Denominators.
Even if you are not a regular user of statistics, you
probably remember that word from arithmetic. You know, the “4” in ¼, as opposed
to the “1”, the numerator. Why is this important in the current policy debate?
Well, if you know, for example, that a majority of, say, Republicans (or Democrats) like
a policy, it would be a mistake to assume that a majority of all people like it.
In health care policy, in particular, denominators, and how they are chosen, are
important, because by choosing an inappropriate one you can “prove” a point
that is wrong.
I recently was present for a debate on the issue of “health
care is a human right” in an undergraduate class. The students did well, and
although almost all personally supported the “pro” side, the “anti” side was able
to find arguments in the literature, often from organizations like the CATO Institute.
To a significant degree, however, they were either philosophical objections
(“what is a human right?”) or, conversely, pragmatic irrelevancies to the issue
(“a lot of doctors don’t take Medicaid”). Many of the assertions are belied by
the facts. For example, the Northwestern economist
Craig Garthwaite, interviewed in VOX, notes that if drug companies
can’t make huge profits, innovation will go down, and most of the world depends
upon the innovations discovered in the US. In fact, of all New
Molecular Entities (NMEs) discovered, a little over 1/3 are in the US.
But even this ignores another important point – many or most of these were not
originally discovered by pharmaceutical companies using their hard-earned
profits on Research and Development (R&D), on which they spend much less
than on marketing, but by government (National Institutes of Health, NIH)
supported university research, which the drug companies skim for the most promising
ones. So what is the denominator there? All NMEs, or only those funded by drug
companies?
The students also cited these opponents of
healthcare-as-a-right or Medicare for All who also assert that, in a similar
manner, it would cause quality to decrease. If everyone has access, and hospitals and
doctors can’t make more money on some, they opine, then those people will not get all the
best, most modern and effective care. This is where denominators come back in. Even
if it were true that there might be decreased quality for those who currently
have unfettered access (very questionable), it is obvious that the quality of
care would increase for those who now
get little or none! Overall, when the whole population is considered as the
denominator, the quality of care would absolutely go up. Denial of care, as
asserted long ago by Schiff, Brennan and Bindman, is “the gravest of all
quality defects”.[1]
If a hospital, for example, reports excellent outcomes for people treated there
for heart attack, but only those with good insurance were admitted for
treatment and the overall rate of death from heart attack in the community
rose, it would be painting a very skewed picture. If what you mean is “I have
real privileges, and I am afraid that by spreading access out to everyone I
might lose that privilege”, then say that; don’t dress it up by pretending
quality would decrease!
A common assertion we hear, particularly from “moderates”,
or at least from the politicians, pundits, and media who assert that they speak
for moderates, is that “Most people obtain health insurance through their
employers and are generally satisfied with their choice of providers, coverages
and the amount they contribute to their family’s healthcare.” This may be true,
or it may not be. The majority of people current have health insurance coverage through their employer, but whether
they are generally satisfied is another question. The main thing is that they
are much more likely to be satisfied when they are healthy and do not have to
utilize health care very much or at all. Even then, the copays and other
surprise costs can prove burdensome, but it is only when something happens that
causes them to need to use a lot of healthcare that it becomes critical,
bankrupting them and often even making that care inaccessible. When you and the members of your family are
not sick, costs can be low (and you can be satisfied) but when you are sick is
when all the hidden costs kick in. In this case, the important denominator
might be a smaller group, those who used healthcare, rather than everyone.
These excess costs include the various legal scams described
by Elisabeth Rosenthal “Where
the frauds are all legal” on December 7, 2019 in the NY Times (discussed by me in Scamming
Medicare: It's the providers and insurers, not the patients!,
December 19, 2019), when her husband had a serious accident. They also include
the “surprise bills” that come because, even though you went to a hospital that
was in your insurance network and saw a surgeon who was in your network, it
turns out that the ER group or the anesthesiology group contracted by the
hospital, or the assistant surgeon your surgeon picked, is not in network. Boom! $10,000, $100,000 bills! No one is “satisfied”
by this.
Such problems are most often faced by those with multiple
chronic diseases, often older people, who have to see the doctor, be
hospitalized or be operated on more often. Most people, in most years,
are not in need of major or expensive care, so they are the “satisfied well”.
But something bad and expensive could happen to any of us any day: Your doctor surprises
you by telling you that you have cancer! You are in a car (or bicycle) accident
and need big surgeries! Your baby was premature and needs to be in neonatal
intensive care! We are all at risk in a system where only some people are
covered, and only some of the time, and for some things, and for certain
providers.
Recently, there was big news when the large
Culinary Workers of America union came out to oppose Sen. Sanders’ Medicare for
All plan, which the union suggests would void the excellent health
care coverage that they have won for their members. The union deserves
tremendous credit for having negotiated this coverage in the current and recent
negative environment for unions, especially for a membership that is largely
relatively low-paid, minority, female, and often non-English speaking. However,
to suggest that it would be a loss for their members is deceiving. For one
thing, the coverage of a Medicare for All plan would be at least equal to this
excellent plan; it would cover everyone for everything. Health coverage is a
great benefit, but the money that employers pay for their contribution (which
unlike workers’ contributions is tax-deductible) is money that they don’t pay
in wages. The benefits of M4All compared to the CWA plan are well-described in this Quote of the Day by Dr. Don McCanne. And the CWA contract is a relative outlier and not guaranteed to be
as good next time; remember the many General Motors workers who were the
exemplars of having “Cadillac coverage” during prior healthcare insurance
debates, but who lost most of those benefits when GM “restructured” after
bankruptcy – if they were not laid off altogether?
At least as important are the relatives, friends, and
neighbors of those covered workers who work for small companies without good –
or any – health insurance plans, or are disabled, or unemployed for longer or
shorter periods. This is the “community”, the “population” that needs to be
considered as the denominator. Many
CWA (and other union) members realize this; while the union
leadership may rightly be proud of their accomplishments in negotiating, this
does not bring excellent health coverage or care to all of the people. The
denominator needs to be all of us.
Only a universal single payer system, an improved and
expanded Medicare for All, will do that.
[1]
Schiff GS, Brennan AB, Bindman TA, A Better-Quality Alternative Single-Payer
National Health System Reform, JAMA
272(10):803-808, September 14, 1994.
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