The number of uninsured Americans has dropped to a historic 9.1 percent since the enactment of the Affordable Care Act six years ago.

According to the U.S. Department of Health & Human Services, an estimated 20 million people have gained health insurance coverage between the passage of the law in 2010 and March of this year.

“Our country has made undeniable and historic strides thanks to the Affordable Care Act,” HHS Secretary Sylvia M. Burwell said earlier this month, noting that for the first time in our history, fewer than one in 10 Americans lacked health insurance.

“Our country ought to be proud of how far we’ve come and where we’re going.”

But 19 states still refuse to expand Medicaid for the poorest of the uninsured. And many low- and middle-income families still find that participating in state exchanges is out of their reach or that the process is just too complex.

Stanford health policy experts, state government officials, mobile health and private health-care executives recently gathered on campus to look at the impact of the Affordable Care Act, six years after its adoption.

The consensus was the Act has done more to grant access to health care for Americans than any other government program since Medicaid was adopted in 1965 to help the poor, and Medicare to subsidize the elderly in 1985.

Yet the law’s initial technical missteps, continuing red tape and opposing provisions — as well as the lack of support by so many states and members of Congress — continue to undermine the Act.

“As most of you know, the heath-care sector in the U.S. is large and extremely complex,” said Mark Duggan, director of the Stanford Institute for Economic Policy Research, which sponsored the conference. He said total health-care spending in 2016 would amount to $3.4 trillion, an average of more than $10,000 per person.

Yet one-third of those health-care costs go to waste, said Thomas Goetz, co-founder and CEO of the health-care startup Iodine, which uses apps and data visualization to better inform consumers about their health-care and drug choices.

Goetz told the audience of faculty and students that medication — for depression and anxiety, chronic pain and autoimmune diseases — are typically ineffective up to 50 percent of the time.

“The solution isn’t more randomized clinical trials,” said Goetz, whose company recently launched an app that allows users to take a depression test and decide which antidepressant might work best for them. “The goal is to look at patients as consumers and catalysts — versus patients as passive.”

But has the ACA been effective? It seems the reviews are still mixed.

Kate Bundorf, associate professor of health research and policy at the School of Medicine, noted that this an exciting time for policymakers because the evidence on the effects of the Affordable Care Act is starting to emerge.

She said the Congressional Budget Office estimates that the coverage provisions of the ACA increased government spending by $110 billion and reduced the number of uninsured by 22 million in 2016.

While many analysts were concerned that employers might drop health insurance for workers in response to the subsidies for coverage available through the exchanges, employment-based coverage has remained stable.

Whether the ACA has slowed the rate of growth of health-care spending is still up for debate.

While spending did slow down around the time of the Act’s implementation, it is difficult to determine whether the lag was caused by the ACA’s provisions or other factors such as the recession or increases in cost-sharing for private insurance. And the most recent estimates indicate the rates of growth in spending have begun to increase, possibly signaling a return to historical levels, Bundorf said.

“The big surprise was that not all states expanded Medicaid, with the Court ruling allowing states to opt out,” said Bundorf, who is also a senior SIEPR fellow.

The Supreme Court ruled in 2012 that states could decide individually whether to expand the Medicaid insurance program for the poor.

John Bertko, chief actuary for California’s health exchange, Covered California, describes the Affordable Care Act “as actuarial puzzle to work on every day.”

He should know. Bertko worked on the Obamacare actuarial tables for three years.

One of the most significant changes to the American health-insurance system, he said, are those 32 states that expanded Medicaid under the the ACA. Americans who earn less than 138 percent of the federal poverty level now qualified for Medicaid and the Children’s Health Insurance Program.

Just as the Medicaid expansion went into effect in 2014, a provision of ACA also increased payments for primary care physicians who accepted Medicaid. However, for budgetary reasons, those increased payments only lasted for two years.

“So you have this huge expansion of the number of people qualifying for Medicaid and at the same time payments for suppliers dropped down,” he said. “So lots of Medicaid card carriers were left floating around looking for providers.”

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“When you insure people, you’re going to increase costs and the costs have gone up,” said Bhattacharya, a core faculty member of Stanford Health Policy and senior fellow at SIEPR and the Freeman Spogli Institute for International Studies.

