Replacing the Affordable Care Act -- what's so complicated?

Nobody knew health care could be so complicated? Er, except everybody but Mr Trump.  And yes, it's a huge behemoth of a system, but the devil is in the detail.  It's when you throw in all the special interests, political considerations, back-scratching, etc. that it quickly gets complicated.  But before all that happens, there are only three basic choices when it comes to providing medical insurance, and they are easy to grasp.  Choosing among them, though, has become much more of a political choice than an unloaded purely economic one.

Here's what we had before the Affordable Care Act (ACA): private insurance, either from one's employer or purchased individually.  For this to work, of course, just as any other business, insurance companies must make a profit, and that's harder when customers get sick; purchasers actually using their insurance isn't good for the bottom line.  That's why there's so much talk about people with "pre-existing conditions".  These are people who insurers know will cost them money and that's why people with "pre-existing conditions" were essentially uninsurable before the ACA, except as members of large employee pools comprised primarily of healthy people who had to buy in as a condition of their employment.  And that's why insurance companies used to charge women, older people, smokers, and so on more; they were more likely to cost money.  And that's why insurance companies also had policies such as lifetime caps on benefits.  To stay in business, insurers have to make a profit.  It's their reason for being.  This system can work well for healthy people and insurance companies.

The second option is something like the ACA, where everyone, pre-existing condition or not, can buy insurance -- an appropriate thing to point out on Rare Disease Day 2017.  As with auto  insurance, the only way this is financially viable is if everyone is required to buy in; just as good drivers subsidize unsafe drivers, healthy people subsidize people more likely to use healthy insurance.  Thus, the hated "mandate", the requirement that everyone buy in or be penalized on their taxes.  Many detractors of the ACA believe the mandate can simply be eliminated, that a replacement for the ACA can cover as many people, as cheaply, without one.  But, that's impossible. This is the same kind of privitized system that has worked without major snags for many years in Switzerland, for example. There, insurance is compulsory, and insurance companies must offer a basic plan which they aren't allowed to profit from although people can purchase bells and whistles, which is how the insurers make a profit.

The third option is the public option, often these days described as Medicare for all.  Government-supplied health insurance, paid for by tax dollars.  It's cheaper than the first two options in large part because it's non-profit, and the infrastructure required by private insurers to validate or deny claims doesn't exist.  National health has worked well in many rich countries for decades, keeping costs down and providing access to medical care to all.

And that's it.  There's no other "terrific" "cheaper" alternative anyone has thought of that can replace the ACA. The only options are a system that's totally private; something like the ACA with its mandate; and national health.  Unfortunately, this wasn't very well explained when President Obama was working on the Affordable Care Act, and it's not being explained now.  The Republicans in control of Congress aren't going to give us national health; and while it seems that many of them would be happy going back to what we used to have before the ACA, opinion polls are showing that people are less and less happy with that option.  Will Trumpcare be Obamacare renamed, then?  We'll have to wait and see.  

In any case, whatever system we adopt, we've still got problems.  Although the rising cost of medical care in the United States has slowed some with the ACA, at almost 18% of GDP health care spending here is the most expensive in the world, far exceeding that of any other high-income country, most of which have national health care (e.g., source).  In part it's because of the high cost of medical care, the higher use of expensive technology (e.g., MRI's, mammograms and C sections) and the exorbitant cost of pharmaceuticals.  And this is even with limitations imposed by insurance companies to control costs.  In addition, the cost of individual premiums has soared for people who aren't eligible for government subsidies to help cover the cost of insurance, in part, because fewer healthy people have purchased insurance than companies anticipated.  And deductibles and co-pays have risen sharply.  Insurance companies still have to turn a profit to stay in the health insurance marketplace.

Source

And, all this spending hasn't made us healthier than people in countries that spend even considerably less.

Source

So,  even if Trumpcare is as terrific and as cheap as we've been promised, it's hard to see how it will cut the high cost of medical care, and make us a healthier nation.  That is complicated, especially when private profit, rather than public health, is its fundamental basis.

