Good Studies Go to the Back of the Bus

It's a rare day when my daily newspaper doesn't include at least one medical or health related article. My subjective impression is that they frequently report on potential “breakthroughs,” but many of them are never heard of again, suggesting that the early results were not reproducible.

A new study by Senthil Selvaraj and two colleagues suggests that newspapers do not publish the best available studies. In medical research, the main criterion of a good study is whether participants were randomly assigned to receive either the treatment or some control procedure such as a placebo. In medical jargon, this is called an RCT study, which stands for randomized controlled trial. The major alternative is an observational study, in which the participants are contrasted with a comparison group that may differ from them in uncontrolled ways (a cross-sectional study), or are compared to themselves at an earlier time (a longitudinal study). Some observational studies are merely descriptive and lack a comparison group.

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The authors selected the first 15 articles that dealt with medical research using human subjects published after a predetermined date in each of the five largest circulation newspapers in the US. Referring back to the original research reports, they classified each study on several dimensions, the most important being whether it was an RCT or an observational study. For comparison, they selected the first 15 studies appearing in each of the five medical journals with the highest impact ratings. These impact ratings reflect how often studies appearing in these journals are cited by other researchers.

The main finding was that 75% of the newspaper articles were about observational studies and only 17% were about RCT studies. However, 47% of the journal articles were observational studies and 35% were RCT studies. A more precise rating of study quality using criteria developed by the US Preventive Services Task Force confirmed that the journal studies were of higher quality than the studies covered by the newspapers.

They also found that the observational studies that appeared in the journals were superior to the observational studies covered by the newspapers. For example, they had larger sample sizes and were more likely to be longitudinal rather than cross-sectional.

In one sense, these results are not a surprise. We could hardly have expected newspaper reporters to be as good a judge of study quality as the editors of prestigious medical journals. The authors, like many before them, call for more scientific literacy training for newspaper reporters, but it's hard to be optimistic that this will happen.

What criteria do the reporters use in selecting studies to write about? I was struck by the fact that observational studies resemble anecdotes more than RCT studies do. In addition, the newspapers chose observational studies with smaller sample sizes. These results could be driven by the base rate fallacy—the fact that the average person finds anecdotes more convincing than statistical analyses of much larger samples. In fact, the lead paragraph of these stories is often a description of some John or Jane Doe who received the treatment and got better. The results could mean either that reporters fall victim to the base rate fallacy, or that they think their readers are more interested in anecdotal evidence.

You may also be interested in reading:

Letters, . . . We Get Letters

Death By Anecdote, Part 1

The Singer, Not the Song

In 2010, social psychologist Eric Knowles and two colleagues published a study showing that some of the opposition to health care reform results from prejudice toward African-Americans and dislike of Barack Obama. The research was a panel study in which participants were interviewed several times over the internet.

During the first contact, Knowles measured implicit prejudice against blacks using a variation of the Implicit Association Test. This test measures an automatic tendency to associate white Americans with the concept “good” and black Americans with the concept “bad.” This bias this is unintentional and occurs without our awareness. Knowles found that the people high in implicit prejudice toward African-Americans reported more negative attitudes toward Obama before the 2008 election and were less likely to vote for him. This is one of several studies to show that racial prejudice influenced votes in both the 2008 and 2012 elections.

These negative attitudes toward blacks spilled over onto Obama's policies. People high in implicit prejudice were more opposed to health care reform in 2009, before the Affordable Care Act (ACA) was passed. How do we know their opposition to health care reform was due to prejudice rather than political conservatism, which is highly correlated with prejudice in this country? Knowles did an experiment in which he described a health care plan. For half the participants, it was presented as Bill Clinton's 1993 plan and for the other half, it was presented as Obama's plan. (The actual description was of features that both plans had in common.) Implicit prejudice had no effect on attitudes toward the “Clinton” plan, but when it was attributed to Obama, the more prejudiced participants were more opposed to it. This study was replicated two years later with the same results.