“The total expenditure on the poor, the costs have gone up,” Bhattacharya said. He added here has been no change in the mortality rate of Americans since adoption of the Act. “It’s difficult to find mortality benefits from the social benefits.

Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, reminded the audience the main goal of the ACA was to expand insurance coverage for Americans.

“And it certainly has been a success at doing that,” he said.

Still, Levitt added, roughly 30 million non-elderly Americans remain uninsured. And many of those who are insured are opting for high-deductible plans to keep their monthly premiums down.

“Twenty percent of people who are insured say they have a problem paying their medical bills because they don’t have a lot of money in the bank and have large deductibles,” he said.

If the other states would follow the lead of the top 10 states leading the way on ACA enrollment, Levitt said, there would be a great improvement overall.

Bundorf said the so-called Cadillac Tax would raise some revenue and the incentive to create more employee-sponsored insurance plans.

But the highly contentious levy that was supposed to go into effect in 2018 has bene delayed to 2020 while Congress, the IRS, unions and big business debate its fairness.

The provision of Obamacare would impose a 40 percent excise tax on the portion of most employer-sponsored health coverage that exceed $10,200 a year and $27,500 for families. The goal is to control the growth of health-care spending by eliminating pricier benefit plans and curtail excessive health-care use.

“The problem with the Cadillac Tax is that, with time, it becomes the Chevy tax,” said Levitt. “I don’t think it will ever go into effect — but it will precipitate something that can replace it.”

Triage nurses typically assign patients to emergency room doctors who are on call or working a shift. But what if the doctors themselves determine whom among them is better suited to take on the next patient?

Classic economic theory predicts “moral hazard” in teams, which means one member behaves inefficiently because in the end someone else will pay the consequences. Yet many successful organizations promote teamwork.

So how does this puzzle relate to health care?

This is the question that Assistant Professor of Medicine David Chan, a core faculty member at Stanford Health Policy, tackles in his new study in the Journal of Political Economy.

Emergency departments (ED) nationwide cost a combined $136 billion to run each year, significantly impacting the growing health-care sector of the U.S. economy. Visits to the emergency rooms are increasing despite the implementation of the Affordable Care Act, causing them to be overcrowded and underfunded.

Chan studied two organizational models: one in which physicians are assigned patients in a nurse-managed system and one in which the doctors divide patients among themselves in a self-managed system.

“I find evidence that physicians in the same location have better information about each other and that, in the self-managed system, they use this information to assign patients,” Chan writes.

He said that by simply allowing physicians to choose patients, a self-managed system reduces emergency room lengths of stay by 11-15 percent, relative to the nurse-managed system.

“This effect occurs primarily by reducing a `foot-dragging’ moral hazard, in which physicians delay patient discharge to forestall new work,” Chan writes. A triage nurse is often in another room and has a difficult time observing true physician workload, whereas peer physicians who work together can.

“So, for example, if there are two physicians working at a time when there are a whole bunch of patients in the waiting room, then each physician knows that the minute he discharges a patient, he is more likely to get another one,” Chan said in an interview. This might lead the physician to dilly-dally on the release of that patient, knowing that he’ll immediately be signed another before he gets a break.

However, two physicians who can observe how busy the other one truly is will be less likely to stall, even if they want to avoid new patients.

Chan studied a large, academic emergency room that treated 380,699 patients over a six-year period. He looked at length of stay, measuring each physician’s individual contribution. He also observed patient demographics and used the Emergency Severity Index, an ED triage algorithm based on a patient’s pain level, mental status, vital signs and medical condition.

Besides measuring the effect of the self-managed system in this large hospital, Chan combined evidence to support the hypothesis that teamwork improves outcomes because of mutual management with better information.

He found that the only difference in outcomes between the two organizational systems was foot-dragging. Clinical outcomes or even the number of tests ordered were about the same under a self-managed or nurse-managed system.

Moreover, the foot-dragging behavior grows as physicians may anticipate future work by the number of patients in the waiting room, even if they end up seeing the same number of patients.

Finally, physicians refrain from this behavior when being watched by another physician in the same location, even in the nurse-managed system, when that other physician does not otherwise have any role in the physician’s patient care.

“I think the biggest takeaway is that such efficiency gains can be widespread in health care, particularly because there is so much at stake hidden behind information in patient care that is not transparent,” Chan said.

