Doctor’s Office Care at Hospital Prices
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.@BobbyJindal argues that simple reforms in Medicare billing could save patients and taxpayers somewhere between $346B and $672B over the next 10 years.
The Sweet Life: The Long-Term Effects of a Sugar-Rich Early Childhood
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Using a regression discontinuity design exploiting the end of sugar rationing in September 1953, Gertler and Gračner find that birth cohorts post-dating the policy change experience worse lifetime outcomes in many health measures as well as economic success.
Core argument: Early childhood sugar exposure increases adult chronic inflammation prevalence, driving elevated diabetes, cholesterol, and arthritis diagnoses across the lifespan.
We study the long-term effects of exposure to a sugar-rich diet in early childhood on health and economic well-being in later adulthood, and identify diet as a possible pathway. We exploit the end of sugar and sweets rationing in 1953 in the UK as a natural experiment inducing variation in exposure to a sugar-rich diet in early childhood. We find that the end of rationing increased the adult prevalence of chronic inflammation, an important marker of chronic disease. We also find increases in poor metabolic health; particularly diabetes, cholesterol and arthritis. Finally, we find that excessive intake of sugar also results in worse economic outcomes; specifically, in reduced human capital accumulation, a lower likelihood of having a skilled occupation, and a lower accumulation of wealth. While the effects of a sugar-rich diet early in life may have affected these outcomes directly via physiological programming, we find that a sugar-rich diet early in life elevated free sugar consumption across lifespan, consistent with evidence that life-long dietary preferences and habits form early, and that sugar may be addictive.Takeaways by Macro Roundup® AI
- Early childhood sugar exposure increases adult chronic inflammation prevalence, driving elevated diabetes, cholesterol, and arthritis diagnoses across the lifespan.
- Sugar-rich early diets reduce skilled occupation likelihood and wealth accumulation in adulthood, leading to measurably worse economic outcomes.
- Childhood sugar rationing’s end established lifelong consumption patterns, demonstrating that early dietary habits drive sustained preference formation into adulthood.
Nursing Is the Surefire New Path to American Prosperity
AI Summary. Nursing offers wages nearly double the national median, with advanced-degree nurses earning over $130,000 annually and facing job growth projected at 35% over the next decade—more than ten times the rate expected across all occupations.
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The median annual wage for a nurse in 2024 was $93,600; those with an advanced degree earned $132,050. The Labor Department forecasts that employment of nurses with advanced degrees will increase 35% btw 2024 and 2034 relative to job growth of 3%.
Core argument: Nursing careers offer median wages nearly double the national average, positioning healthcare as a high-income employment sector.
The median annual wage for registered nurses in the U.S. is $93,600, compared with $49,500 for all occupations, according to the Labor Department. For nurse practitioners and others with advanced degrees, it is $132,050. The Labor Department projects that employment of advanced-degree nurses will increase by 35% from 2024 to 2034, eclipsing the expected 3% growth across all occupations. Registered-nurse employment is projected to rise 5% over that period.Takeaways by Macro Roundup® AI
- Nursing careers offer median wages nearly double the national average, positioning healthcare as a high-income employment sector.
- Advanced-degree nursing positions are projected to grow eleven times faster than overall job growth through 2034.
- Sustained wage premiums and rapid job expansion in nursing reflect structural demand from an aging population requiring care.
Case for Mask Mandate Rests on Bad Data
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The IHME model’s failure to update for behavioral changes led to flawed projections, undermining the case for a mask mandate.
IHME failed to update their model for behavioral changes"...Unfortunately, the IHME modelers’ findings contained an error that even minimal scrutiny should have caught. The projected number of lives saved, and the implied case for a mask mandate, are based on a faulty statistic. Using a months-old survey, IHME modelers assumed erroneously that the U.S. mask-adoption rate stood at only 49% as of late September, and therefore had plenty of room to increase to “universal adoption,” defined as 95%, or to a more plausible 85%. According to more recent survey findings, however, America’s mask-adoption rate has hovered around 80% since the summer...."
Phillip Magness, "Case for Mask Mandate Rests on Bad Data,"Wall Street Journal, November 11, 2020, https://www.wsj.com/articles/case-for-mask-mandate-rests-on-bad-data-11605113310
CBO presents options for covering the uninsured
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@JamesCapretta 30mm Americans under 65 were uninsured in 2019, 20m eligible for subsidized coverage but unenrolled, 9.8mm ineligible for subsidies. Addressing gaps is crucial for near-universal coverage, as highlighted by the CBO’s analysis.