Fast forward to 2014. Aaron Chatterji and colleagues just published a study asking why members of the House of Representatives did or did not vote for the ACA. The study only included Democrats, since only one of 177 Republicans voted for the bill. The researchers looked at whether three variables were related to the legislators' votes: (1) the percentage of their constituents without health insurance, (2) Obama's margin of victory or defeat in the 2008 election in their district, and (3) political contributions from health insurance companies. The statistical analysis also controlled for eight demographic variables, such as the age and racial composition of the district, and five Congressperson characteristics, such as their own 2008 margin of victory. The results were:

• Percentage of constituents without health insurance was unrelated to the legislators' votes.
• Obama's margin of victory made a significant difference. The 219 Democrats who voted for the ACA came from districts in which Obama's average margin of victory was +30%, while the 39 Democrats who voted against it came from districts in which Obama lost by slightly under 10%. Obama's margin of victory accounted for 47% of the variance in these Representatives' votes.
• Political contributions from the health insurance industry also had no relationship to voting.

The authors note that if the Congresspeople had the best interests of their constituents in mind, there should have been greater support for the ACA from Representatives whose districts contained a higher percentage of uninsured people. At different places in the article, they refer to this as either ignoring their constituents' preferences or ignoring their constituents' needs. The latter is more accurate, since they have no measure of voter preference. Maybe some of the people who needed the ACA did not prefer it (or did not know they preferred it). It is primarily the needs of their poorer constituents that these legislators ignored. This is no surprise, since there is a growing body of research showing that politicians votes are consistent with the opinions of their constituents in the top third of the income distribution, but the opinions of the lower and middle thirds are disregarded.

Of course, Obama's margin of victory or defeat is also a salient indicator of constituent preferences, and these Congresspeople were very responsive to it. However, the presidential election was not a referendum on health care reform, which played only a minor role in the campaign, but is more reasonably regarded as a measure of Obama's popularity. It appears that the legislators voted for or against the ACA based on the evidence of Obama's popularity in their district.

The common thread among both studies is that both citizens' and legislators' attitudes toward health care reform seem to be less influenced by the substance of the policy than by attitudes toward the President himself. At the present time, politicians in 24 states (including Pennsylvania) are ignoring the needs of their poorer citizens by refusing to implement the ACA's provision to expand Medicaid. Is this decision also driven by attitudes toward the President?

By the way, the fact that political contributions from insurance companies had no effect on voting doesn't really contradict the hypothesis that politicians are influenced by campaign contributions. The health insurance industry never clearly favored or opposed the ACA, since it has both advantages and disadvantages for them. In fact, the authors never predicted whether health insurance money would make a Congressperson more or less likely to vote for the bill.

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Steven Brill Returns on Healthcare Costs

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Time magazine writer Steven Brill now has a regular column called Bitter Pill on healthcare costs.  Last night he appeared on The Daily Show to discuss how costs have changed since the Affordable Care Act has come into effect.  Similarly, Aaron Carroll has argued that costs have to be brought under control for even single payer to work.

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Will Ferrell and Larry the Cable Guy's take on the Affordable Care Act and Single Payer

Not This Will Ferrell

Healthcare for All PA board member Will Ferrell (not the star of Anchoman 2) has shared the great clip above of NBCs medical analyst Dr. Nancy Snyderman endorsing single payer. I had to share with you all.  Will Ferrell has also had an Op/Ed posted in the Delaware County Times  on Dec 13 seen at the bottom.

Below is comedian Larry the Cable Guy telling Sean Hannity his opinion of the Affordable Care Act.  Unlike other rantings and ravings on Fox News, this is actually funny.

SINGLE-PAYER, MEDICAL INSURANCE, and the CORBETT PLAN

Recently, Governor Corbett unveiled a Medicaid expansion plan called Healthy Pennsylvania.  Few would disagree with the Governor’s objectives of increasing access, improving quality and making healthcare affordable for all Pennsylvanians. 

Medicaid is a healthcare program funded by both the state and the federal government that provides direct care to individuals with limited income.  The fastest growing population group in this category are seniors whose income falls within the threshold of income limits for Medicaid. In effect Medicaid supplements Medicare which is for all people over the age of 65. Medicaid has income limits, while Medicare does not.  Most of the Medicaid supplement is used for long term care facilities.

