humani nil a me alienum puto

random rants about news, the law, healthcare law, economics and anything I find amusing

Who are the Uninsured?

Back in 2005, I co-authored an article with Richard Stuhan, a partner at Jones Day.  The article was primarily about the concerted and misguided  efforts to sue non-profit hospitals for their alleged failure to provide charity care.  The plaintiffs contended that such provision of charity care was a legal obligations of 501(c)(3) tax exempt entities.   These suits, while striking the public policy cord concerning the plight of the uninsured and the inflation of health care costs and charges, were based upon ill conceived legal theories and, accordingly,  failed miserably.  But they probably were a precursor of congressional interest in charity care provided by non-profit hospitals and health systems — which is currently playing out and has resulted in some significant changes, most notably the new Form 990s.

One of the items we briefly discussed in that article, an issue that should be a major large part of the health care reform debate, is the scope of the health care insurance (or, more particularly, uninsured) problem in the United States.  Who accounts for the uninsured figures and why are they uninsured is critical to forming the debate about solutions.  The debate, I would think, is fundamentally different if a substantial portion of the uninsured could afford insurance or could access other forms of insurance (SCHIP, Medicaid, etc.), but decide for personal reasons not to obtain insurance or face administrative, educational or transactional barriers to signing-up for federal or state-sponsored insurance programs for which they would otherwise be eligible.   Circa 2003, the uninsured level was approximately 45 million, but a very significant portion of this populations was either eligible for federal or state programs or were from households that were significantly above the federal poverty level and could, technically, afford insurance.

Periodically, this issue has popped up with one study or another discussing the scope of the uninsured problem — addressing who are they, why are they not insured.   Of course, with this new round of health care reform, the issue of the uninsured should be front in center in the debate.  Recently, a report was issued entitled WHO ARE THE UNINSURED? An Analysis of the Characteristics of Americans Without Health Insurance by the Employment Policies Institute.   This seems to be a fairly politicized organization that has written studies before that have been scorned by some.   So, with that disclaimer and taking the study with a grain of salt, its conclusions are still notable. Assuming its numbers are correct, approximately 43% of the 2006 18-64 year-old uninsured are in households at greater than 2.5x the federal poverty limit.  This is not inconsistent with previous studies I had seen and I would think could be fact checked.

By no means does this take away from the significant and troubling 47% who are involuntarily uninsured.   But the number of individuals and households that have the means to, but choose not to, purchase health care insurance is important to the current debate.  What impact does this very significant portion of the uninsured have for risks of adverse selection, individual/employer mandatory coverage requirements, the level FPL subsidies and other components of healthcare reform bills being proposed.

Filed under: Health Law, Reform, , , , ,

TED Talk: Reimagining Global (Health) Data

I just love these TED talks. I previously have postedabout TED. I first discovered it when Pogue (NYT columnist) was talking about the conference and the wonderful web site. This talk is by Hans Rosling who was confronted by a dilemma. There’s tons of great data out there that tells wonderful stories about the world that can inform policy, destroy myths, demonstrate compelling trends, affect both our views of the world and what we have done and can to to improve. But tables and non-interactive graphs are just incredibly boring — and the underlying stories can be completely missed. Take a look at his presentation and then take a visit to his site. Kudos to Health Economist blog to turning me onto this. Really neat stuff. I’m trying to think how I could use something like this in a presentation (even being a lawyer — has to be something creative I can glom onto here).  About Hans Rosling from TED:

Even the most worldly and well-traveled among us will have their perspectives shifted by Hans Rosling. A professor of global health at Sweden’s Karolinska Institute, his current work focuses on dispelling common myths about the so-called developing world, which (he points out) is no longer worlds away from the west. In fact, most of the third world is on the same trajectory toward health and prosperity, and many countries are moving twice as fast as the west did.

What sets Rosling apart isn’t just his apt observations of broad social and economic trends, but the stunning way he presents them. Guaranteed: You’ve never seen data presented like this. By any logic, a presentation that tracks global health and poverty trends should be, in a word: boring. But in Rosling’s hands, data sings. Trends come to life. And the big picture — usually hazy at best — snaps into sharp focus.

Rosling’s presentations are grounded in solid statistics (often drawn from United Nations data), illustrated by the visualization software he developed. The animations transform development statistics into moving bubbles and flowing curves that make global trends clear, intuitive and even playful. During his legendary presentations, Rosling takes this one step farther, narrating the animations with a sportscaster’s flair.

Rosling developed the breakthrough software behind his visualizations through his nonprofit Gapminder, founded with his son and daughter-in-law. The free software — which can be loaded with any data — was purchased by Google in March 2007. (Rosling met the Google founders at TED.)

Rosling began his wide-ranging career as a physician, spending many years in rural Africa tracking a rare paralytic disease (which he named konzo) and discovering its cause: hunger and badly processed cassava. He co-founded Médecins sans Frontièrs (Doctors without Borders) Sweden, wrote a textbook on global health, and as a professor at the Karolinska Institut in Stockholm initiated key international research collaborations. He’s also personally argued with many heads of state, including Fidel Castro.

