Impostos sanitaris

 Health Taxes. Policy and Practice

Pràcticament totes les mesures fiscals influeixen en la salut de les persones, a través dels seus impactes en el comportament, el consum, els ingressos i la riquesa. No obstant això, un subconjunt reduït de mesures fiscals pot estar dirigit més directament a millorar la salut orientant-se a comportaments i riscos que se sap que estan fortament associats amb els resultats de la salut. L'objectiu d'aquest llibre és tractar el tema d'aquestes mesures, que definim com a "impostos sanitaris". El llibre pretén enumerar els impostos sanitaris clau d'interès, explorar els seus efectes positius i negatius i com influeix en aquests efectes el disseny d'aquests impostos i el context en què s'apliquen. Es pregunta com i on es poden implementar. De manera crítica, construeix un argument al llarg del llibre sobre per què els responsables polítics de tot el govern s'han de preocupar pels impostos sanitaris.

 Contents:

Introduction (Franco Sassi, Jeremy A Lauer, Agnes Soucat, Angeli Vigo, and Jeremias Paul)

The Place for Health Taxes in the Wider Fiscal System (Céline Colin, Gioia de Melo, and Bert Brys)

Protecting and Promoting Health Through Taxation: Evidence and Gaps (Lisa M Powell and Frank J Chaloupka)

Supply-Side Responses to Health Taxes (Annalisa Belloni and Franco Sassi)

The UK Soft Drinks Industry Levy as an Incentive for Beverage Reformulation (Martin White, Jean Adams, Cherry Law, and Peter Scarborough)

The Labour Market Impact of Health Taxes (Sarah Mounsey, Lisa M Powell, and Frank J Chaloupka)

Impacts of Health Taxes on the Attainment of the SDGs (Norman Maldonado-Vargas and Blanca Llorente)

Expanding Health Taxation to Other Unhealthy Behaviours and Harmful Activities (Andreia Costa Santos, Thiago Hérick de Sá, Michael Oliver Hinsch, Ernesto Sanchez Triana, and Jeremy A Lauer)

The Design of Effective Health Taxes (Lisa M Powell and Frank J Chaloupka)

Health Taxes and Illicit Trade: Evidence and Courses of Action (Norman Maldonado-Vargas)

Public Governance and Financing, and Earmarking Health Taxes (Ceren Ozer and Susan P Sparkes)

Managing the Politics of Earmarked Health Taxes (Katherine Smith and Mark Hellowell)

Monitoring and Measuring Health Taxes (Rosa Carolina Sandoval, Maxime Roche, Anne-Marie Perucic, Miriam Alvarado, Itziar Belausteguigoitia, Luis Galicia, and Guillermo Paraje)

Health Taxes and Trade Law (Benn McGrady and Kritika Khanijo)

A Political Economy Analysis of Health Taxes (Thomas F Babor, Jeff Collin, and Maristela G Monteiro)

The Role of Civil Society in Tobacco Tax Reform in the Philippines (Filomeno Sta Ana, Angeli Vigo, and Jeremias Paul)

The Future of Health Taxes: Helping It Happen (Angeli Vigo, Jeremy A Lauer, Franco Sassi, and Agnes Soucat)

 

Efficient health insurance as a first best

 Sick Insurance: Adverse Selection and Regulation of Health Insurance Markets

When heterogeneity in consumer tastes and needs, and in cost and quality of products, are publically observable, markets can price, sort, and match these variations, and product choices made by consumers yield demand signals that foster efficient resource allocation. These conditions hold, roughly, for a broad swath of economic activity, allowing lightly regulated private markets to successfully approximate allocative efficiency. However, in health care systems around the globe today, participants do not necessarily see the big picture of lifetime health costs and quality of life, and in many systems the incentives that consumers and providers face do not promote efficient allocation of health care resources. Information asymmetries are the fundamental source of difficulties in health insurance markets and in efficient provision of health services. Additional factors contributing to poor performance of health markets include (1) government regulation that is intended to protect the disadvantaged and promote equity, but creates incentives antagonistic to allocative efficiency, (2) inefficient provider organizations and non-competitive conduct, sometimes sheltered by government policies, and (3) behavioral shortcomings of consumers in promoting their own self-interest, including inconsistent beliefs regarding low-probability future events, myopia, and inconsistent risk assessment.