James Capretta, "CBO presents options for covering the uninsured," American Enterprise Institute, October 5, 2020, https://www.aei.org/articles/cbo-presents-options-for-covering-the-uninsured/
Allison Percy and Karen Stockley, “Who Went Without Health Insurance In 2019, and Why?” Congressional Budget Office, September 2020, https://www.cbo.gov/system/files/2020-09/56504-Health-Insurance.pdf
Jared Maeda and Karen Stockley, “Policies to Achieve Near-Universal Health Insurance Coverage,” Congressional Budget Office, October 2020, https://www.cbo.gov/system/files/2020-10/56620-near-universal-coverage.pdf
Capretta here makes no sense according to CBO“…0 million people are uninsured because they are residing in the U.S. without proper legal status; as such, they are ineligible for subsidized coverage.6 million people are ineligible for employer coverage but have incomes too high to qualify for subsidized premiums through the ACA exchanges; they could enroll in plans offered in the nongroup market but would be required to pay the full premiums themselves. Finally, there are 3.2 million people who have incomes below the federal poverty line and live in states that did not expand Medicaid as allowed by the ACA.This group falls into a “coverage gap” in current law; their incomes are too low to qualify for subsidized premiums in the ACA exchanges and yet too high to qualify for Medicaid. The first priority of any future effort to cover the uninsured should be to ensure this population can enroll in either Medicaid or another alternative that requires no premium payment….”
And only 1/3 of persons not insured not eligible for subsidized coverage“…In 2019, an estimated 30 million people under the age of 65, or 12 percent of that population, were uninsured. One reason for the lack of insurance coverage was a lack of subsidized options. About one-third of uninsured people under the age of 65 did not have access to coverage that was subsidized by the government or an employer: 13 percent were noncitizens who were not lawfully present in this country; 11 percent had income that was less than 100 percent of the FPL and lived in a state that did not expand Medicaid; and 9 percent had income that was too high to qualify for marketplace subsidies(see Figure 1)…”
“…About two-thirds of the 30 million uninsured people under the age of 65 had access to some form of subsidized coverage but were not enrolled, although those options were subsidized to different degrees: 17 percent were eligible for Medicaid or CHIP; 19 percent were eligible for subsidized coverage through the marketplaces established under the ACA; and 31 percent had access to coverage through an employer. Most of those people could have purchased health insurance that cost less than 10 percent of their income, but fewer people had an option that cost less than 5 percent of their income. Those people lacked health insurance coverage because they did not consider it to be worth the cost or because of the complexities of the enrollment process, among other reasons….”
But bottom line according toCBO only 9.8mm people who are currently uninsured are not eligible for subsidized coverage under the current systems, and 4mm are not lawfully present in the country, so only5.8mm peoplearen’t being captured by the current system. The other 20mm people don’t have health insurance because to quote CBO “…Those people lacked health insurance coverage because they did not consider it to be worth the cost or because of the complexities of the enrollment process, among other reasons…”
A Health Plan For President Trump
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The Heritage “Trump” healthcare proposal aims to transform the current system by delinking health care from employment, allowing individuals to own portable insurance.
This is Heritage’s health care proposal you asked about. It’s not a comprehensive plan but offers a series of potential, in many cases current innovations based on the current system (some of these, like telemedicine, likely have been accelerated by the pandemic)
Steve
- Provide opportunity for individuals to delink health care from employment. “…In an ideal world, most people would own their own health insurance and take it with them as they traveled from job to job and in and out of the labor market. Some employers may have better insurance than is available on the open market. But others might prefer to make a cash contribution to help employees pay their own premiums rather than provide insurance directly. Some employers were actually doing that before Obamacare. They used an account called aHealth Reimbursement Arrangement (HRA), providing tax-free funds employees could use to buy their own health insurance. But with Obamacare came regulations and threats of steep employer fines that effectively deep-sixed this option. Thankfully, the Trump administration is reversing course. Beginning next January, employers will be able to use HRAs to help employees obtain their own coverage with the administration’s blessing…”
- Make Medicare more open to “direct primary care.”“….Under the arrangement, Medicare would pay a fixed monthly fee to a physician or physician group instead of the traditional fee-for-service payments. In return, the physicians would provide virtually all primary care. The fees would range from $90 to $120 a month, depending on the patient’s age and medical complexity….”
