Tuesday, May 23, 2017

Evidence-Based Policy Making? - Dumb Things Politicians Say About Health Care Policy

There have been multiple legislative attempts at major health care reform in the US.  Typically, such attempts feature considerable public debate, including speechs, congressional committee hearings, sometimes progressing to debates by the House and Senate.  (For example, see this Frontline chronology of the proceedings up to the passage of the Affordable Care Act, aka "Obamacare," in 2009.)  Usually the discussion includes some real experts on health care policy, and some real health care professionals, and at least appears to reference some data about medicine, health care, and health economics. Whether previous debates were truly evidence-based is not clear, but it appeared to me that they at least acknowledged the importance of evidence, and maybe even at times a rigorous approach to it.

However, the proceedings up to the passage of the American Health Care Act seemed somewhat different.  There were no public committee hearings or debates.  Per a Los Angeles Times article in April, 2017 (via the Chicago Tribune):

President Trump and House Republicans, in their rush to resuscitate a bill rolling back the Affordable Care Act, are increasingly isolating themselves from outside input and rejecting entreaties to work collaboratively, according to multiple healthcare officials who have tried to engage GOP leaders.

In particular,

And senior House Republicans and White House officials have almost completely shut out doctors, hospitals, patient advocates and others who work in the healthcare system, industry officials say, despite pleas from many healthcare leaders to seek an alternative path that doesn’t threaten protections for tens of millions of Americans.

'To think you are going to revamp the entire American healthcare system without involving any of the people who actually deliver healthcare is insanity,' said Sister Carol Keehan, president of the Catholic Health Assn., whose members include many of the nation’s largest medical systems.

While the experts have been shut out, some of its supporters of the AHCA in the US House of Representatives have been free with their explanations of their actions.  Some have been rather alternative, so to speak.   Some recent examples, in chronologic order,

Rep Roger Marshall (R-Kansas): the Poor "Just Don't Want Health Care"

As reported by the Washington Post, March 9, 2017

'Just like Jesus said, ‘The poor will always be with us,’ ' Marshall said in response to a question about Medicaid, which expanded under Obamacare to more than 30 states. 'There is a group of people that just don’t want health care and aren’t going to take care of themselves.'

He added that 'morally, spiritually, socially,' the poor, including the homeless, 'just don’t want health care.'

'The Medicaid population, which is [on] a free credit card as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising. And I’m not judging; I’m just saying socially that’s where they are,' he told STAT, a website focused on health-care coverage.

The problem is that Marshal, who is a physician, did not provide evidence that there is some essential characteristic of the poor that causes them to make bad health decisions, or discus whether perhaps the poor face constraints on their health care decision making that the rich do not.  The implication appears to be that Marshal is treating an promoting an ideological or religious opinion as if it were derived from epidemiology.

House Speaker Paul Ryan (R-Wisconsin) The Problem with "Obamacare" is "the People Who Are Healthy Pay for the People Who Are Sick."

As reported by MSNBC, March 9, 2017

Take today, for example, when the GOP House Speaker did a little presentation on Capitol Hill for reporters in defense of his controversial American Health Care Act, which some have begun calling 'Trumpcare.' At one point during the slideshow – complete with Ryan’s sleeves rolled up – the Wisconsin Republican tried to explain what he sees as the Affordable Care Act’s fatal flaw:

'The fatal conceit of Obamacare is that we’re just gonna make everybody buy our health insurance at the federal-government level, young and healthy people are going to go into the market and pay for the older, sicker people. So, the young healthy person is going to be made to buy health care, and they’re going to pay for the person, you know, gets breast cancer in her 40s or who gets heart disease in his 50s. […]'

'The whole idea of Obamacare is … the people who are healthy pay for the people who are sick. It’s not working, and that’s why it’s in a death spiral.'

As MSNBC reported, the problem is with that is

that Ryan doesn’t seem to understand what “insurance” means.

Look at that quote again: The whole idea of Obamacare is … the people who are healthy pay for the people who are sick.' Well, yes. The whole idea of health insurance is to establish a system in which the people who are healthy pay for the people who are sick.

This really isn’t that complicated. In fact, it’s incredibly common for the vast majority of Americans: we pay premiums, the money goes into a pool, funds from that pool pay for care. It’s Insurance 101.

If Ryan disapproves of this model – which is weird, given that his own reform bill is built on consumers getting coverage through traditional insurance – there are effectively three alternatives. If the healthy aren't going to pay the sick, who will? The sick can try to pay for themselves, the government can pick up the tab, or the sick simply won't get care.

Rep John Shimkus (R-Illinois) Why Should Men Have to Purchase Prenatal Care? 

As reported by the Washington Post, March 9, 2017, regarding a hearing in the House of Representatives Energy and Commerce Committee

'What mandate in the Obamacare bill does he take issue with?' Doyle asked Shimkus, using the formal parlance of congressional committees.

'What about men having to purchase prenatal care?' Shimkus said.

At that point, one could hear the room start to stir.

'I’m just . . . is that not correct?' Shimkus said. 'And should they?'