Under the Affordable HealthCare Act, states may expand the eligibility for Medicaid, with the Federal Government picking up much of the cost. This expansion is optional for the states, although many states have already agreed to sign on.

Note, it is important to distinguish between health insurance and healthcare. Healthcare programs such as Medicaid and Medicare pay directly the doctors and hospitals that provide healthcare services to people.

With health insurance, people pay premiums to private insurance companies, who then pay the doctors and hospitals for healthcare services provided to those paying the premiums. Under Governor Corbett’s plan federal Medicaid funds would be used to buy health insurance for eligible participants, rather than providing direct healthcare.

HealthCare 4 All PA (HC4APA) believes this is a poor use of money that only increases the cost and limits the funding pool available to pay for actual healthcare.  The reasoning is simple-health insurance has administrative costs in excess of 15%, meaning that 15 cents of every dollar does not go to pay for healthcare. Contrast this with Medicare and Medicaid where administrative costs are about 3%.

Therefore, under the Governor’s plan to turn Medicaid healthcare into an insurance program, more money will be spent and fewer people will be treated due to this disparity in administrative costs. HC4APA also believes that decisions about your healthcare should be made by you and your doctor, not by an insurance company whose primary motivation is to receive more money in premiums than they must pay out to doctors and hospitals. 

HC4APA does agree with the Governor that the best healthcare delivery solutions are developed at the state and local government levels. States have often been called the laboratories of the nation. Following this ideal, HC4APA has developed a Single-Payer healthcare delivery system. Single-Payer simply means that Pennsylvania would develop a healthcare delivery system modeled after Medicare, meaning doctors and hospitals would be paid directly for healthcare services provided to each of us.

The system would be funded by taxes paid by all businesses and by all individuals.  It is clear, however that such taxes would be significantly lower than individuals and businesses are already paying in insurance premiums, deductibles and co-pays for healthcare. We can be confident of this because HC4APA contracted and paid for an Economic Impact Study (EIS) performed by several leading healthcare economists. This study demonstrated that Pennsylvania’s healthcare costs could be reduced by some $17 billion each year under a single- payer plan.

Currently, the costs of healthcare are very high and growing well ahead of the rate of inflation. If we, collectively, do not address these costs, the healthcare system will become unsustainable in its present configuration. A single-payer plan attacks those costs.

In addition, many other forms of business and personal insurance include healthcare cost components. These include vehicle and homeowners insurance and for businesses, workers compensation and liability insurance.  The costs of these insurance policies would also decline when the state implements single-payer.

The bottom line is that a single-payer healthcare plan costs less and fosters free and open market competition.  Single-payer moves the marketplace competition from the insurance company to the medical providers who will have to compete directly for your healthcare needs.

We encourage you to visit www.healthcare4allpa.org to learn more about the single-payer plan and to read the EIS that will document the value of the plan. Then become an activist by networking with family and friends, asking them to support the bill by calling their Legislators and ask them to vote for Senate Bill 400 and House Bill 1660. This will only happen if we the people want it to happen. We have the power.

William Ferrell

Board Member HC4APA  

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The Oregon Health Experiment: The Gift That Keeps On Taking Away

Be prepared for a barrage of conservative criticism of the Affordable Care Act (ACA) that may be assumed to have negative implications for single-payer health care as well.

As I've noted before, the Oregon Health Experiment is a randomized control group design, far superior to most health care research. In 2008, Oregon hoped to expand Medicaid, but didn't have enough money, so they held a lottery. They invited everyone who was eligible to apply. Of the 90,000 applicants, 30,000 were randomly selected to receive Medicaid, while the losers became eligible for the control group. In previous data analyses, it was found that the Medicaid group spent 35% more on health care than the control group. They visited primary care physicians (PCPs) and were admitted to hospitals more often, and spent more on prescription drugs. They were also healthier and freer of financial worries, although most of the health differences are not statistically significant due to insufficient sample sizes in the study.

