I’ll have more to say about comparative effectiveness soon but this LA Times op-ed touches on the subject:
Investigators from Dartmouth used Medicare bills submitted by doctors and hospitals for patients who died and compared spending across geographies and across hospitals. The theory is that because all the patients died, any variation in spending must be waste. They then extrapolated these findings to identify high-spending geographic regions and high-spending hospitals for all Medicare costs.
Voila: a map in which Minnesota is the paragon and Miami and Los Angeles are the profligates. We dug a little deeper into relevant state health and hospital-use data for Los Angeles County. What we found was quite striking and pointed to one of the key differences in costs and outcomes for healthcare paid by Medicare.
The per capita income in L.A. County is $24,705; in the state of Minnesota, it is $37,373. More than 38% of L.A. County citizens live below the poverty line, 57% are black or Latino, and 24% are uninsured. In Minnesota, 11.6% live at or below the poverty line, 9% are black or Latino, and only 8.8% are uninsured. In L.A. County’s core — Central and South Los Angeles — the differences are even more striking: 56% of the residents are at or below the poverty line, 80% are black or Latino, and 41% are uninsured.
The authors’ conclusion?
Controlling the rate of growth of healthcare spending is an imperative. Unfortunately, there are no easy fixes. It will require incentives for patients and physicians to reduce unnecessary healthcare utilization and to make prevention play a larger role. It will also require societal decisions about what constitutes value, particularly at the end of life.
Further, it means addressing the underlying causes of healthcare disparities — disparities that will not disappear just because healthcare reform is enacted. Applying geographic-specific data to make cuts to particular regions, however, could lead to significant harm to the underserved, critically ill in Los Angeles and other U.S. cities and to the safety-net hospitals that serve them.
According to the Census Bureau 28% of the people aged 18 to 64 in Los Angeles County are without health insurance. That’s substantially over the 15% national average and it’s quite a bit higher than Cook County’s 20%. That doesn’t suggest a national problem or an urban problem but an LA County problem, a California problem.
Local conditions and policies affect local problems and demand local solutions. While it might not be fair to blame California, it’s not fair to the rest of us for us to pay for the consequences of those local conditions and policies. California needs to step up to its own problems and cope with them on its own rather than trying to federalize them.
Stop contributing to the confusion already!
Being without insurance is NOT being without healthcare. I am a proud non-participant in the religious superstition that is insurance just as I am a proud non-participant in Roulette, where the 96% payoff rate far exceeds that of any kind of insurance.
Indeed: Insurance works against health care, since the non-insured person has the option to spend the premium savings on health care in another country, like Thailand or Brazil, where much more health care can be had for much less. This is not an option for the insured unless he is rich enough to spend his own money on top of the healthcare insurance premiums he has been paying.
I don’t understand the criteria for deciding what is a local problem, or why necessarily the state is the dividing line.
Hurricanes are a Florida/Alabama/Louisiana problem. Why do we federalize those expenses? Floods tend to be problems for those states on the Mississippi river. Why is the Corps of Engineers there spending federal money? If flu is epidemic in Kansas and not in Utah, why should federal funds be spent? We also spend federal money on primary education, on welfare, and of course on medicare and medicaid which may be problems in one state and not another.
Obviously the role of states is enshrined in the constitution, but that doesn’t alter the fact that the state construct is absurd. CA and ND are both states? CA is big enough to be a nation state and North Dakota has one fifth the population of my county.
And why shouldn’t the state of CA decide that health care is a city or county problem? Why should folks in Santa Barbara be taxed to cover the costs of Angelenos?
In the end isn’t it all just a series of evasions and refusals to accept responsibility?
Technically they are a, Texas, Lousiana, Mississippi, Florida, Georgia, South Carolina, and to a lesser extent North Carolina and Virginia problem. That is 16% of the states, but still a regional problem. It is a large enough problem that can affect more than one state simultaneously. A hurricane can impact say, Florida, Mississippi, and Lousiana for example. Further, given where all of the oil and natural gas pipelines are…it starts to become a national problem.
Still I suppose we could hav built much of that infrastructure somewhere else. So why didn’t we? Time inconsistency. Once you have an activist government you run this risk.
Why should I be taxed to pay for someone else’s pre-existing condition?
What is the role of the state insurance departments? I can think of only a few.
1. Some states increase the coverage mandates, so the state needs to make sure that additional coverage is included in the policies.
2. State agencies might want to check that the policies are written in clear language. Since most policies are based upon industry standard forms, that doesn’t seem very onerous.
3. State agencies want to make sure that the insurance companies are adequately capitalized/ reinsured. The current state complaint is that the insurance companies use holding companies or various separate corporations to conceal assets/liabilities.
The first one seems to be the kicker. Should states be the primary forum to determine minimum coverages or should the lobbiest train their sights on Congress?
It makes a great deal of difference if the policies of the states cause the problems. Moral hazard.
I think I meant to put my comment in the other thread in which state regulators were mentioned.
As far as this thread, I think there are differences in political culture, demographics, and health care supply that make federalizing health care inappropriate.
However, I don’t see how we can deal with portability without significant federalization.
“It makes a great deal of difference if the policies of the states cause the problems.”
I have to confess I laughed out loud.
So Miami and LA have problems. You don’t say.
Michael, you been workin’ on that?