Reproductive Health Funding and Why it Matters

Conflict and war can have an enormous impact on demography and population health. When active fighting breaks out in an area it can lead to large and chaotic population movements - if you’ve been paying attention to the news about conflict in the Middle East you’ve most likely seen images of huge populations fleeing countries like Syria and Iraq and the resulting influx of millions of refugees arriving in places such as Europe.

The chaotic settings in which these populations find shelter are often rife with sanitation, hygiene and other problems. Difficult, strategic decisions must be made on behalf of humanitarian agencies regarding how best to allocate limited funding to properly address the needs of these populations. Unfortunately reproductive health isn’t normally a high priority – although it really should be. One of the best ways to improve the health of a population is to address morbidity and mortality in very early childhood. Everyone in a population goes through the childbirth bottleneck. Everyone has a biological mother. Targeting these age and sex groups can have far-reaching impacts.

An IDP (internally displaced person) camp along the Thailand-Myanmar border. Photo by Suphak Nosten

Most of my work focuses on health issues along the Myanmar-Thailand border and while there has been a decrease in fighting recently, in the very near past there was active civil war and sporadic flows of refugees seeking safety in the mountains on the Thai side of the border. By the early 1980s there were many small refugee and internally displaced person camps scattered along the border. In the mid-1990s (between 1994 and 1998) most of these smaller camps were consolidated into one of 9 currently existing camps. Today, Maela refugee camp, roughly 60 kilometers north of Mae Sot, Thailand, is the largest of these camps with a current population of roughly 37,000. It has been in existence now for over 30 years.

One thing that is easy to miss in an age of constant news bombardment is that these populations, these refugee camps, don’t just disappear with the news cycle. Sometimes refugee camps last for a very long time. Today there are second-generation refugees who were born, and continue to live, in Maela camp.

Shoklo Malaria Research Unit, a field station of the Mahidol-Oxford Tropical Medicine Research Unit, operated the only antenatal clinic in Maela camp until this past December (2016). Recently we analyzed records and data from our experiences in providing contraceptives to refugee women in this long, drawn-out refugee setting. Given the current dire refugee situation of the world, we thought our experiences might have relevance not only for the current refugee situation but also for the future, given that many people will likely be living in large refugee settings for the foreseeable future.

The first thing that became obvious from our analysis is that obtaining a good understanding of basic demographics can be rather difficult.  Information really is a first casualty of war – gaining a handle on data about the population can be difficult even decades later. Furthermore, population counts can have political implications, or conversely, population estimates are sometimes the result of political sentiments.  For Maela camp there are two main sources of population counts – one comes from the humanitarian agency that provides food (the Thai-Burma Border Consortium (TBBC)) and the other is from the United Nations High Commissioner for Refugees (UNHCR) that provides humanitarian and social services. Until very recently UNHCR counts have systematically been much smaller than TBBC counts.

Population estimates have varied widely by the reporting source. We estimated the reproductive age female population for Maela camp by year using data from both TBBC (black) and UNHCR (blue) population estimates.  A loess curve (solid line) is fit to the data points and 95% confidence intervals for the curve are shown in dark gray.

Our data also show that, when provided in a socio-cultural appropriate manner, men and women in refugee settings willingly uptake contraceptives. The population we work with can properly be considered a high fertility (or natural fertility) population meaning that, with some exception, families are large and people are happy with that. But even in a high fertility population contraceptives have important health implications.  Men and women should be able to regulate their family size and spacing if they choose. Unintended pregnancies can result in incredible burdens, especially in already difficult settings, with health consequences for children, families, and entire communities leading to intergenerational transfers of poverty and nutritional deficits [1,2]. Households with few working-age adults and many dependents tend to be households with economic and nutritional deficiencies.

We also note that funding has a huge impact on the uptake of contraceptives and even the type of contraceptives that are chosen. Yes, men and women in the camp chose to readily use contraceptives, but the availability of contraceptives and the type of contraceptives available were directly influenced by funding. In this setting and in others, most of that funding could best be described as “rescue funding”, with reproductive health services normally operating on small and dwindling budgets but occasionally being “rescued” by a new source of funding. Given the importance of reproductive health (including the availability of contraceptives) and the dependence of reproductive health services on funding, funding agencies should carefully consider what they fund and should give careful consideration to funding cuts.

