The Common Inheritance, The Common Defense

A bit of self promotion here, but I’ve got a piece in today’s Boston Globe that might be of interest to some here.

It’s a look at what the idea of the commons — not just the abstract, model commons of Garrett Hardin’s famous essay, but the historical commons as actually lived and used — can tell us about current problems.  The TL:DR is that commons are not inherently prone to tragedy, but that the preservation of communal goods requires…wait for it…communal action: regulation, self-regulation.

This is, of course, exactly what the Republican Party denies — more, loathes and condemns.  With Trump, they’re getting their way, but its vital to remember that the consequences that will flow from these decisions are not down to him, or simply so: the entire Republican power structure is eager to do this, and when we pay the price, we must remember who ran up the bill.

Anyway, here’s a taste from my piece.  Head on over to the Globe’s site if you want more.

The idea of the commons is deeply woven through the history of the English countryside. Shakespeare captured this idyllic approach to nature’s wealth in “As You Like It,” when the shepherd Corin explains to the cynic Touchstone the joys of his life. “I earn that I eat, get that I wear,” he says, adding that “the greatest of my pride is to see my ewes graze and my lambs suck” — in the unowned, readily shared Forest of Arden.

There can be trouble in such an Eden, as Hardin pointed out in an influential 1968 paper. Hardin asked what would happen if access to a commons were truly unfettered — if Corin and every other villager ran as many sheep as they could there. In such cases, Hardin argued, the endgame is obvious: Too many animals would eat too much fodder, leaving the ground bare, unable to support any livestock at all.

The evolution of resistance to antibiotics fits that story perfectly. The first modern bacteria-killing drug, penicillin, came into widespread use in 1944, as American laboratories raced to produce millions of doses in time for D-Day. The next year, its discoverer, Alexander Fleming, used his Nobel Prize lecture to describe precisely how this wonder drug could lose its power, telling the sad tale of a man who came down with a strep infection. In his tale, Mr. X didn’t finish his course of penicillin, and his surviving microbes, now “educated” (Fleming’s term), infected his wife. When her course of penicillin failed to eradicate these now-resistant microbes, Mrs. X died — killed, Fleming said, by her husband’s carelessness. It took just one more year for this fable to turn into fact: In 1946, four American soldiers came down with drug-resistant gonorrhea, the first such resistance on record.


Go on — check it out.  You want to hear about the great Charnwood Forest rabbit riot.  You know you do…

Image: Jacopo da Ponte, Sheep and Lambc. 1650.

Two great philosophers for the next four years

Okay, now it’s real so let us rely on two great philospophers for the next four years:

And it looks like America agrees with Ron Burgundy

CBS News:

It has been 10 weeks since Donald Trump was elected president, and more Americans disapprove (48 percent) than approve (37 percent) of the way he has handled his presidential transition. They are split on his cabinet picks. Views divide heavily along party lines.

Just days before his inauguration, Donald Trump’s favorable rating (32 percent) is the lowest of any president-elect in CBS News polling going back to Ronald Reagan in 1981, when CBS News began taking this measure.

Well we’ll have to survive being “governed” by the Brietbart comment section so we can either laugh or cry while we bang our heads into our desks today.

Dreaming of impossible dreams and guaranteed disappointment

The Wall Street Journal has a good quote on what Americans say they want for healthcare and what has to happen for that to happen:

Cheap insurance means either very little gets covered or the people who need a lot of coverage can’t get insured. Covering sick people means either massive subsidies (public or private) from the healthy to the sick and restricting the size of those subsidies means limiting choices.  Democrats got hammered for choosing to cover sick people via either Medicaid expansion or through subsidized private sector insurance with a coercive participation mechanism.  Republicans will get hammered for telling people to go die quietly in the corner and here’s a tax deduction that only matters if you’re healthy and wealthy.

This is the core problem of health policy.  There are no pure win-win solutions for the healthy and the sick at the same time.

Evidence based care in Medicaid

We want to do evidence based care.  We want to do things that work and avoid things that don’t work.  This sounds simple.  Let’s look at two very good natural experiments on unintended pregnancy rates:


    Since 2008, Colorado has successfully increased access to family planning services throughout the state, particularly for the most effective contraceptive methods, such as intrauterine devices (IUDs) and implants.

  • The Colorado Family Planning Initiative has increased health care provider education and training and reduced costs for more expensive contraceptive options, enabling more than 30,000 women in the state to choose long-acting reversible contraception….
  • When contraception, particularly the long-acting methods, became more readily available in Colorado between 2009 and 2013, the abortion rate fell 42 percent among all women ages 15 to 19 and 18 percent among women ages 20 to 24.
  • Colorado is a national leader in the use of long-acting reversible contraception, and reducing teen pregnancy and repeat pregnancies.

    • Teen birth rates in our state have declined more rapidly than in any other state or the nation as a whole.
  • The birth rate for Medicaid-eligible women ages 15 to 24 dropped sharply from 2010 to 2012, resulting in an estimated $49 million to $111 million avoided expenses in Medicaid birth-related costs alone.

More reliable and effective contraception was made available to Colorado women who had the choice to elect Long Acting Reverisble Contraception (LARC) or do something else.  A significant number of women elected to use LARC and the increased autonomy and reliability produced amazingly good results.



Reducing contraceptive availability led to higher abortion rates and higher unplanned pregnancies. Earlier live births have massively negative multi-generational repercussions for both the parents and kids.