Filed under: Health Law, Personal Posts, Public Health, , ,

Haunting Images

I found this article interesting as it is local in flavor and surrounding what some might think is a morbid topic.  I disagree, and can see why dissection of a cadaver would be a central experience in the education of medical student. When I was in high school, I interned at the Cuyahoga County Morgue and observed an autopsy.  There I learned that Quincy (yeah, I’m that old and way before CSI) was not really how it worked.  I became an attorney, of course.

diss-colorCWRU’s Allen Memorial is putting on an exhibition of photos from a century or more ago showing medical students with their cadavers.  Many of the exhibits and photos are from the recently published book, Dissection, Photographs of a Rite of Passage in American Medicine 1880-1930 by James Edmonson from Case Western Reserve University and John Harley Warner from Yale University.  As is discussed in the link to the photo below, during this era there was limited access to cadavers for anatomical teaching.  So, learning, for many students, required a bit of self help.  We’ll leave it at that.  The link on the photo at left has some of these photos.

I find the photos fascinating.  Here we are, seeing photos of these student in the prime of their life exhibiting their anatomical subjects, that they treat well, humorously or in poor taste, but that all recently lost of the spark of life.  And these students, too, are now long, long since passed.  From the Plain Dealer article:

dissectionLong before “Tales from the Crypt ” “The Twilight Zone” and horror author Stephen King there were medical students.  Students who at the turn of the 19th-to-the-20th century posed for photos with bodies they had dissected in their studies; who gathered in groups around flesh-peeled cadavers and skulls like hunters displaying trophies…Dissection portraiture had its heyday from 1880 to 1930…The photos were a visual representation of a rite of passage dissection to a new identity a “boundary-crossing experience that left the participant forever changed ” as Warner wrote in the book…Back then there was no legal means of obtaining bodies for dissection. Some were unclaimed bodies but many were provided by grave-robbers known as “professional resurrectionists.” … Warner described most of the photos as almost “reverential” in the treatment of the subject some bearing such phrases written on the dissection tables as “Know Thyself ” “Man s usefulness endeth not with death” and “Her loss is our gain.” But he noted that others the gag photos and macabre images almost seem to revel in the transgression — posing human remains in outlandish poses or providing such accompanying table-epigraphs as “Such the vultures love ” “Rest in pieces” and “The Lord giveth We taketh away.”

via Case Western Reserve University’s Allen Memorial Medical Library displays ‘Haunting Images’ from a century ago – Metro –

Filed under: Bioethics, Health Law, Personal Posts, , , , ,

Birds or Pigs; The Swines Have It?

We’ve had a lot of stories the past several days about the swine flu outbreak in Mexico and smaller groupings of confirmed cases in New York, California and elsewhere in the United States.   There has been years of discussion on the H5N1, so called avian flu, pandemic risks.  We all remember the impact of SARS.  And we’ve been rocked, recently, by what some have tagged a ‘depression’ but all of noted as the largest economic downturn since The Great Depression.  The losses associated with this ‘Great Recession’ are still playing out.

But I was wondering — what if the Swine Flu became a pandemic at this time?  All indication (including the CDC site) indicate that aside from some serious implications for Mexico City’s public health, the cases in the United States have been mild, with no hospitalizations.  The 1918 flu pandemic that took 20m lives world-wide, however, is the standard modern example of potential personal and economic costs of a flu pandemic.  Not to minimize the terrible pain and suffering that such a pandemic would cause by putting an economic slant on it– but I was wondering what might be the economic impact to our already tottering United States economy if a pandemic struck.

So I took a look at a study the CDC had commissioned in 1999.  It showed the potential U.S. economic impact of a pandemic.   The CDC used this as a way to assist the public policy discussion in light of strategies regarding flu immunization — i.e., which immunization policy could provide the best net value in the case of flu pandemics of differing severity.   It’s beyond this post (or its author) to analyze the article and it’s conclusions.  But I thought the numbers were notable and summarize the potential economic exposure (without vaccination).  And, of course, this looks at U.S. exposure only.  A pandemic would have a far reach.  Look how quickly in this age of easy travel the virus spread from Mexico to the United States and even potentially exposed the President of the United States during his trip.  From the CDC’s study:

Without large-scale immunization, the estimates of the total economic impact in the United States of an influenza pandemic ranged from $71.3 billion (5th percentile = $35.4 billion; 95th percentile = $107.0 billion) (gross attack rate of 15%) to $166.5 billion (5th percentile = $82.6 billion; 95th percentile = $249.6 billion) (gross attack rate of 35%) (Table 6). At any given attack rate, loss of life accounted for approximately 83% of all economic losses. Outpatients, persons ill but not seeking medical care, and inpatients accounted for approximately 8%, 6%, and 3%, respectively, of all economic losses (Table 6) (Appendix II).

* * * *

If it cost $21 to vaccinate a person and the effective coverage were 40%, net savings to society would result from vaccinating all age and risk groups (Figure 2). However, vaccinating certain age and risk groups rather than others would produce higher net returns. For example, vaccinating patients ages 20 to 64 years of age not at high risk would produce higher net returns than vaccinating patients ages 65 years of age and older who are at high risk (Figure 2). At a cost of $62 per vaccinee and gross attack rates of less than 25%, vaccinating populations at high risk would still generate positive returns (Figure 2). However, vaccinating populations not at high risk would result in a net loss (Figure 2).

via The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention.

There’s also an interesting Congressional Budget Office (CBO) assessment (and see generally the goverment web page)  of possible economic effects of an avian flu pandemic.  That study concludes that a pandemic involving a highly virulent flu strain (such as the one that caused the pandemic in 1918) could produce an impact worldwide similar in depth and duration to an average postwar recession in the United States — but citing studies ranging from a .5% to 6% decrease in GDP.  Query, of course, what impact if such a pandemic hit during an ongoing recession.

Filed under: Comparative Effectiveness Rearch, Health Law, Personal Posts, Pharmacy, Risk Management, , , ,


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