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Tag: Deaths of Despair

“Hospital Mergers Kill”: An Economists’ Exercise in Reality Distortion

By JEFF GOLDSMITH

In late June, 2024, two economists, Zarek Brot-Goldberg and Zack Cooper, from the University of Chicago and Yale respectively, released an economic analysis arguing that hospital mergers damage local economies and result in an increase in deaths by suicide and drug overdoses in the markets where mergers occur. Funded by Arnold Ventures  their study characterizes these mergers as “rent seeking activities” by hospitals seeking to use their economic power to extort financial gains from their communities without providing any value. 

The Brot-Goldberg-Cooper analysis was a spin-off of a larger study decrying the lack of federal anti-trust enforcement regarding hospital mergers. These two studies used the same economic model. The data were derived from the Healthcare Cost Institute, a repository of commercial insurance claims information from three of the four largest commercial health insurers, United Healthcare, Humana and Aetna (a subsidiary of struggling pharmacy giant CVS) plus Blue Cross/Blue Shield. HCCI’s contributors account for 28% of the commercial health insurance market.

The authors use a complex econometric model to manipulate a huge, multifactorial data base comprising hospital merger activity, employer health benefits data, county level employment data and morbidity and mortality statistics. This data model enabled a raft of regression analyses attempting to ferret out “associations” between the various domains of these data.

Using HCCI’s data, the authors construct what they termed a  “causal chain” leading from hospital mergers to community damage during their study period–2010 to 2015.  It looked like this: hospital mergers raise prices for private insurers-these prices are passed on to employers–who respond by laying off workers–some of whom end up killing themselves. So, according to the logic, hospital mergers kill people. Using the same methodology, the authors argued that between 2007 and 2014, hospital price increases of all sorts killed ten thousand people. 

A classic problem with correlational studies of this kind is their failure to clarify the direction of causality of data elements.  The model lacked a control group–comparable communities that did not experience hospital mergers during this period–because the authors argued that mergers were so pervasive they could not locate comparable communities that did not experience them.    

The model focused on a subset of 304 hospital mergers from 2010 to 2015, culled from a universe of 484 mergers nationally during the same period. The authors excluded mergers of hospitals that were further than fifty miles apart, as well as hospitals with low census. The effect of these assumptions was to exclude most rural hospitals and concentrate the mergers studied in metropolitan areas and cities. The densest cluster was in the I-95 corridor between Washington DC and Boston. See the map below:

According to the model, these mergers resulted in an average increase of 1.2% in hospital prices to commercial insurers, 91% of which were passed to their employer customers in those markets. This minuscule rate increase had a curiously focused and outsized effect–a $10,584 increase in the median employer’s health spending in the merged hospitals’ market.

According to the model, local employers “responded” to this cost increase by reducing their payrolls by a median amount of $17,900, all through layoffs–70% more than the alleged merger cost increase. This large overage was not explained by the authors. Moreover, the layoffs took place almost immediately, in the same year as the merger-induced increases, even though many health insurance contracts are multi-year affairs, and lock hospitals in to rates for that period.

At the end of the “causal chain,” 1 in 140 laid off people in those communities for whatever reason killed themselves through suicide or drug overdoses. By extrapolation, the authors accuse the perpetrators of overall hospital rate increases of killing ten thousand people in the affected communities during seven years overlapping the study period.   

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How’s Human Evolution Going? The Harris-Walz Health Policy team wants to know.

By MIKE MAGEE

Clearly the Harris-Walz ticket has been doing their homework. Last week, the book above was spotted on one prominent thought-leader’s pile: “Human Evolutionary Demography.” It’s a 780 page academic Tour de force read by veteran scientist Oskar Burger, leader of the Max Planck Institute for Demographic Research and the Laboratory of Evolutionary Biodemography.

That’s the Institute founded in 1917 in Berlin whose first director was Albert Einstein. These days, its researchers work (in an age of “alternate facts”) to separate justified belief from opinion. Their major focus is on “categories of thought, proof, and experience” at the crossroads of “science and ambient cultures.”

This is the field of Human Evolutionary Demography, a blending of natural science with social science. Demographers study populations and explore how humans behave, organize and thrive focusing heavily on birth, migration, and aging.

This has been a year of just that in American politics. First, the fallout of the Dobbs decision caught Republicans with their electoral pants down in reproductive freedom referendums in Kansas, Michigan, Kentucky and Vermont. Southern migration of Democrats to former red states like Michigan, Arizona, Georgia, and North Carolina have turned them various shades of purple. And this summer, octogenarian candidates from both parties have been all the rage, literally.

Up until July 21, 2024, the race for the Presidency was between two aging candidates with visible mental and physical disabilities. The victor was destined to a term of office that would extend into his 80’s.

The emergence of Kamala Harris as the Democratic nominee was a reflection of the electorates growing discomfort with turning a blind eye to the realities of aging. It also suggested that Americans, especially Gen X’ers, have grown tired of Boomer dominance in the lives of an increasingly multi-cultural America – tired as well of growing income disparity, attacks on reproductive freedom, and declining life expectancy in America.

But why the sudden interest in “Human Evolutionary Demography?” The answer lies in the numbers. Back in 2012 Oskar Burger studied Swedes and noted that in 1800 their life expectancy was 32 years. They gained an additional 20 years in the century that followed, and 30 more years by 2000.

What stumped Burger was not the gains over these two hundred years. Instead he focused on the question, “Why did it take the human race so long to progress?” The bottom line is this, we left chimpanzees behind in the evolutionary dust some 6.6 million years ago. We limped along, not faring very well, for all but the last 200 years. In the past century, a moment in time spanning just 4 of our historic 8000 plus human generations, we took off.