“Even if we don’t fully anticipate all of these gains, we could still achieve a lot by tinkering and using these changes as natural experiments to figure out what works and what doesn’t,” Chan said. “We can further use these results, particularly the evidence pointing at a mechanism, to think of what other innovations might work.”

The U.S. government has invested $1.4 billion in HIV prevention programs that promote sexual abstinence and marital fidelity, but there is no evidence that these programs have been effective at changing sexual behavior and reducing HIV risk, according to a new Stanford University School of Medicine study.

Previously: PEPFAR has saved lives – and not just from HIV/AIDS, Stanford study finds
 

Americans spent $3 trillion on health care in 2014, or about $9,523 per person. That’s up 5.3 percent from the previous year. That increase isn’t expected to slow down; for about the next decade, the U.S. government  expects spending to grow 5.8 percent on average each year.

As policymakers look for ways to cut down this spending, one idea gaining traction is to incentivize consumer-directed health plans (CDHP). These high-deductible, low-cost plans are already growing in popularity. About 20 percent of people who are covered by employer-sponsored health insurance are enrolled in some type of CDHP.

In theory, CDHPs would reduce health-care costs because consumers would choose less expensive health care when they pay for it themselves. But does that theory pan out in practice? M. Kate Bundorf, an associate professor of political economy, examines the benefits — and the trouble spots. Bundorf is also a core faculty member at Stanford Health Policy.

Science and common sense tell us that the teenage brain is more vulnerable to peer pressure and susceptible to nicotine addiction than at any other stage of development.

That’s why California legislators recently voted to raise the legal age to buy cigarettes and tobacco products from 18 to 21. If Gov. Jerry Brown signs the bill, California will become the second state, after Hawaii, to raise the age limit on the unhealthy products.

Yet while more than 100 cities around the country have adopted such laws — including New York, Boston and Cleveland — New Jersey Gov. Chris Christie in January vetoed such a bill, despite strong bipartisan support from his state legislators.

Health policy advocates see the Christie veto as a setback in what they believe is an otherwise accelerating movement toward “Tobacco 21” laws as a new tool for curbing young people’s potential addiction to tobacco products and e-cigarettes.

Michelle Mello, a Stanford professor of law and health research and policy, and colleagues from Harvard University and Baylor College of Medicine argue in this New England Journal of Medicine article that there is new evidence to suggest these laws are effective, have great public support and have minimal economic impact in the short term.

“The vast majority of smokers begin smoking during adolescence, a period when the brain has heightened susceptibility to nicotine addiction,” they write. “Nearly everyone who buys cigarettes for minors in the United States is under 21 years of age; raising the sale age prevents high school students from buying tobacco products for their peers.”

In 2013, only eight U.S. municipalities had adopted Tobacco 21 laws. By March 2016, at least 125 localities and the state of Hawaii had done so, and California is on the cusp of following suit. In September 2015, the first federal Tobacco 21 legislation was introduced (Tobacco to 21 Act, S. 2100) by U.S. Senator Brian Schatz (D-HI).

The authors note an analysis of the effects of one such law adopted in Needham, MA, revealed a 47 percent reduction in the smoking rate among high school students, along with a reported decline in area retail tobacco purchases. The decreases were significantly greater than those in 16 comparison communities without Tobacco 21 laws.

And a 2015 report by an Institute of Medicine (IOM) committee provided evidence from two different simulation models that increasing the minimum age to 21 would lead to a 12 percent reduction in smoking prevalence. Another simulation study predicted that there would be an even larger effect: a nearly 60 percent reduction in adolescent smoking within seven years after nationwide implementation of a Tobacco 21 law.

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Two national public opinion studies published in 2015 found that 70 to 75 percent of Americans — including a majority of current smokers — support raising the minimum purchase age to 21. The authors themselves conducted a national survey of 1,125 American adults regarding their attitudes toward various public health laws.

“We found that three in four Americans support the adoption of a federal Tobacco 21 law,” they write. “Majority support extends across all major socio-demographic groups, including 68.3 percent support among young adults 18 to 24 years of age.”

Opponents of the federal and state bills — namely Tobacco interests, convenience store owners and e-cigarette manufacturers — say that states should not be in the business of policing public choice. Store owners contend raising the age limit would hurt sales, as snacks and soft drinks are typically ancillary purchases with cigarettes.