Rep Shimkus, apparently like Rep Ryan, does not seem to understand the concept of health insurance.  The Post article put it this way,

Here’s how insurance expert and columnist Nancy Metcalf answered a similar question from a Consumer Reports reader that year:

Health insurance, like all insurance, works by pooling risks. The healthy subsidize the sick, who could be somebody else this year and you next year. Those risks include any kind of health care a person might need from birth to death — prenatal care through hospice. No individual is likely to need all of it, but we will all need some of it eventually.

So, as a middle-aged childless man you resent having to pay for maternity care or kids’ dental care. Shouldn’t turnabout be fair play? Shouldn’t pregnant women and kids be able to say, 'Fine, but in that case why should we have to pay for your Viagra, or prostate cancer tests, or the heart attack and high blood pressure you are many times more likely to suffer from than we are?' Once you start down that road, it’s hard to know where to stop. If you slice and dice risks, eventually you don’t have a risk pool at all, and the whole idea of insurance falls apart….

Rep Mo Brooks, (R-Alabama): "People who Lead Good Lives" Do Not Get Sick

As reported by Vox on May 2, 2017, Rep Brooks said in an interview on CNN to explain why people with pre-existing conditions should personally pay for their health insurance

allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool that helps offset all these costs, thereby reducing the cost to those people who lead good lives. They’re healthy; they’ve done the things to keep their bodies healthy. And right now, those are the people who have done things the right way that are seeing their costs skyrocketing.

He seems to be arguing first that people who virtuous ("good") are healthier than others.  He certainly provided no evidence for this assertion, which, like the assertion by Rep Marshall above, appears to be ideological or religious judgment disguised as epidemiology.

Rep Paul Labrador (R - Idaho) "Nobody Dies Because They Don't Have Access to Healthcare"

As reported by CBS News on May 6, 2017

Labrador made the comments the day after the U.S. House passed a GOP-led health care bill repealing and replacing chunks of Obamacare. Labrador, a member of the conservative House Freedom Caucus, was responding to an audience member who expressed concern about how the bill would affect Medicaid recipients.

'You are mandating people on Medicaid accept dying. You are making a mandate that will kill people,' the audience member said, before being drowned out by Labrador's response.

'No one wants anybody to die,' Labrador said. 'You know, that line is so indefensible. Nobody dies because they don't have access to health care.'

It is not completely clear whether Rep Labrador meant access to health care, or access to health care insurance. A person with appendicitis, acute bacterial pneumonia, a myocardial infarction, etc, etc who fails to seek acute care because of lack of a means to pay for it could well die. As an absolute, this statement is obviously untrue.  

Mick Mulvaney, Director of the Office of Management and Budget: "The Person Who Sits at Home, Eats Poorly and Gets Diabetes" Does Not Deserve Health Insurance

As reported by the Huffington Post on  May 12, 2017

he drew a distinction between people like Kimmel’s son, born with a congenital heart disease, and people who end up with conditions like diabetes. 'That doesn’t mean we should take care of the person who sits at home, eats poorly and gets diabetes,' Mulvaney said, according to a Washington Examiner account consistent with real-time social media reports. 'Is that the same thing as Jimmy Kimmel’s kid? I don’t think that it is.'

This is not exactly the clearest statement but it seems to imply that only people who make unhealthy life-style choices get diabetes, which certainly as an absolute is not true; and furthermore that people who develop diseases due to poor life-style choices do not deserve care.  The juxtaposition suggests that driving this is an ideological or religious judgment about who is deserving.

Video diversion: would Mr Mulvaney think this person deserves "health care?"


In 2003 I published an article entitled "A Cautionary Tale: the Dysfunction of American Health Care," which summarized the views of health care professionals about the causes of health care dysfunction.  One of the major findings was the importance of " attacks on the scientific basis of medicine."  In turn, I hypothesized that some of these attacks stemmed from the rise of post-modernism, then a fashionable intellectual affectation on university campuses, mainly of the avant garde left-wing.  I wrote then:

Postmodernism is 'an attempt to question the fundamental philosophical and political premises of the West.   It argues that many of the concepts we take for granted—including truth, morality, and objectivity—are culturally ‘constructed’'  To postmodernists, truth is just what the powerful say is true.

Now it seems that post-modernist "thought" has escaped the confines of left-wing humanities departments, and infiltrated political discourse, and for some unfathomable reason, seems to particularly affect some of those who profess to be conservative. After all, in January, KellyAnne Conway, a senior White House adviser, defended the administration's arguments as "alternative facts." (Look here.)

Facts, however, are stubborn things.  Evidence is evidence, no matter what politician it might offend.  Basing legislation on the sorts of alternative thinking displayed in the cases above could lead to real life, or life and death consequences for the sick, injured and vulnerable.  True health care reform requires clear thinking and the input of people who actually know something about health care. 


Live IT or live with IT said...

Sounds like the same non-evidence based nonsense spread by HIT zealots.

Unknown said...

One of the thorniest issues in health outcomes is to establish some sort of causality in the relationship between health and income. For instance, are people who are clinically depressed poor because they are depressed, or is it the other way around.
There are ways to untangle this with econometrics, but there isn't any dataset collected for this reason to work on.

We don't know.