This period coincided with rapid scientific and technologic advances, cleaner air and water, greater nutritional support, improved education and housing, expanded public health related governmental policy, and establishment of a safety net for our most vulnerable citizens.

But in the past decade, growth in U.S. life expectancy has all but stalled. For the first time, we actually saw declines each year from 2014 to 2019. For the decade just past, the numbers improved overall by less than 1/2 of 1 %. When first studied, declines were blamed on losses in working age adults due to trauma, addiction, suicide or “deaths of despair.”

But recent studies reveal losses due to poor maternal/fetal care, especially in red states, and made worse by fallout of the Dobbs decision. A second complicator has been losses starting at age 65 from complications of cardiovascular disease and diabetes, made worse by obesity and poor health care follow-up.

This has led the Max Planck Institute to issue an alert to U.S. health experts: “Our findings suggest that the U.S. faces a ‘double jeopardy’ from both midlife and old-age mortality trends, with the latter being more severe.”

Women’s reproductive advocates say it’s really a “triple jeopardy” demanding grass roots advocacy focused on access today, and political victory up and down the ballot in November. In their words, “Today, and every day, we work to ensure that every patient who seeks sexual and reproductive health care can access it, and to build a just world that includes nationwide access to abortion for all — no matter what.”

If this is true, a careful read of “Human Evolutionary Demography” could direct a 3-prong approach for the health policy leaders in the Harris-Walz campaign:

  1. Expanded safety net to address “deaths of despair.”
  2. Expansion of the ACA toward Universal Health Insurance to address the chronic disease burden of older Americans.
  3. Federal guarantees of reproductive freedom and open access to reproductive care.

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

The Real Red Wave: Why the Biden Presidency is in Peril

By JEFF GOLDSMITH

Democrats’ despair after Joe Biden’s pallid and halting debate performance stems from the realization  that the uphill climb needed to prevent the return of Donald Trump might be too steep. What is less obvious is the awareness of the urban intelligentsia of the root causes of the adverse political climate, which can be seen in this map, taken from the Economist’s April 20 feature on declining US population.

A map of the united states

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America’s economy is booming, and the gap between its economic performance and that of the rest of the world is widening. The on-the-ground political reality is very different depending crucially on where you live. People who live in the red parts of this map do not need convincing that all that wealth, and the power that goes with it, has eluded them. Many of them believe that it has been stolen from them by corrupt leaders and the oligarchs and corporate interests that finance their campaigns.

That is the underlying reality of MAGA.  Ninety percent of those red counties voted for Donald Trump in 2020. People in metro Austin, Manhattan or the suburbs of Houston do not resonate with the need to make America great again. It’s already great for many of them.

For folks living in the abandoned parts of the US, the on-the-ground reality is absurd gas prices, unaffordable mortgages, a mountain of forever debt, deteriorating public services, dreams cruelly out of reach and the despair that goes with all of it-alcohol and drug dependency, depression and anxiety, obesity, domestic violence. There is an almost perfect correspondence between the above map and that of the epidemic of “deaths of despair” suicide, drug overdoses and alcohol poisoning. This phenomenon is rooted in middle-aged whites, the overwhelming demographic of the red parts of this map, but affects all demographic segments including black and Hispanic folks who traditionally supported Democrats.     

After 2016, political analysts believed that the prevalence of non-college educated whites in a local electorate was the single best predictor of Donald Trump’s shocking victory. That was not the case. A post-election analysis by the Economist revealed that a better predictor of Trump’s victory was a composite measure of health/life expectancy, specifically “county-level data on life expectancy and the prevalence of obesity, diabetes, heavy drinking and regular physical activity (or lack thereof)”, the mapping of which again correlates remarkably with the map of population decline above.

The very same forces of outmigration and economic stagnation are destroying these communities’ local health systems, as well as their schools, commercial businesses and churches. The same red areas are also areas where local physicians have retired and were not replaced, and whose hospitals closed or merged with larger regional conglomerates. A recent scurrilous analysis by Yale and University of Chicago economists blamed the rising deaths of despair and  local business’s economic struggles on hospital mergers, an absolutely “from central casting” example of blaming the victim. 

The bitter irony of this political season is that the Biden Administration’s remarkable roster of Congressional achievements in 2021 and 2022- the American Rescue Plan, the American Infrastructure and Jobs Act, the Chips and Science Act and the Inflation Reduction Act showered many tens of billions in temporary relief spending and capital investment for manufacturing and infrastructure on these red areas. Because many of these investments take years to execute, credit for them will be claimed by future administrations.

Yet due to the arrogance and isolation of the progressive policy advocates that shaped this legislation, it was simply self-evidently obvious that the most ambitious domestic reconstruction program in the ninety years since Roosevelt will help many of the most economically challenged areas in the country. Proud and sparsely attended ribbon cutting ceremonies made the local newspaper, if there still is one. News of these investments never arrived via the partisan news channels and hyper-targeted social media venues on which most ordinary Americans rely these days. That attitude of “self-evident good works”  is of a piece with the “Why Bother Visiting Wisconsin” arrogance that let Trump into the White House in the first place. 

If post-debate polling is any guide, all these trillions of dollars of good works, funded with money borrowed from our grandchildren, will not be enough to turn the red tide, which could well leave the Republicans firmly in control of all three branches of the federal government. As they go to their cushy post-administration redoubts at the Brookings Institution, Yale, Hopkins and Harvard’s Kennedy School of Government, and hobnob at Aspen Institute and Martha’s Vineyard cocktail parties, the executors of all these good works, for the unforgiveable political sin of failing to communicate effectively with the struggling working class they used to champion, will have fully earned their retirement. 

Jeff Goldsmith is a veteran health care futurist, President of Health Futures Inc and regular THCB Contributor. This comes from his personal substack

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