It is hard to draw direct, causal relationships between something like reproductive health funding and reductions in morbidity and mortality because there are complex relationships between health care delivery and health outcomes. However, we do know that during the time that SMRU operated the antenatal clinic in Maela camp both maternal and neonatal mortality decreased drastically. From 1986 to 1990 there were about 499 maternal deaths for every 100,000 births while in 2006 – 2010 there were 79 per 100,000 births [3].  In 1996 there were approximately 43.5 deaths for every 1,000 neonates and by 2011 there were 6 per 1,000 [4,5].

When funding was available, refugees in Maela camp willingly chose to use contraceptives leading to safer, better-planned pregnancies, which leads to health improvements of mother and child. A focus on reproductive health in conflict and refugee settings is extremely important and can have a drastic impact on population health. When people are given the opportunity to be more in charge of important parts of their lives, they are more likely to break out of difficult poverty cycles, and subsequently go on to live healthier lives. We believe this is a good thing.

photo by Suphak Nosten

A link to our new paper here

SrikanokS., Parker D.M., Parker A.L., Lee T., Min A.M., Ontuwong P., Tan S.O.,Sirinonthachai S., McGready R. Empirical lessons regarding reproductivehealth in a protracted refugee setting: a descriptive study from Maela camp onthe Thai-Myanmar border 1996-2015. PLoS One.

1. Wagmiller Jr RL, Adelman RM. Childhood and intergenerational poverty: The long-term consequences of growing up poor [Internet]. Columbia University Academic Commons. 2009. Available: http://hdl.handle.net/10022/AC:P:8870

2. Corak M. Do poor children become poor adults? Lessons from a cross country comparison of generational income mobility [Internet]. IZA Discussion Paper. 2006. Available: http://ftp.iza.org/dp1993.pdf

3. McGready R, Boel M, Rijken MJ, Ashley E a., Cho T, Moo O, et al. Effect of early detection and treatment on malaria related maternal mortality on the north-western border of Thailand 1986-2010. PLoS One. 2012;7. doi:10.1371/journal.pone.0040244

4. Luxemburger C, McGready R, Kham A, Morison L, Cho T, Chongsuphajaisiddhi T, et al. Effects of malaria during pregnancy on infant mortality in an area of low malaria transmission. Am J Epidemiol. 2001;154: 459–465. 

5. Turner C, Carrara V, Aye Mya Thein N, Chit Mo Mo Win N, Turner P, Bancone G, et al. Neonatal Intensive Care in a Karen Refugee Camp: A 4 Year Descriptive Study. PLoS One. 2013;8: 1–9. doi:10.1371/journal.pone.0072721

Save the Planet? Nonsense! But still.....

One hears a lot of Doomsday pleas that we should cut back on our consumption of carbon fuels, eat less meat, fish less, and so on--or else!  Or else what?  Or else, as it's often expressed, we'll destroy the planet!  Scientists speaking to each other about agricultural sustainability or climate change use less excessively inflammatory rhetoric, though even they can engage in catastrophism when the public media cameras are on.  Concern for the future is understandable, but exaggeration is not sensible if you stop to think about it. Crying "Wolf!" can backfire, because the Earth is not in imminent danger!

Human activity, even if we let our population rise to 10 or more billion and burn every single last chunk of coal and drop of oil, will not destroy the Earth.  No amount of energy conservation and sustainability will save the Earth from destruction, because it's not headed that way anyhow, and people haven't the power to destroy it (though, would we be able to come close with a nuclear WWIII?).

Indeed, it's possible that imminent catastrophe rhetoric reinforces the reactionary view that this is scientific nonsense and we should just close climate-change government-sponsored web sites and de-fund environmental science.

Part of the problem is that this is like the frog in a boiling kettle: the water gets hot so gradually that the frog doesn't notice it until it's too late.  We humans are not very good at long-term thinking or planning, perhaps because longterm thinking wasn't possible or useful as we evolved, when each day's food, safety and mates were what was at stake.  When change is slow, as global warming is, people often feel less inclined to self-denial today in exchange for a viable tomorrow.

