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Offering commentary and analysis from Washington, Oregon, and Idaho, The Cascadia Advocate is the Northwest Progressive Institute's uplifting perspective on world, national, and local politics.

Thursday, February 8th, 2018

The curious logic of Professor Adam Carroll

Last week, Indi­ana Uni­ver­si­ty School of Med­i­cine pro­fes­sor Adam Car­roll filed a piece for the New York Times with a provoca­tive premise. Titled Pre­ven­tive care saves mon­ey? Sor­ry, it’s too good to be true, it argued that invest­ing in pre­ven­ta­tive care does­n’t actu­al­ly yield sav­ings. Here’s its open­ing and closing:

The idea that spend­ing more on pre­ven­tive care will reduce over­all health care spend­ing is wide­ly believed and often pro­mot­ed as a rea­son to sup­port reform. It’s thought that too many peo­ple with chron­ic ill­ness­es wait until they are tru­ly ill before seek­ing care, often in emer­gency rooms, where it costs more. It should fol­low then that treat­ing dis­eases ear­li­er, or screen­ing for them before they become more seri­ous, would wind up sav­ing mon­ey in the long run.

Unfor­tu­nate­ly, almost none of this is true.


In the short term, less smok­ing would lead to decreased spend­ing because of reduc­tions in health care spend­ing for those who had smoked. In the long run, all of those peo­ple liv­ing longer would lead to increas­es in spend­ing in many pro­grams, includ­ing health care. The more peo­ple who quit smok­ing, the high­er the deficit from health care — bare­ly off­set by the rev­enue from tax­ing cigarettes.

But mon­ey doesn’t have to be saved to make some­thing worth­while. Pre­ven­tion improves out­comes. It makes peo­ple health­i­er. It improves qual­i­ty of life. It often does so for a very rea­son­able price.

There are many good argu­ments for increas­ing our focus on pre­ven­tion. Almost all have to do with improv­ing qual­i­ty, though, not reduc­ing spend­ing. We would do well to admit that and move forward.

Some­times good things cost money.

We can agree that good things usu­al­ly do cost mon­ey, but this seems like espe­cial­ly curi­ous log­ic to get to that con­clu­sion. Yes, if few­er peo­ple smoke, more peo­ple will live longer to get sick of oth­er things and die instead from that, requir­ing treat­ment along the way that might be expen­sive. But this is sort of like argu­ing that fire alarms don’t save mon­ey in the hous­ing mar­ket because the homes that don’t burn down with­in one hun­dred years become more expen­sive to maintain.

True, it saved an awful lot of mon­ey when that New York State lot­tery win­ner put off going to the doc­tor till he found out he had stage four can­cer.

Since he could­n’t afford to catch it ear­li­er, he just straight up died, skip­ping right past all that expen­sive chemother­a­py, hos­pi­tal, and hos­pice care, for months or years of remis­sion and return.

By Car­rol­l’s rea­son­ing, we real­ly should count improved access to repro­duc­tive auton­o­my as mon­u­men­tal health­care sav­ings because it means you’re not only sav­ing the cost of an unplanned preg­nan­cy or abor­tion, you’re also sav­ing the econ­o­my from a life­time of future health­care costs.

Euthana­sia on demand, espe­cial­ly for peo­ple over 80, would involve lots of cost-sav­ing, and what care could pos­si­bly be more pre­ven­ta­tive than mak­ing sure no one ever needs to use health ser­vices again?

So that’s just not a use­ful or real­ly even an hon­est way to look at things, even if that’s what the stud­ies he ref­er­ences were say­ing, and I’m not con­vinced they were, espe­cial­ly when it comes to emer­gency room vis­its increasing.

Mass­a­chu­setts: The imple­men­ta­tion of health care reform in Mass­a­chu­setts was asso­ci­at­ed with a small but con­sis­tent increase in the use of the ED across the state. Whether this was due to the elim­i­na­tion of finan­cial bar­ri­ers to seek­ing care in the ED, a per­sis­tent short­age in access to pri­ma­ry care for those with insur­ance, or some oth­er cause is not entire­ly clear and will need to be addressed in future research.