- Expanded use of telemedicine“…Medicare doesn’t pay for any of this. And since private insurers and employers tend to pay the way Medicare pays, the entire country is missing out on incredible advances in telemedical technology….Federal law (the Social Security Act) allows Medicare to pay for telemedicine only under strictly limited circumstances… The CMS is acting aggressively to change this. As of January 1 of this year, doctors in Medicare Advantage plans and accountable-care organizations can now bill Medicare if they use phone, email, Skype, and other technologies to consult with patients remotely to determine if they need an in-office visit. Patients can be anywhere, including their own homes. Doctors can also bill Medicare to review and analyze medical images patients send them. And they can bill for telemedical consultations with other doctors. But these are still baby steps. Congress needs to liberate telemedicine once and for all….”
- Allow specialized healthcare plans“….The most successful Obamacare insurers are Medicaid contractors. The plans that have survived in the exchanges look like Medicaid managed care with a high deductible. The networks include only those doctors who will accept Medicaid fees coupled with all the hassle of managed-care bureaucracy….Before Obamacare, most states had risk pools for the small number of people who entered the individual market with an expensive preexisting condition and were denied access to ordinary insurance coverage. The risk-pool plans looked like garden-variety Blue Cross plans, with access to almost all doctors and hospitals. While some risk pools had problems — such as being over-subscribed and unable to take new customers — those problems were discrete and addressable…..Health Care Choices Proposal, developed by the Health Policy Consensus Group and supported by more than 100 conservative leaders across the country. This proposal would block-grant Obamacare funds to the states and give them wide discretion to reform their individual health-insurance markets. The Center for Health and the Economy estimates that this proposal would lower health-care premiums by as much as a third, would insure about the same number of people as Obamacare, and would better protect people with preexisting conditions and high health costs….”
- Expand use of Health Savings Accounts, “…To take advantage of the full potential of HSAs, we need three policy changes: (1) People should be able to use completely flexible HSAs, wrapping them around any health-insurance plan and using them to pay for any medical costs the plan does cover; (2) they should be able to use their HSAs to pay premiums as well as out-of-pocket expenses; and (3) health plans should be allowed to have “shared savings programs,” where enrollees who choose better and cheaper care get to keep their share of their savings in their HSA…”
Marie Fishpaw and John Goodman, "A Health Plan For President Trump," Heritage Foundation, August 2, 2019, https://www.heritage.org/health-care-reform/commentary/health-plan-president-trump - Make Medicare more open to “direct primary care.”“….Under the arrangement, Medicare would pay a fixed monthly fee to a physician or physician group instead of the traditional fee-for-service payments. In return, the physicians would provide virtually all primary care. The fees would range from $90 to $120 a month, depending on the patient’s age and medical complexity….”
Pre-Existing Condition Fiction
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@WSJ: Number of non-elderly individuals with previously declinable pre-existing conditions range btw 53.8mm-61mm.
Editorial Board, "Pre-Existing Condition Fiction,"Wall Street Journal, September 30, 2020, https://www.wsj.com/articles/pre-existing-condition-fiction-11601507970
Gary Claxton, Cynthia Cox, Anthony Damico, Larry Levitt and Karen Pollitz, "Pre-Existing Condition Prevalence for Individuals and Families," Kaiser Family Foundation, October 4, 2019, https://www.kff.org/health-reform/issue-brief/pre-existing-condition-prevalence-for-individuals-and-families/
DHHS, “Health Insurance Coverage for Americans with Pre-Existing Conditions: The Impact of the Affordable Care Act,“ Department of Health And Human Services, January 5, 2017, https://aspe.hhs.gov/system/files/pdf/255396/Pre-ExistingConditions.pdf
Rachel Fehr, Cynthia Cox and Larry Levitt, “Data Note: Changes In Enrollment In The Individual Health Insurance Market Through Early 2019,” Kaiser Family Foundation, August 21, 2019, https://www.kff.org/private-insurance/issue-brief/data-note-changes-in-enrollment-in-the-individual-health-insurance-market-through-early-2019/
I haven’t found an estimate of what % of the 13.8mm persons have a pre-existing condition.