In addition, sociologically speaking, climate change messages can be seen as a scientific or 'left-wing' elite telling everyone else that they have to scale-down, while at least some have noticed the fact that the same elite fly all over the world to have meetings, promote their books, and deliver their message (and flying is among the worst CO2 polluters).

In fact, most of what is being said by science, even taking scientists' vanities, frailties, and grant-hungers into account, is basically right.  The climate clearly is changing, the seas rising, agricultural patterns changing, many species endangered.  Of course, there have always been changes in patterns of rainfall, temperature, and vegetation, though the time scale generally has been glacially slow, so to speak, with the possible occasional exception of major meteorite strikes or huge volcanic eruptions etc.  The current speed is one reason human activity seems surely to be at least partially responsible.
Another important point isn't that climate is changing, but that the pace we're seeing today may not be reversible even if our behavior is contributing, because our ability to change the course of geoclimate might be limited.

But that doesn't mean that the science-deniers and their ilk hiding their head in the sand are right. They're as self-willed ignorant as scientists say they are.  They are pretending that the science is wrong, when the real truth is that they don't like the answers the science is giving us.

The real risk
If climate is always changing, and Save the Earth is a misleading slogan, the problem is that even if the Earth is not in danger, we are!  And that is the very, very personal and selfishly short-sighted reason that we should slow down global warming if we can, increase use of renewable energies, keep funding climate sciences, and so on.  Let's take a look at the wolf that really is at our door, and making enough evidentiary noise that we can't miss it.  What is at stake is not the Earth, but the kind of constancy we, like any species, rightfully feel comfortable with.

In fact, climate change does pose very serious, very real, and potentially dire risks. There are at least a few likely, foreseeable consequences of climate change:

1. Threatened lifestyles.  On the more mundane side, having to change where and how we live, what we eat, how we interact with each other, and so on, are major dislocations of lifestyle.  Being animals, we like our 'territory' to be familiar and feel safe.  The levels of ill-will and unhappiness that would ensue major cultural upsets due to climate change and its consequences, would be upsetting to a great many people. There may indeed be changed patterns of wealth, lifestyle, disease in us and/or our animal and plant food sources.  We may exhaust some minerals vital to our technological support systems. Even peacefully, gradually adapting to a lower-consuming lifestyle could avoid this, but would be disruptive; even if we lived very well in lower-consuming times in the past, social and psychological factors will be strained if our life-ways are changed too much or too fast. 

2.  Mass dislocation.  Most cities and urban concentrations are near natural waterways.  That's because they were founded over many centuries when water-borne trade and transport of goods etc., the stuff that makes concentrated populations possible, was the only real means of large-scale transportation.  So, if water levels rise along coasts and major lakes or rivers, or if waterways dry up, there will be dislocations that make todays middle east refugees look like tiddly-winks by comparison.  If tens of millions of Londoners and New Yorkers (not to mention residents of China or India) need to relocate, they'll have to go where there already are people.  This mass internal migration will be seen by the 'recipients' as 'Yugely' more of a threat than refugees today pose. 

3.  Exacerbated inequality and suffering.  Other large-scale dislocations of many sorts will mean economic deprivation for some who were well off, and new privilege for others.  Climate change alters agricultural areas, drying some up and making others flourish. Food being one thing people really do fight over, one can anticipate major economic dislocation and very large-scale competition for the new food producing areas, by those whose breadbaskets dried up.  This means war and potentially on a massive scale.  With 10 billion people, and industrial-scale weaponry (including nukes), the suffering will potentially be massively unprecedented.

In the overall scheme of things, a few island populations imminently needing relocation is an enormous event for the islanders but not a terribly large event globally.  But when cities become inundated, and food hard to come by, when refugees number in the many millions, and they're armed, well, that may be a definition of Arm-aggedon (forgive the pun).

We should be talking turkey to the public. Even if climate change is human-accelerated, it is not the first time there has been major climate change.  The Earth, and even the human species, will survive it.  Scientists should not be pressed by the intentionally uneducated into over-stating the case.  The planet is not in danger.  But in a sense there really is a wolf knocking at the door, and it is worth saving the planet as we know it.

What is in danger is our way of life.  And that's something humans kill for.