And some veterans’ organizations and Republican legislators have said it is wrong to take away the decision on whether to smoke from young people who are nevertheless old enough to marry, vote and join the military.

But Mello and her coauthors, Stephanie R. Morain, PhD, MPH, and Jonathan P. Winickoff, MD, MPH, say the long-term benefits of raising the age limit far surpass the near-term economic concerns, which they believe are overstated.

Research indicates that in the short term, raising the tobacco-purchasing age to 21 would result in a 2-3 percent annual decrease in total tobacco sales.

“Over the longer term, the revenue loss from decreased smoking prevalence will be substantial,” they concede. “But allowing future generations to become addicted to nicotine in order to preserve tobacco revenue fails the red-face test as an argument against Tobacco 21.”

If a federal law raising the legal age of purchasing cigarettes were implemented today, the Institute of Medicine estimates that would result in 249,000 fewer premature deaths, 45,000 fewer deaths from lung cancer, and 4.2 million fewer lost-life years among Americans born between 2010 and 2019.

“Local and state efforts have succeeded in extending Tobacco 21 protections to more than 16 million Americans,” the authors write. “We believe the time has come to expand this effective, broadly supported approach to a much greater share of the population.”

Nearly 100 health economists from across the United States signed a pledge urging U.S. presidential candidates to make chronic disease a policy priority. Karen Eggleston, a scholar of comparative healthcare systems and director of Stanford’s Asia Health Policy Program, is one of the signatories. 

The pledge calls upon the candidates to reset the national healthcare agenda to better address chronic disease, which causes seven out of 10 deaths in America and affects the economy through lost productivity and disability.

Read the pledge below.

The threat of a pandemic claiming millions of lives and devastating economies around the world is as serious as the potential perils of global climate change, renowned economist Larry Summers told a Stanford audience during a recent visit to campus.

The world is taking dramatic and costly steps to prevent the calamitous impact of climate change on the economies and national security of most countries. Yet preparations for a worldwide pandemic on the scale of the 1918 flu are vastly underfunded and ill-formed.

“My biggest fear is that the world is way short of focus on all the issues associated with pandemic,” said Summers, former treasury secretary in the Clinton administration and Harvard president emeritus, who in recent years has focused on the economics of global health care.

“We are talking about something that could kill surely tens of millions and perhaps 100 million people, and the Stanford football program is substantially more expensive than the WHO budget for pandemic flu,” he said. “It’s just crazy that we are so underinvested and underprepared.”

Summers, the Charles W. Eliot University Professor at Harvard, also served as director of the White House National Economic Council in the Obama administration. He was in conversation with Stanford Health Policy’s Paul Wise for the March 8 event co-sponsored by the Stanford Institute of Economic Policy Research for faculty and students.

The World Health Organization budget for outbreaks and crisis response has been reduced by nearly 50 percent from 2012 to 2015. Some global health experts blame these cuts in part for its slow response to the Ebola outbreak in West Africa and the ongoing Zika crisis in Brazil.

In Brazil, Zika has been linked to a spike in cases of microcephaly, a birth defect marked by small head size and underdeveloped brains. Brazil has confirmed more than 640 cases of microcephaly and is investigating an additional 4,200 suspected cases. Puerto Rico is now preparing for an expected outbreak there.

Summers said the mortality rate from the great flu pandemic was far greater than the recent Ebola outbreak in West Africa, which killed some 11,300 people mostly in Sierra Leone, Liberia and Guinea. Some 50 million people died worldwide during the 1918-1919 flu pandemic.

‘I don’t want to minimize in any way the significance of Ebola, but there are things to worry about that are vastly larger,” said Summers, who gave the keynote address for the January unveiling of the National Academy of Medicine’s report on global health risks.

That report by the Commission on a Global Health Risks Framework for the Future found that, compared with other major threats to global security, the world has “grossly underinvested” in efforts to prevent and prepare for the spread of infectious diseases. The commissioners — some 250 independent experts in health, governance and research and development — estimate $60 billion in annualized expected losses from pandemics.

“Pandemics cause devastation to human lives and livelihoods much as do wars, financial crises and climate change,” the report said. “Pandemic prevention and response, therefore, should be treated as an essential tenet of both national and global security — not just a matter of health.”