The seminal contributions to economic analysis of Kenneth Arrow, George Akerlof, Joe Stiglitz, Mike Spence, Mike Rothschild, and John Riley establish that when there are information asymmetries between buyers and sellers, adverse selection, moral hazard, and counter-party risk can result, causing markets to operate inefficiently or unravel. Asymmetric information between buyers and sellers, or market regulations that restrict competitive underwriting and force common prices for disparate products, can induce adverse selection. Moral hazard occurs when effort to avoid risks cannot be observed by sellers and stipulated in insurance contracts, and buyers have less incentive for risk-reducing effort when some of their potential losses are covered. When the productivity and cost of medical interventions is not known to all parties, then buyers and third-party-payers may not make informed decisions on therapies. Counter-party risk occurs when sellers evade payment of benefits for losses, or fail as agents to respect the interests of the consumers who are their principals. Adverse selection of buyers with high latent risk or low risk-reducing effort, or sellers with high counter-party risk, make insurance less attractive to buyers, and may cause insurance markets to unravel. Administrative overhead will induce less than full insurance. By itself, this does not make insurance market outcomes inefficient, but increasing returns to scale in administrative costs may lead to an inefficient concentrated market.

In principle, the problems of asymmetric information can be overcome by government operation or regulation of health services; in practice, there remains a major mechanism design problem of designing incentives that handle the asymmetries; e.g., “single payer” systems permit additional levers of control, but information asymmetries cause principal-agent problems even in command organizations. Legal mandates and regulations can make adverse selection worse. Government policy on private health insurance markets often reflects a social ethic that individuals should not be denied health care because of inability to pay, expressed for example in requirements that hospitals admit uninsured patients with life-threatening conditions, and a social ethic that insurance contract underwriting should not be based on risk factors such as gender, race, and pre-existing conditions. When these requirements are not publically financed, they are implicit taxes on insurers and providers that are at least in part passed through to consumers as higher premiums that increase the effective load for low-risk consumers. Both the higher loads and the prospect of public assistance as a last resort reduce the incentive for consumers to buy insurance and to pay (or copay) for preventative care.

The United States has, more than any other developed country, relied on private markets for health insurance and health care delivery. These markets have performed poorly. Denials and cancellations, exclusion of pre-existing conditions, and actuarially unattractive premiums have left many Americans with no insurance or financially risky gaps in coverage. Administrative costs for health insurance in the United States are seven times the OECD average. These are symptoms of adverse selection. Delayed and inconsistent preventative and chronic care, arguably induced by incomplete coverage, have had substantial health consequences: the United States ranks 25th among nations in the survival rate from age 15 to age 60. This impacts the population of workers and young parents whose loss is a substantial cost to families and to the economy. If the U.S. could raise its survival rate for this group to that of Switzerland, a country that has mandatory standardized coverage offered by private insurers, this would prevent more than 190,000 deaths per year.

Given the damage that information asymmetries can inflict on private market allocation mechanisms, the obvious next question is what regulatory mechanisms can be used to blunt or eliminate these problems. This involves examining closely the action of adverse selection and moral hazard, and the tools from principal-agent theory and from regulatory theory that can blunt these actions. There is an extensive literature relevant to this analysis that can be focused on the regulatory design question. Less well investigated are the impacts of consumer behavior, particularly mistaken beliefs. This paper examines these issues, and studies the impacts of regulations intended to promote equity and efficiency. More practically, this paper investigates these issues with reference to the private market in the United States for prescription drug coverage for seniors, introduced in 2006 and subsidized and regulated as part of Medicare.

The efficient regulatory design is mandatory universal insurance, this is the answer. But it has to be eficient, otherwise appears duplicate insurance, paying twice for the same. This is the worst second best, a combined failure of mandatory and private coverage.

Do sin taxes work?

The Use of Excise Taxes to Reduce Tobacco, Alcohol, and Sugary Beverage Consumption

The summary:

Of the 188 countries that reported 2016 tobacco tax and price data to the WHO, 173 levied an excise tax on manufactured cigarettes (61). Tobacco taxes have increased in many countries since the 2005 entry into force of theWHO’s Framework Convention on Tobacco Control. The treaty emphasizes the effectiveness of tax and price increases in reducing tobacco use, particularly among young people.On average, cigarette excise taxes account for 32% of the price in LMICs and 48% in HICs. Many, but not all, countries tax some or all other tobacco products, generally at rates well below the rate imposed on manufactured cigarettes. 

Nearly all governments levy excise taxes on at least some alcoholic beverages. Of the
192 countries that provided data to the WHO in 2012, 155 levied an excise tax on beer, 138 on wine, and 151 on distilled spirits; alcohol sales were banned in some of the nontaxing countries (52, 62). Alcoholic beverage excise taxes appear to be relatively low, according to the limited information provided.  As with cigarette taxes, alcohol excise taxes account for a lower share of price in LMICs than in HICs (both lower, in general, than for cigarettes). Among 74 reporting countries, excise taxes as a share of retail prices ranged from a low of 0.3% in Kyrgyzstan to a high of 44.9% in Norway, with an average of 17.3%. Taxes as a percentage of price are, generally, lowest on beer and highest on distilled spirits.

