Tuesday, March 27, 2012

Affordable Care Act

I have not commented on the Affordable Care Act in a while.  With the Supreme Court case right now, I think it is worth commenting on again.

  • Yesterday, I saw a public radio program's site asking for comments on mandated health care.  First things first--no one is mandating health care.  What is being mandated if it is considered constitutional is health insurance--that is not the same as health care.
  • Just because people have health insurance doesn't mean that they will use care or use it to achieve any higher quality of health care services than they are now.  Yes, they will have reduced financial barriers.  But there are many more barriers that are non-financial.  Anyone who has ever wanted to see a new physician for a non-emergency reason has probably experienced a long wait.  For some people that is not a problem. For others, it might discourage them from seeking care.  And even if a person gets more care it doesn't inherently mean that it will be any more coordinated.
  • While there are non-financial barriers, empirical research suggests that people who pay less for care when they need to use it use MORE care.  (In other words, medical care follows the same response to price that almost everything else does.)  Are there some people who will use less care or at least less expensive care because they get preventive care or have a chronic condition managed better and stay out of the hospital?  Of course.  But, at a population level it is quite possible that making care less expensive at the time people need it will end up leading to spending more on health care rather than less.
  • I realize that people with pre-existing conditions would like to not have to worry about financing their health care expenditures.  That is true of all of us.  If insurers are no longer allowed to restrict the enrollment of people with pre-existing conditions, individuals with pre-existing conditions will be able to get financial protection that they could not get before. What will that do to premiums?  When individuals who are expected to spend more are added to the risk pool, the premiums will necessarily go up.  Now, that may be offset by health care providers not needing to charge some extra to make up for uninsured individuals, but there is no guarantee.
  • Finally, with many more people with insurance who wish to consume a greater quantity of care, that will put more pressure on an already crowded health care system.  Without an increase in care providers, the waits that we already experience will grow longer.
So, is the net result good, bad, or otherwise?  Some people will obtain financial protection who did not have it before.  I am glad that is the case.  If they pay for it directly that will shift at least some of the financial responsibility for care.  There is an argument for fairness in that.  However, there is no guarantee that overall we will pay less as a society, that individuals with insurance will pay lower premiums, or that anyone will get higher quality care in a more timely way than we are now.  

Monday, March 12, 2012

Role of Government in Tanning Salons

As my last entry for my students in the School of Public Health third term course, I'd like them to think about tanning salons.  We are nearing spring with lots of opportunities for outdoor recreation for adults, for children, and for adults watching children (i.e., sports like baseball and lacrosse).  In any case, Idaho is apparently considering restrictions on the use of tanning salons by minors--and not even all the way up to 18, just up to 15.  You can find the story here.

What is interesting from an economist's point of view is the question--why do we need government regulation in this case?  Is it market power?  Probably not.  In most places where tanning salons spring up there are quite a few of them.  Monopolistic competition may be the best description of the market, but it certainly doesn't appear to be a concentrated market.

Is there a lack of information?  Maybe.  But the messages about sunscreen, skin cancer, etc., seem pretty wide spread.  That is true both in the US and Australia where I visited in January.  It seemed like you couldn't go more than one half hour without some type of public service commercial on television focusing on protecting oneself from skin cancer.

Is there a compelling need?  Maybe.  But on what basis?  Is there a disparity?  Is it to protect children?  If it is to protect children how does the government role fit with the parent role?  Why regulate for children and not adults?  Are there less direct measures that might result in a change in the use of tanning salons and now raise so much political controversy in a state that has historically placed a high value on personal freedom?

The question of personal freedom always leads to "freedom to do what?"  And that is a reasonable question.  Freedom to put oneself at risk for something?  If so, who pays for the consequences?  The article mentions motorcycle helmets--again, what is the risk and who pays?  Even for my beloved sport of running...if I put myself at risk for injury who should pay if I get injured?  What is the role of insurance--where those enrolled share risk--when people have some control over their own risk?  For example with running--what is the net risk?  Presumably lower for any disease related to cardiovascular health over time but a lot higher for sports-related injuries than my sedentary colleagues.  How shoudl we price that and at what level should we price it?  Me?  My employer?  Some other group?

There are no easy answers here--as usual.

Final question--the article comments on winners and losers from a policy like this.  Perhaps some entrepreneurs who expected to make more money on tanning salons are financial losers.  Perhaps younger teens who want use the tanning beds are "utility" losers.  But who would gain from this regulation--other than parents and public health experts with the utility of knowing their kids are at less risk (and there may even be some parents who agree with their teens' use of tanning salons).  Does anyone gain financially? 

Wednesday, March 7, 2012

Maryland State Law and CAM Providers

I am lucky enough to be able to afford to be treated by a massage therapist either before or after each REALLY long race that I run. (For me, I classify anything longer than a half marathon as a REALLY long race.) My practitioner brought the Maryland 2012 HB0238 and SB0337 to my attention. These are laws that involve the Nursing Board and who needs to be licensed. The synopsis of the bill on the state House website reads:

Exempting individuals who provide gratuitous care for specified individuals from the requirement that an individual must be licensed or certified before practicing specified health occupations; exempting individuals who respond to a disaster situation in the State from the requirement that an individual must be licensed before practicing registered nursing or licensed practical nursing under specified circumstances; authorizing the Board to grant specified licenses by endorsement; etc.

That seems to focus on exceptions to the rule of being licensed.

My practitioner is concerned about the language that refers to the licensed practical nurses. The language reads that a practitioner

"...in a team relationship an act that requires specialized knowledge, judgment, and skill based on principles of biological, physiological, behavioral, or sociological science to:

(1) Administer treatment or medication to an individual;

(2) Aid in the rehabilitation of an individual;

(3) Promote preventive measures in community health;

(4) Give counsel to an individual;

(5) Safeguard life and health;

(6) Teach or supervise; ..."

Now, these are specifically applied to licensed practical nurses in the language of the bill. However, practitioners like "breathworkers, midwives, doulas, herbalists, life coaches, sound/music therapists, art and poetry therapists, movement, dance, and eurythmy therapists, samyama healing practitioners, meditation teachers, acupuncturists, massage therapists, bodyworkers (reiki, zero balancing, rolfing, etc.) yoga therapists, ayurvedic consultants, counselors and other practitioners of alternative healing arts" might be interpreted as falling under this regulation and then be required to get new licensing that is controlled by the Nursing Board.

I don't know whether there is a hidden underlying intent here. However, consider the following:

(A) a history of conflict among health professions when it comes to scope of practice and control;

(B) an increasing number of nurse practitioners who have to compete for patients;

(C) people having to struggle with insurance and pay more out of pocket despite health care reform; and

(D) a growing number of non-medical providers interested in health and well being.

I think there might be an incentive for nurses (perhaps in collaboration with physicians) to limit the entry of others' into the market for providing services to maintain and improve health and there may be a close relationship between at least some nurses/physicians and both legislators and regulators within the executive branch. Perhaps there is an argument that consumers lack information about providers who are not regulated by the state's Nursing Board (or the equivalent for physicians) but it is not clear that there is a market failure here that needs regulating.

It's worth your consideration--regardless of what state you are in.