A new analysis by the Oregon research group reports that the Medicaid participants were also more likely to visit the emergency room (ER). Specifically, during their first 18 months on Medicaid, they made an average of 1.43 ER visits compared to 1.02 in the control group—a 40% difference.

This should not have been a surprise. If you reduce the cost of a service, people are more likely to use it. However, some ACA proponents claimed that Medicaid expansion would save money by reducing ER use. Although the ER accounts for only 4% of health care spending, an ER visit is more expensive than visiting a doctor. The pro-ACA argument was that if patients established a relationship with a PCP, they would have a place to go for medical care and these doctor visits would prevent potential emergencies. For example, Health and Human Services Secretary Kathleen Sebelius said in 2009:

Our health care system has forced to many uninsured Americans to depend on the emergency room for the care they need. We cannot wait for reform that gives all Americans the high quality, affordable care they need and helps prevent illnesses from turning into emergencies.

It is important to note that these results are not due to the fact that Medicaid provides health insurance for poor people. Private health insurance patients are also more likely to use the ER than the uninsured.

Increased ER use might not be seen as a problem if the visits were real emergencies. However, the study found ER use to be higher even for non-urgent care that should ideally have been treated by a PCP. These results could be used by the opposition to suggest that single-payer might cause an massive influx of people outside the ER waving torches and pitchforks and demanding free care.

There are several considerations that may place these results in clearer perspective.

• The time frame of the study, 18 months, may not have been sufficient to change uninsured people's lifelong habits of going to the ER every time they were sick. A three-year study of Romneycare in Massachusetts found an estimated 5-8% reduction in ER use.

• Medicaid expansion could have been accompanied by education regarding when to go to the ER and when to visit your PCP. Of course, some may argue that education is not enough and should be supplemented by punishment, such as a co-payment, for “inappropriate” ER use.

• Taking a broader view, the problem may be with the health care system rather than the patients. PCPs tend to be available Monday through Friday from 9 to 5—times that are inconvenient for most employed people. You can't always get same-day appointments with a PCP. A 2012 survey by the Commonwealth Fund found that in the US, only 35% of PCPs see patients after hours. In nine European countries and Canada, the average was 80%.

This study is one of a growing number that show that providing health insurance to the uninsured alone does not save money. The ACA contains some cost controls, such as the Independent Payment Advisory Board, which may eventually reduce costs. Single payer eliminates the cost of private insurance, which will save much more. Other changes may be needed. One of them may be asking PCPs to become more consumer-friendly by seeing more patients on evenings and weekends.

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Big News From Oregon--Not All of It Good

Tom Corbett to PA's Working Poor:  "Drop Dead"  Part 1.  Medicaid Improves Health and Saves Lives

Letters, . . . We Get Letters

When it comes to persuading the Pittsburgh Post-Gazette to publish my letters, I'm batting about .050. My one success, almost ten years ago, was a note about music. Of course, newspapers get many letters, and it's their right to choose which ones to publish. Ordinarily, I wouldn't bore you by griping about their decisions. However, I've managed to persuade myself that my latest experience may be of interest to other letter writers, so I'm going to risk playing the fool.

My story begins on December 8, when the P-G published Molly Rush's letter advocating single payer health care. This was followed on December 16 by a reply from Jim Roth—a pharmaceutical salesperson(!)—implying that single-payer is too costly and denies health care to some citizens. If you're going to continue, you should stop and read Mr. Roth's letter.

The next day, I wrote the following:

Mr. Roth notes that all countries with single-payer finance it with a value added tax. However, the type of tax used to fund health care is irrelevant. The important point is that single payer costs those countries considerably less than our complex system of public and private insurance. According to a 2013 report of the Organization for Economic Cooperation and Development (OECD), the US currently spends on average $8,508 per person each year on health care, compared to an OECD average of $3,322. Yet the US is 26^th out of 40 OECD countries in life expectancy. The amount Americans spend on health care due to the combined burden of taxes, insurance and out-of-pocket costs would be greatly reduced under single-payer.

