I teach health policy. Pity me.  I have traveled the length and breadth of the purple state of Wisconsin attempting to explain to skeptical, and sometimes hostile, audiences what the Affordable Care Act actually entails.  I've been yelled at on National Public Radio, which is odd, but not the worst thing to ever happen to a person.  In a purple state, the questions come from every possible corner of the political maze.  "Why doesn't the ACA pay for acupuncture?"  Gee.  We're just trying to get it to pay for cancer treatment, or I don't know, well child visits.  

Or, "Why should I pay for those freeloaders to have heath care?" Um.  You already are.  That's the point.  Or, after I run out the statistics on how little bang we get for our buck compared to other industrialized countries, I hear that I am biased or unpatriotic - you know, in that nice, Wisconsin way. "How can you say we have bad healthcare?  My doctor is the best in the world!  He's given me two quadruple bypasses and pulled me from the brink of death twice!"  Uh, huh.  Health care scholars call that "rescue medicine."  Or in unguarded moments, "Zombification."

On the whole though, people are pretty reasonable when they learn the facts, and how the Affordable Care Act, depending on its implementation, might help, or in some cases, inconvenience, them.  So I usually come away from these encounters scratching my head.  Why all the hostility if, once presented with the facts, people generally think the Affordable Care Act is a reasonable, and probably a good thing?

Then I encountered this piece about food labeling.  I like food labels.  I want to know as much as I can about what I'm putting in my mouth before I snarf it.  Apparently, Dick Nigon of Sterling, VA did too.  Until he realized that the useful information about the 700+ calories in the Big Mac he was about to eat came to him courtesy of - yes, Obamacare.

In a recent Washington Post story about food labeling, Sarah Kliff quotes Nigon:

I did find one customer who had noticed the calorie labels: Dick Nigon of Sterling, Va. He and his wife, Lea, had stopped by McDonald’s after seeing an exhibit at the Renwick Gallery. Dick had ordered for the couple, noticed the calorie labels and liked them.

“I like that you have the information before you order,” he told me, when I asked about the labels. “It’s better than some kind of government health mandate in Obamacare.”

I told him that the calorie labels were, in fact, a government health mandate in Obamacare.

“Well that changes things a bit,” he responded. “I thought this was more of a voluntary sort of thing. Now I’m not quite sure how I feel about it.”

As one of my favorite bloggers succinctly summed up: "What’s dumber: the notion that McDonald’s would voluntarily tell customers the calorie count of their greasy-ass food, or the way that the mere mention of Obama' changes his mind?"

Now imagine sound of health policy teacher banging her head against the wall....


Thanks, all, for all of the comments - my head doesn't hurt from the wall-pounding.   And thanks, especialy, to theotherside for your thoughtful comment and questions.  I think that the answers to your question are fairly complex, especially if we set aside the libertarian "you can't make me" knee-jerk response to mandates.  I'll try to answer succinctly, but forgive me if I start to geek out:


Generally, when think about health care quality, we think of three factors:  Access, Quality, and Cost.  We know we rank poorly compared to other countries on both access and cost because: A) 28.4% of Americans 25-64 have no insurance (this is the most useful statistic because, after preliminary ACA implementation, young adults under 25 can remain insured on their parents' plans, and all adults 65 and over are eligible for Medicare); B) the complexity built in to our multiple insurance company system means that we pay approximately $68,000 per physician in overhead (and this does NOT include the overhead charged by insurance companies, which is now capped under ACA); C) we are chronically over-tested and over-treated, especially in the last six months of life.  

And this is where the rubber meets the road on quality measures.  On one hand (and I oversimplify), there are those who argue that broadening access, especially to preventive care equals quality.  There is some evidentiary support for this claim.  For example, according to the most recent Commonwealth Fund data, the US ranks highest among Western industrialized nations in mortality amenable to healthcare (preventable deaths), a problem caused primarily by a lack of early intervention for those who lack access to primary care and screning.  However, others think that quality equals being able to treat any illness at any age, regardless of risks or co-morbidities.  

To give an example of this latter conundrum, countries with Universal Coverage tend to view health care as a limited resource and therefore use evidence-based guidelines to assist in governing care decisions.   So, for example, "frailty scales" are used to estimate the likelihood of successful surgery in the oldest old.  An eighty-five year old with robust health may come through joint replacement surgery very well, while an eighty year old with numerous other ailments may have a successful joint replacement but never recover from the surgical assault on the body or the effects of anesthesia.  In some countries, like the UK, this kind of "comparative effectiveness" assessment is used to allocate care.  Not in the US.  If the patient wants the procedure and has coverage, they will get the procedure, even if the physician knows that the likelihood of post-surgical dementia, disability, and institutionalization are high.  And yes, using instruments like frailty scales is a form of rationing.  

Currently we ration health care based on ability to pay.  If we were to implement comparative effectiveness guidelines in order to expand access and make healthcare affordable for all, we would ration based on the likelihood of treatment success. Of course, this kind of change would be implemented VERY slowly in the U.S.  Still, using evidence to allocate health care resources is a radical change in the zeitgeist of a free-market health care economy, and would likely be a tough pill to swallow.  And is, I think, the true dividing line between those who oppose reform and those who support it.

Originally posted to WiscProf on Tue Sep 25, 2012 at 07:17 AM PDT.

Also republished by Virginia Kos, Community Manifesto Initiative, Badger State Progressive, ClassWarfare Newsletter: WallStreet VS Working Class Global Occupy movement, and Progressive Hippie.

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