Ore­gon: We did not find that Med­ic­aid caused a sta­tis­ti­cal­ly sig­nif­i­cant decrease in emer­gency-depart­ment use for any of the con­di­tions we con­sid­ered; indeed, once again the vast major­i­ty of point esti­mates are pos­i­tive. We found sta­tis­ti­cal­ly sig­nif­i­cant increas­es in emer­gency-depart­ment use for sev­er­al spe­cif­ic con­di­tions, includ­ing injuries, headaches, and chron­ic conditions.

ACA over­all: We found that total ED use per 1,000 pop­u­la­tion increased by 2.5 vis­its more in Med­ic­aid expan­sion states than in non­ex­pan­sion states after 2014. … Among the vis­it types that could be mea­sured, increas­es in ED vis­its were largest for injury-relat­ed vis­its and for states with the largest changes in Med­ic­aid enrollment.

Although Oregon’s increase in ED vis­its appears to be per­ma­nent pre­vi­ous research sug­gests that the increase in ED vis­its may be tem­po­rary because of pent-up demand. Future research should revis­it how ED vis­its con­tin­ued to change beyond the first year of imple­men­ta­tion in 2014.

‘When peo­ple can afford to go to the Emer­gency Room with­out bank­rupt­ing them­selves, they’re more like­ly to.’ Well, yes, and an increase in peo­ple using the Emer­gency Room still seems entire­ly con­sis­tent with low­er­ing health­care spend­ing over­all because, for a lot of peo­ple, their pre­ven­tive care is going in to get some­thing checked out when it’s real­ly hurt­ing instead of about to kill them.

Indeed, expand­ing Med­ic­aid meant more peo­ple with injuries requir­ing emer­gency care actu­al­ly both­ered to go get it.

Car­roll dis­miss­es a study that found that all sorts of pre­ven­ta­tive care would lead to sav­ings in health­care of ‘only’ $3.7 bil­lion per year in 2006.

But it saves mon­ey to accom­plish this each year:

What’s more, the increased costs of [invest­ing in an evi­dence-based pack­age of pre­ven­tive ser­vices] would be recouped. Put dif­fer­ent­ly, more than two mil­lion peo­ple would have been alive dur­ing 2006—or 780 peo­ple in a city of 100,000—if pre­ven­tive care had been wide­ly deliv­ered in pri­or years, all with­out an increase in net cost.

‘Peo­ple healthy enough not to die’ tends to involve cost-sav­ings in the sense that a lot of mon­ey has been invest­ed in a giv­en per­son already in edu­ca­tion and job skills. ‘Peo­ple healthy enough not to be ill for extend­ed peri­ods of time or per­ma­nent­ly dis­abled’ saves mon­ey, too. It might save mon­ey not to ever change your oil, but a car that no longer runs is con­sid­er­ably less use­ful as a car.

Soma­lia does­n’t spend very much on pre­ven­ta­tive health­care, and the costs show up in peo­ple who are unnec­es­sar­i­ly infirmed and need some­one else to take care of them instead of engag­ing in pro­duc­tive eco­nom­ic activity.

Most sus­pi­cious is the fact that Car­roll went about mak­ing his case by focus­ing on an uptick in emer­gency room vis­its and peo­ple sur­viv­ing lung can­cer to die of heart dis­ease rather than a more straight­for­ward look at how oth­er OECD nations’ increased avail­abil­i­ty of pre­ven­ta­tive care seems to result in peo­ple liv­ing longer, health­i­er lives while their gov­ern­ments spend less on health­care overall.

To be fair, Car­roll is mak­ing only a soft sort of argu­ment, but I don’t think his links sup­port his claim, that his claim even makes sense on its own terms, or that even if those were valid, that’s the most sen­si­ble conclusion.

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