So that’s plans accessed though an exchange. Anotherstudyby the Kaiser Family Foundation found that in 2018 13.8mm individual were insured through plans purchased on the exchange (however that’s not everyone buying individuals plans, I have always purchased directly from Blue Cross/Blue Shield without going through an exchange)“…Total individual market enrollment, measured on an average monthly basis, increased from 10.6 million in 2013 to a peak of 17.4 million in 2015, before declining to13.8 million in 2018….”If you use Kiser’s 27% of non-elderly adults who had pre-existing conditions against that total enrolment 13.8mm *.27 that would imply3.726mm individuals with such a condition were accesses health care on the exchanges cheaper than they otherwise would be. Now that’s prob not a fair assumption as the exchanges tend to be younger people who don’t get health care though their employer.
"... The question is not how many Americans have a health condition,but how many Americans buying insurance in the individual insurance market have a condition that makes them difficult to insure at prices they can pay. Keep in mind that the Affordable Care Act set up a subsidized transitional plan for anyone with pre-existing conditions denied insurance in the individual market. Peak enrollment: about 115,000 in 2013.The White House in an executive order last week noted that, by the Obama Administration’s own report, a mere 2.7% of an estimated roughly 130 million people with pre-existing conditions gained access to health insurance through the Affordable Care Act.... "
Okay, so basically the WSJ editorial board argued that the number that really matters is the number of American’s who are not covered by Medicare/Medicaid nor employer provided health insurance who get covered though plans purchased on exchange.
Table from HHS:
Kaiser goes on to note, and I think this is a good answer to your questions, 53.8mm (non-elderly) have a condition that would have left them uninsurable in the individuals markets, however most of these people are getting insurance though their employer so they can avoid individual plans“…A larger share of non-elderly adult women (30%) than men (24%) have declinable pre-existing conditions in 2018, unchanged from 2015. We estimate that23.7 million men have a pre-existing condition that would have left them uninsurable in the individual market pre-ACA, compared to 30.1 million women. Pregnancy explains part (about 2 million women) but not all of this difference….”
Using HHS’s narrow definition that number goes to61mm non-elderly Americans.That HHS estimate was mirrored by the Kaiser Family Foundation, "... estimate that 27% of nonelderly adults have a declinable health condition, which is about53.8 million people in 2018…. The prevalence of declinable conditions also increases with age among non-elderly adults: ranging from 18% of those in the 18-34 age group to 44% for those in the 55-64 age group….”
You are correct Biden was using a pretty broad definition of “Pre-existing condition” including high blood pressure and behavioral issues, using HHS’s broad definition you can say 133mm. HHS“…As shown in Table 1, we find that theACA is protecting between 23 and 51 percent of nonelderly Americans--61 to 133 million people--with some type of pre-existing health condition from being denied coverage, charged significantly higher premiums, subjected to an extended waiting period, or having their health insurance benefits curtailed should they need individual market health insurance coverage….”
I think a good answer to your question, how many people (non-elderly) have a condition significant enough to have an impact on the price of insurance is somewhere btw 53.8mm-61mm.
Ed Comment:Hmm. There are 330mm Americans; 140mm under 25 yrs old (who don’t use much healthcare) and 50mm over 65, which leaves 140mm adults 25 to 65. If 60 to 130mm people have preexisting condition than a vast majority of those people would have preexisting conditions. If you define preexisting conditions so large that nearly every adult has one, then you have sort of defined it away. It’s like saying a majority of people are poor. That can’t be the definition of poor. 75% of the adults 25 to 65 have private insurance. 20% plus don’t work/are too poor to buy insurance. So something don’t smell right.
Ed Comment."Wsj had an editorial yesterday saying the number of people on public insurance with existing conditions was a couple 100 thousand, which was unbelievable low. Biden said 100mm which seems like a lie since there are only 350 mm people. That defines pre-existing so loosely that everyone has one. What matters are conditions significant enough to cause significant changes in the price of insurance. Anyway, I don't know what it means. Please find a pithy non partisan summary (or 2)….”