Summers estimates that pandemic flu risk is in the same range of global climate change in terms of expected costs over the next century. Yet a potential pandemic is getting only 2 percent of the attention and resources that global climate change has today.

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Summers also chaired the Lancet Commission on Investing in Health, an independent group of 25 leading economists and global health experts from around the world. Their landmark report, Global Health 2035, provides a specific roadmap for this achieving “a grand convergence” in health within our lifetimes. Ahead of the U.N. General Assembly last fall, Summers led a joint declaration together with economists from 44 countries calling on world leaders to prioritize investments in health.

Wise, in the Department of Pediatrics at Stanford and senior fellow at the Freeman Spogli Institute for International Studies, asked Summers how one plans for pandemics when faced with so many failed governments and conflicts around the world.

“One of the central challenges that I worry about a lot in the deliberations of pandemic control is that many of the (regions) of greatest concern are characterized by chronic political instability, conflict and very weak governance,” said Wise, who for more than 30 years has been traveling to rural Guatemala to provide medical care to children there for his Children in Crisis project.

Summers said the world has been fortunate that there are so many brave and devoted medical workers who are trained to go into these conflict regions to try and contain outbreaks.

“But I think it would be disingenuous of me to say that you can solve these problems without in some way containing the failed state,” he said.

Wise then asked Summers what sort of advice he would give to the Stanford students who were trying to decide between a career in which one might use economics to make a fortune on Wall Street, or use economics for the greater good.

“I have always believed that you can count — and you can care,” Summers said. “There is nothing about counting and using numbers and analyzing the math that means you don’t care in a moral way.”

When a physician works with a patient and saves her life, he said, that has a profound and direct impact on both the patient and physician. But working on a vaccination program that has the potential of saving thousands of lives one day comes with delayed gratification.

“But the impact of making the world a better place and enabling people to survive and avoid grieving the loss of of a family member is as great — or greater,” he said.

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Infant deaths in Massachusetts for much of the 1800s accounted for more than 20 percent of all deaths, many due to diarrhea, cholera and other gastrointestinal disorders.

But from 1870 to 1930, the infant mortality rate plummeted from around 1 in 5 white infants to 1 in 16 for both Massachusetts and the entire United States.

Studies have shown that the dramatic decline was due to the impact of a clean-water system in Boston and other major U.S. cities at that turn of the 20^th century.

Now, new research by Stanford Health Policy’s Marcella Alsan indicates that effective sewage systems installed in Boston and surrounding municipalities complemented the water treatment plants and had a significant role in protecting the lives of children.

“We were motivated to investigate this because there was a watershed moment when infant mortality began to decline in the U.S. and Massachusetts that we wanted to understand,” said Alsan, an assistant professor in the Department of Medicine, and the country’s only physician who is a tropical disease expert and economist.

“In retrospect, the daunting challenges these engineers and medical professionals faced in designing, financing and executing such a massive project is incredible,” Alsan said in an interview. “It was really inspiring to read the history of how it all came together.”

She and co-author, Claudia Goldin of Harvard University’s Department of Economics, analyzed about 200,000 of infant death certificates in Boston and 54 other Massachusetts municipalities spanning the years 1880 to 1915.

The impetus behind the creation of the Metropolitan Sewerage District was complaints regarding the stench of sewage among Boston’s upper-class citizens.

“The first of a series of hearings was given by the sewerage commission at the City Hall on Friday night,” read a story in an 1875 edition of the Boston Medical and Surgical Journal. “From the statements made it would appear in various parts of the district including most of the finest streets, the stench is terrible, often causing much sickness.”

A joint engineering and medical commission was appointed in 1875 to devise a remedy and a massive drainage project got underway.

Alsan and Goldin found that an overwhelming number of deaths in the greater metropolitan area were due to gastrointestinal disorders, but that this improved significantly when sanitation canals became part of the overall water systems.

“We find robust evidence that the pure water and sewerage treatments pioneered by far-sighted public servants and engineers in the Commonwealth saved many babies,” they write in a working paper. “It must also have enhanced the quality of life for the citizens of the Greater Boston area even if it did not reduce the non-child death rate by much.”