The evidence strong suggests that significant improvements in quality of life can be made and significant expenditures reduced if contraception is made readily available.

And guess what Congress will consider to be a high priority:

House Speaker Paul Ryan announced Thursday that Republicans will move to strip all federal funding for Planned Parenthood as part of the process they are using early this year to dismantle Obamacare.

Wahoo… the evidence will strongly support the hypothesis that this policy will lead to more unintended pregnancies, more abortions and far worse outcomes for far more Americans.

Evidence based policy making — Hoo Yaa

What about the children

From McClatchy we sit a clear trade-off between making sure kids are healthy and able to contribute to a bright future or high income tax cuts:

4.4 million children could lose health coverage in 2019 if the Affordable Care Act is partially repealed through the budget reconciliation process, according new report by the Urban Institute, a progressive, non-partisan think tank.

Likewise, the uninsured rate for … children would more than double in 2019 from … from 4.1 percent to 9.6 percent for children under age 18, the report found…

Of the 4.4 million children who would lose coverage in 2019, 88 percent would have working parents

The previous ACA repeal bill also allowed states to lower child eligibility levels for Medicaid and the Children’s Health Insurance Program (CHIP) beginning in 2017. If all states did so, another 8.9 million children would be without coverage in 2019

So we’re looking at between 4 and 13 million children being sacrificed to the altars of Moloch.

Good to know.

And we call ourselves civilized.

The illusion of value in ER diversion

I want to highlight something that bothers me about the entire idea of getting massive cost savings from emergency room diversions (via TPM):

The example Rep. Bill Huizenga (R-MI) gave in an interview with was from his own experience when he waited until the morning after to take his youngest son to the doctor with an injured arm, because he did not want to waste money on an expensive emergency room visit. The arm, it turned out, was broken.

“We weren’t sure what was going on. It was in the evening, so I splinted it up and we wrapped it up, and the decision was, okay, do we go to the ER? We thought it was a sprain, but weren’t sure,” Huizenga said, adding that he and his wife “took every precaution and decided to go in the next morning.”

“When it [comes to] those type of things, do you keep your child home from school and take him the next morning to the doctor because of a cold or a flu, versus take him into the emergency room? If you don’t have a cost difference, you’ll make different decisions,” he said.

I hate this example for a lot of reasons including the fact that a broken bone is a legitimately good reason to go to the emergency room. It is a source of significant pain, significant impairment and over time a simple break left untreated can lead to a complex set of breaks that requires very expensive surgery. But that is besides the greater set of points why this is a bad story to tell.
Let’s go back to the most important graph in healthcare:

ER utilization can be broken into three components.  True emergencies that lead to admissions.  Here ER utilization is expensive but very valuable.  Then there are acute emergencies that occur either off hours or can not be handled at the PCP or Urgent Care office due to the lack of equipment where the ER may not admit but they are an appropriate resource.  Asthma attacks and broken bones are common pediatric examples of this case while unspecified chest pains and shortness of breath are good examples of older people.  And then there are the cases where the ER is overkill.  The problem is that ER overkill is a real problem but it is not a big driver of total medical spending.  It might be a $5-$10 per member per month in the most aggressive modeling.

Marginal ER utilization for flip a coin decisions where having a large deductible could drive people to wait a day or two before getting a broken bone treated is not that big of a deal. Those are the cases on the left hand side of the graph.  People who don’t use the ER a lot, who don’t use a lot of services a lot don’t cost the system a lot of money.  Shifting a single in-network medium severity ER visit to a single in-network medium severity Urgent Care visit might lower the contract expenditure by $200 or $300.  If the kid’s arm is broken and it needs surgery, that is 5% of the total episode of care cost.  If there is nothing beyond an “oowie”, the shift might save 75% of the episode cost of care.  The shopping paradigm is that it will change behaviors among people who are not driving most of the healthcare spending.  It will save money but it is limited in what it saves as the people use a lot of medical resources will blow through any out of limit cap very quickly.

And this story only makes sense if there is a significant substitution effect between ER and Urgent Cares.

Secondly we are seeing that expanded urgent care utilization does not have significant impact on ER utilization.

Read more

Network information

Loren is a healthcare wonk. He knows this shit cold and he is right, no one in their right mind would think to call the in-network hospital to see if the anesthesiologist would be in-network if a laboring mother to be needed/wanted an epidural.

As other wonks in the tweet stream noted, the best that he could hope for is the hospital to give him a non-binding informational advisory that their anesthesiologists were or were not in network. And even here, the information is incomplete. Many carriers will offer a number of different networks in the employer and individual markets. Some carriers will tell providers that they are in seven of the twelve networks offered. In those cases, the office manager or the billing clerk might be able to tell an interested patient who is trying to effectively shop for planned care whether or not Dr. Smith is in-network for them. Here the system may not be working but it is not flailing around completely in a fireball of fail.

However not all carriers will do this. Instead they’ll send Dr. Smith seven contract amendments for the seven current networks that they want Dr. Smith in. They will never send him the other five narrow network amendments to sign or reject. So when a patient is trying to conform to the system that we impose on them, the billing manager will honestly say “Yep, we take all plans from Mayhew Insurance….” and three months later as the claim is submitted and everyone expects an in-network charge, the patient gets whacked with an out of network bill.

Our provider information systems are designed to fail in a Kafka-Goldberg-Dilbert menage a trois.