Steve Comment: So this is from HHS, over 40mm individual have one of the followinghigh blood pressure, behavioral health issues and high cholesterol(of course some individuals will have more then one of those conditions.) but they don’t indicate range of severity of the problem, will see if I can find a breakdown of their low estimate. “…As shown in Table 2, we also examine the prevalence of specific pre-existing conditions faced by Americans (focusing on the broader insurer definition). The table lists theeleven conditions with prevalence of 1 million or more among non-elderly individuals with no Medicare enrollment during 2014.These conditions are listed from most to least prevalent, although differences between ranks may not be statistically sign Among the most common pre-existing conditions for non-elderly Americans are high blood pressure, high cholesterol, behavioral health disorders (including, for example, alcohol and substance use disorders, depression, and Alzheimer’s), asthma, arthritis, and obesity. Millions of Americans also have diabetes (13 million), heart conditions or heart disease (16 million), or have at some point been diagnosed with cancer (11 million)….”
Ed Comment:The numbers in this article don't seem to add up. It says 30 mm are uninsured. Then it details 10 million and seems to call it 2/3s. Then it has a category zero million.
Ed Comment:Hard to see that 100mm people are at risk of losing coverage and/or can't get HC. 20 mm are subsidized and don't take it. 2.6 can afford it and don't take it. Half of the remainder are illegals. Many people won't be very sympathetic to them and we still give them some/essential HC so it looks like 3 of the 30 might want it but can't get it. The rest are all covered. That said, I still don't know how many people with pre existing conditions significant enough to truly prevent them from being covered are being "saved" by obamacare. (The ones with employer coverage would get it). So it looks like the true number is at risk is much smaller than 100mm Can you please take all your entries and sort everyone into buckets including the elderly. One bucket would be resting conditions covered by employers. It would be great to see those who were eligible for Medicaid and chips without Obama care and those who were added to it because of Obama care. A clear top down picture would be useful/enlightening.
Jim Capretta Comment:"Thank you for pointing this out (not sure why no one else did). Some numbers got lopped off in the translation from what I submitted to what got posted. Here are the correct numbers in order of the first bulleted points: 5.1 million people 5.5 million 9.4 million Then in the next bullets it should be: 4.0 million 2.6 million I hope this is clear enough.”
Ed you were right, 30mm persons < 65are currently uninsured, but I can’t line his numbers with the reports, according to theCBO(See Figure 1, 67% of uninsured persons are currently eligible for subsidized coverage) Before I sent you a note that it was wrong I wanted to confirm with him, he said it was a typo on AEI’s part.
Capretta, "...In 2019, 12 percent of the nonelderly population — or about 30 million people — went without health insurance..."
Kevin McNellis, Carolyn Ugolino and Emily Vreeland, “Federal Subsidies for Health Insurance Coverage For People Under 65: 2020 to 2030,” Congressional Budget Office, September 2020, https://www.cbo.gov/publication/56650
Steve Comment:I’m still working on thenumber of individuals with pre-existing conditions who currently get coverage through employment and the number who are buying it on the exchanges due to the ACA. This is proving a little hard.But I wanted to show you a topdown snapshot of the <65 population,90% are covered if you exclude illegal immigrants. (According to theKaiser Family Foundationanother67.7mm >65 individuals are enrolled in Medicare in 2020.)According to CBO 155mm (57%) of the 272mm individuals < 65are covered by employment based coverage this year. But in terms of the number of people < 65 “saved” by Obamacare in 2020 CBO estimates13mm(so 5% of <65) individualswere added to Medicaid due to the ACA.See table A-1. In total70mm (28%)individuals <65 are covered by Medicaid. Note one thing from footnotes as this caught me up “The components do not sum to the total population because some people report multiple sources of coverage. CBO and JCT estimate that in every year of the projection period, between 12 million and 14 million people (about 5 percent of the insured population) have multiple sources of coverage, such as employment-based coverage and Medicaid”
Ed Comment:Hard to see that 100mm people are at risk of losing coverage and/or can't get HC. 20 mm are subsidized and don't take it. 2.6 can afford it and don't take it. Half of the remainder are illegals. Many people won't be very sympathetic to them and we still give them some/essential HC so it looks like 3 of the 30 might want it but can't get it. The rest are all covered. That said, I still don't know how many people with pre existing conditions significant enough to truly prevent them from being covered are being "saved" by obamacare. (The ones with employer coverage would get it). So it looks like the true number is at risk is much smaller than 100mm Can you please take all your entries and sort everyone into buckets including the elderly. One bucket would be resting conditions covered by employers. It would be great to see those who were eligible for Medicaid and chips without Obama care and those who were added to it because of Obama care. A clear top down picture would be useful/enlightening.