereby top public sector workers are…respected highly and develop the personal networks for subsequent advancement in either the public or private sectors.””
“Bryan Caplan has argued that Singapore is unique in a way that does not bode well for policy adoption in either direction. In a 2009 paper, he summed up the “Singapore paradox” thusly: The island nation “persistently adopts policies that the democratic process would overturn almost anywhere else on earth, but the same party keeps winning election after election by a landslide. Why doesn’t a rival party promise to abolish the PAP’s unpopular policies and soar to power? How, in short, is Singapore’s political-economic equilibrium possible?”
Caplan probed several explanations in his paper, which he presented in Singapore. He ruled out the idea that the country is not actually a democracy, since it has free and fair (though not competitive) elections. Instead, he found strong survey evidence that Singaporeans were both “unusually concerned about economic performance” and deferential to the party that has delivered consistent economic growth for decades. The 2002 World Values Survey, where Caplan derived his data, reported that 58.8 percent of Singaporeans say “a high level of economic growth” should be their nation’s top priority, compared to 48.6 percent of Americans. In terms of political culture, the differences were much starker: 3.2 percent of Singaporeans reported being “very interested” in politics, and 32.8 percent were “somewhat interested” in politics. In America, the World Values Survey reported those numbers at 18.3 percent and 47.2 percent respectively.
Based on both the last eight months of social upheaval and on the United States’ decadeslong preference for swapping Democrats and Republicans in and out of federal power, Americans are almost certainly less deferential than are Singaporeans. And therein lies the rub: Being 10 percent less democratic requires American voters to trust elites and government far more than they do and, frankly, far more than they should.”
“Yana Chernyak, the assistant director of strategic initiatives at the American Enterprise Institute (and Cowen’s stepdaughter), wrote a guest post for Cowen’s Marginal Revolution blog in 2014 in which she posited that people “run in circles discussing whether Singapore is replicable based on its public and economic policies” and generally miss that “what actually makes Singapore so unique and probably impossible (or at least very difficult) to replicate” is its culture—specifically, Peranakan culture, which is passed down by the descendants of pan-Asian merchants and which holds a “positive view of commercial activity as the machine of wealth creation and basis of improving one’s life.””
“Singapore has combined classical liberal policies such as free trade, an open port, and low taxes with an authoritarian single-party government that centrally plans large swaths of the island’s economy and infrastructure, plays the role of censor in practically every media sector, canes petty criminals, and executes drug offenders. Because of, or despite, this seemingly incongruous combination, Singapore for most of the 21st century has reported higher annual gross domestic product (GDP) growth than the U.S., as well as lower infant mortality, greater trust in government, a comparable GDP per capita, and a longer life expectancy. The island city-state, as its proudest inhabitants love to mention, is also cleaner than the U.S. and has much less crime.”
“Doctors, nurses and caregivers at smaller and poorer hospitals and medical facilities across the country are still struggling to obtain the protective gear, personnel and resources they need to fight the coronavirus despite President Donald Trump’s repeated assertions that the problems are solved.
Health care workers at all types of facilities scrambled for scarce masks, gloves and other life-protecting gear at the beginning of the pandemic. The White House was letting states wage bidding wars against one another, rather than establish a central national manufacturing, supply and distribution chain.
But now, health care workers say a clear disparity has emerged and persisted. Larger and richer hospitals and practices outbid their smaller peers, sometimes for protective gear, sometimes to fill in staffing gaps. And some of those having the hardest time are precisely where the virus is spreading.”
“Black women are disproportionately impacted, dying in childbirth at three to four times the rate of white women.”
“Many factors contribute to overall maternal mortality in the US, from underlying conditions like diabetes to a lack of adequate health insurance. All of these disproportionately impact Black women — Black Americans, for example, are 60 percent more likely than whites to be diagnosed with diabetes. And 11.5 percent of Black Americans were uninsured as of 2018, compared with just 7.5 percent of whites.”
“For Black women, “even when we get prenatal care,” Crear-Perry explained, “even when we are normal weight and not obese, even when we have no underlying medical conditions, we are still more likely to die in childbirth than our white counterparts.” In New York City, for example, a 2016 study found that Black patients with a college education were more likely to have pregnancy or childbirth complications than white patients who hadn’t graduated from high school.”
“Part of the issue is that providers treat Black patients differently from white ones. Black women and other women of color often aren’t listened to when they express pain or discomfort, Jamila Taylor, director of health care reform at the Century Foundation, told Vox.
Racist beliefs about people’s bodies and their ability to experience pain are shockingly widespread: Half of the white medical students and residents surveyed in one 2016 study, for example, believed at least one myth about racial differences in pain perception, such as the idea that Black people’s nerve endings are less sensitive than white people’s. The more myths someone believed, the more likely that person was to underestimate a Black patient’s pain.”
“Advocates have long been calling for greater access to non-hospital births, whether at a birthing center or at home, as a way to combat the discrimination Black patients and other patients of color can face in hospital settings. “Other countries that have better outcomes than we do create a system and a network of birth centers and home births that allow for people to make choices based upon their needs,” Crear-Perry said.”
“COVID-19 has forced doctors to postpone many types of surgeries, but some things can’t wait. Ophthalmologist Jay Singleton saw one man at risk of permanent blindness on a recent Friday evening in New Bern, North Carolina.
“He had a rare type of glaucoma caused by a large cataract, and the only thing to do was to remove it so the pressure would go down inside the eye,” Singleton says. “We knew it was a very real situation because he already had lost one of his eyes to the same thing.”
Singleton had all the skills and equipment necessary for the job at his state-of-the-art vision center. Unfortunately, the government won’t let him use his space for the vast majority of the surgeries he performs.
North Carolina and many other states impose a regulatory tool called a “certificate of need” (CON), which forces health care providers to prove an unmet need in the market before operating a facility, scaling up, or purchasing major medical equipment. In practice, CON laws block new competition, funneling traffic to big hospital systems—the last thing that should happen during a global pandemic.”
“”You have to pick a side,” Singleton says. “If you treat it like a business, you must allow other people to enter the market and compete with you like every other business. If you treat it like a public partnership, then you can’t enrich yourself on the backs of Medicare patients. You can’t have it both ways.””
“15 states—including California, Colorado, and most recently New Hampshire—have eliminated their CON programs.
None of these states has experienced any negative effects. Indeed, Matthew Mitchell, a researcher at George Mason University’s Mercatus Center, says states that got rid of their CON laws have more hospitals and surgery centers per capita, along with more hospital beds, dialysis clinics, and hospice care facilities.
“Forty years of peer-reviewed academic research suggests that CON laws have not only failed to achieve their goals but have in many cases led to the opposite of what those who enacted the laws intended,” he says.”
“Many states, including Connecticut, Georgia, and South Carolina, suspended their CON laws after the pandemic came to America. Other states, such as Rhode Island, rolled back CON laws at hospitals and nursing facilities but not outpatient surgery centers or hospices.
Instead of just being a temporary reprieve, these emergency actions should be expanded and made permanent.”