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They acknowledge that the interpretation of their results is intuitive. But it’s an important one to promote because many developing countries today have yet to heed the lesson of combining safe drinking water and improved sanitation systems.

“Without proper disposal of fecal material, the benefits of clean water technologies for the health of children are likely limited,” they write. “Such a result has relevance for today’s low-and middle- income countries.”

The Millennium Development Goal Target 7.C — to halve by 2015 the proportion of the population without sustainable access to safe drinking water and basic sanitation —was only met for water, but not sanitation. Between 1990 and 2015, 2.6 billion people gained access to improved drinking water sources.

Yet despite that progress, one-third of the global population is still using unimproved sanitation facilities, including nearly 1 billion people who are still forced to defecate in the open. This often leads to cholera, typhoid, hepatitis, polio, and worm infestation.

Diarrhea is the third-largest killer of children under 5 in sub-Saharan Africa, and 44 million pregnant women are infected with worms each year due to open defecation, according to the United Nations. Every minute, 1.1 million liters of human excrement enters the Ganges River in India.

The problem of waste disposal likely will be compounded by rapid urbanization occurring in the developing world, said Alsan, and lack of sanitation and the practice of open defecation costs the world’s poorest countries $260 billion a year.

“We think our findings underscore how complementary these infrastructure investments are, and hope that holds lessons for the developing world,” said Alsan. “In all practicality, it’s very hard to ensure the municipal water supply is not contaminated if the sewage infrastructure is neglected.”

Working Paper: Watersheds in Infant Mortality

Non-smoking campaigns that tell teenage boys they will get lung cancer in 30 years if they don’t stop smoking just don’t work.

“But prevention programs that tell them that girls don’t like smokers make them go pale with fear,” says Keith Humphreys, a professor of psychiatry and behavioral sciences.

Humphreys, an affiliated faculty member of Stanford Health Policy, told an audience at the World Economic Forum in Davos, Switzerland, this January that the better approach to public health campaigns are those tailored to the realities of the human brain.

One of those realities is that our brains have evolved to be vulnerable to addiction, especially if we live in the lower-income tiers of society. An understanding of our evolutionary vulnerability to drugs and alcohol can help us to design effective public policies, Humphreys told the Davos audience.

“Primate research indicates that there may be a political and economic dimension to this,” he said. “When lower primates form a hierarchy, those at the bottom undergo a change in their dopamine system. This makes them more likely to consume drugs in an addictive fashion.”

Addiction can happen to anyone at any level of society — the current opiate epidemic is a case in point — but if you look at wealthy societies, those who have less economic and educational resources are more prone to addiction.

“So as inequality worsens, we really have a risk of creating a disempowered underclass of people who are literally sedated by ever more available psychoactive substances.”

Humphreys is on the NeuroChoice team at the Stanford Neurosciences Institute who attended the forum to present their research into the neural basis of decision-making and how these impact public policy.

He says in this video that neuroscience reveals addictive drugs work on precisely the same brain systems that guide our survival decisions. This is compounded by industrial global capitalism, making the exposure to psychoactive substance nearly universal.

“These two combined realities — our evolutionary conserved vulnerability to addiction and the development of a production and transportation system that can deliver substances worldwide — is why one in six deaths on the planet among adults is attributable to psychoactive substance abuse,” says Humphreys.

Stanford researchers are going after the problem in two ways. First is to use neuroscience to unravel the mechanisms of addiction in the brain. Then, they work directly with public policymakers, such as those who regulate the tobacco, alcohol and pharmaceutical industries, as well as those who oversee health-care and criminal justice systems.

“We communicate to our friends in the policy world what science has to teach about addiction and how you can use that information to do a better job at protecting people and promoting public health,” he said.

He said one of their key messages is that psychoactive substances are not ordinary commodities that should not be regulated.

“That’s probably true for broccoli, but it’s not true for psychoactive substances because they impair our brain’s ability to value things,” he said. And that is why public health policies must take into account the evolutionary-conserved circuits in the brain.

“The magnificent decision-making organ that evolution has bequeathed us is vulnerable to addiction, perhaps particularly if we live on the lower tiers of society. This creates a risk for humanity,” Humphreys said. “Karl Marx was worried that religion would become the opiate of the masses. But if we don’t use neuroscience to make better treatments and better policies regarding addiction, the opiate of the masses will be opiates.”