Mr. Roth claims that people in single-payer countries have longer wait times for elective surgery and are sometimes denied such care. This depends on the country and what you consider “elective surgery.” US insurance companies also refuse to cover some elective procedures. However, if these were serious problems, you would expect residents of single-payer countries to be dissatisfied with their country's health care system. A 2013 survey by the Commonwealth Fund compared consumer satisfaction in the US to nine European countries and Canada, all with single-payer. Americans were by far the most dissatisfied,with 75% saying the system needs fundamental changes or should be completely rebuilt.

Finally, Mr. Roth suggests that we could lower health insurance costs by allowing it to be sold across state lines. It is true that if some states were to deregulate health insurance and if residents of any state were allowed to buy that product, premiums might come down. But those people would be buying insurance with little value should they become seriously ill. The Affordable Care Act is intended to prevent exploitation of consumers by establishing a baseline definition of adequate health insurance.

Of course, the primary purpose of single-payer is not just to save money, but to save the lives of some of the millions of Americans who are currently uninsured.

On December 29, the P-G published two replies to Mr. Roth. Both offered primarily anecdotal evidence suggesting that at least one family—the author's—had lived in a single-payer country and was satisfied with their health care system. The main difference between them is that the first referred to the British system and the second the Dutch. While both were well-written and persuasive, I thought they were redundant, and might have been better supplemented by my data referring to larger numbers of people and countries.

It's possible my letter was rejected because it is poorly written or exceeds their 250-word limit. However, Mr. Roth's letter, at 318 words, also breaks this rule, as do many others they publish. They could easily have edited my letter. Clearly, exceeding the word limit was a mistake. In retrospect, I should have dropped the third paragraph.

My hypothesis, based on this and other previous experiences, is that my letter was rejected because it contained too much data. Imagine an experiment in which parallel letters to the editor are sent to a random sample of newspapers. Both letters would make exactly the same points, but one would support each point with research, while the other would support them with anecdotes or merely claim that these were the author's personal opinions. My guess is that fewer of the data-driven letters would be published.

I have two possible, though somewhat inconsistent, explanations for my hypothesis. The first assumes that the editors wanted to present the single payer argument sympathetically. It's based on a common cognitive error known as the base-rate fallacy. People find anecdotal evidence more persuasive that statistical base rates, even though the base rates summarize data from larger, more representative samples. The people who made the decision may have found the two letters they published to be more persuasive than mine.

My second explanation makes the reasonable assumption that the gatekeepers at the P-G are opposed to single-payer. If so, they may assume that my inclusion of data makes the letter too persuasive. That is, they may be willing to acknowledge that there are some Pittsburghers who favor single-payer, but it may be unrealistic to expect them to publish statistics suggesting that the arguments of single-payer advocates are factually correct.

I hope I'm wrong. I really want to encourage the use of research evidence to change the health care system, and society in general, for the better. If this strategy is counterproductive, that's genuinely disturbing.

You may also be interested in reading:

Death By Anecdote, Part 1

Are You Feeling Lonely?

Gubernatorial Candidate Forum 1/26/14

This coming Sunday, January 26 the Pittsburgh 14th Ward Independent Democratic Club will be holding a forum of the eight candidates for Governor of PA,  It will be held in McConomy auditorium on the Carnegie Mellon Campus from 1-4 PM.  Below is information from the Facebook event page.  As a 501(c)4 organization, Healthcare for All PA/PUSH does not endorse candidates but encourages everyone to gather information on the process.

Pittsburgh 14th Ward Independent Democratic Club's Annual Meeting and Board Elections - We are taking this opportunity to also hold a forum for the eight candidates who have thrown their hats into the ring so far for Governor. 

The event is co-sponsored by the 14th Ward Democratic Committee, the 7th Ward Democratic Committee, and the CMU Young Democrats. 

This will be an excellent opportunity to hear about their stands on issues and state business that is important to you.

The membership drive and Board elections will be going on in the background; the main attraction is the Gubernatorial Candidates' Forum. The Forum is open to the public, but registered Democrats in the 14th Ward (Squirrel Hill, Point Breeze, Park Place, Swisshelm Park, and Regent Square) of Pittsburgh are welcome to join the Club.

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