In 2014,Mexico became the first country in the Americas to adopt a significant tax specifically on SSBs, a one-peso-per-liter tax that raised taxed beverage prices by about 10% (13). Since then, other countries have adopted more significant taxes to reduce SSB consumption and promote health, including several US localities, South Africa, the United Kingdom, Ireland, Portugal, Saudi Arabia, the United Arab Emirates (UAE),Dominica, and Barbados.Most aim to raise retail prices by at least 10%, with a few resulting in more significant increases

Well, unfortunately the article explains the current status (and it helps) though the impact is much more difficult to measure.

En terra ocupada

La situació del sistema de salut a Palestina és delicada des de fa temps. Fa 44 anys que és terra en conflicte i per ara no s'en surten. Les notícies que ens arriben són sempre relatives a la política i successos, però n'hi ha poques de com l'educació i la salut s'han convertit en moneda de canvi. Aquesta carta que ha publicat el Lancet i que adjunto sencera avui ho explica prou bé. Més enllà d'organitzacions com Physicians for Human Rights, n'hi ha un altre d'exemplar Healing across the divides, metges voluntaris que dediquen part del seu temps a projectes humanitaris en terra ocupada. Si voleu conèixer de primera mà el que succeeix són molt interessants els relats després de cada viatge.

The Lancet, Volume 378, Issue 9800, Page 1375, 15 October 2011

Health care and the Palestinian bid for statehood
Ruchama Marton

Everything one can say about the health-care system in Palestine was summed up by the physician and political leader Haidar Abdel-Shafi in the wake of the Oslo Agreement in September, 1993. He said: “We cannot take care of health and education as long as we live under occupation”. On Sept 13, 1993, I happened to be in Gaza city. A taxi driver told me: “My expectations from the Agreement are very few. I would like to have a better health care system, better education for my children and much better roads in the Gaza Strip”. Maybe he didn't ask for too much, but these things were impossible to achieve because of the reallocation of responsibility between the State of Israel and the newborn Palestinian Authority, which took place without a parallel redistribution of power. The costly responsibility for civil needs such as health care and education was shifted to the Palestinians. Yet Israel maintained full power over the borders, movement on the roads, access to water, access to health services, taxes, and the import and export of goods. The Palestinians could not even guarantee their health teams and patients free movement to medical centres, hospitals, and clinics. This new form of occupation was actually worse, since the new “balance” saddled the Palestinians with material costs while providing them with only the illusion of power. Coming back to Tel Aviv in 1993, Neve Gordon and I urgently wrote an 11-point document demanding two main things from Israel: (1) immediate concern by the Israeli medical institutions for the welfare of individual patients until an adequate Palestinian service had been developed, and (2) cooperation between Israel and the Palestinian Authority in the development of an independent medical and health infrastructure. Both sides and the negotiators practically ignored our proposal. The reason I'm mentioning this sad history is that now, as the Palestinian Authority waits to hear whether the UN Security Council will back its bid for full membership, the situation is much the same. Israel has used health and medicine as an instrument of control and oppression of the Palestinian people and leadership in the occupied Palestinian territory throughout the years since 1967. We at Physicians for Human Rights—Israel conceive this situation as a disease for which the cure is the total removal of control by Israel over the Palestinians. There is no way that a future Palestinian state, if there ever is one, can handle the health-care system (or any other socioeconomic system) if the Israeli occupation and control continues. Haider could see it much before most people could. This is why he refused to take part in the negotiations after Madrid and even more so after the White House hand-shaking in September, 1993. Maybe now leaders will see it too. The Israeli policy makers have the inherent obligation of mending all the wrongs inflicted by them during the 44 years of occupation. This is the way the heavy responsibility of building a health-care system will be borne by those who have the power to do it.

PS. Al BMJ hi surt Catalonia i s'oblida d'explicar el perquè de tot plegat.

PS. Ressenya de novel.la sobre les farmacèutiques al Lancet : Pharma in the jungle. Té tota la pinta que pot acabar en una pel.lícula.

PS. Arnold Relman explica els reptes del sistema sanitari americà a New York Review of Books, magistral com sempre.

PS. Feu un cop d'ull a PillEconomics

Taxing unhealthy foods

The effect of prices on nutrition: Comparing the impact of product-and nutrient-specific taxes

Nowadays, many people is asking about evidence oon the impact of taxes for sugar sweetened beverages. The reason is that in Catalonia from May 1st. a new tax has been implemented.Two tax rates have been set in relation to sugar content: For drinks containing more than 8 grams of sugar per 100 ml: €0.12/litre. For drinks containing between 5 and 8 grams of sugar per 100 ml: €0.08/litre
A new article in the Journal of Health Economics sheds light on the issue:

Our main finding from the tax simulations is that nutrient-specific taxes have much larger effects on nutrition than do product-specific taxes, without causing a larger decline in consumer utility. The intuition for this result is that nutrient-based taxes have a much broader base, so it is more difficult to substitute away from any one good in response to such taxes. For example,a 20% tax on soda decreases total purchased calories by 4.84% and decreases sugar consumption by over 10%. However, a 20% sugar tax decreases total calories by over 18% and sugar by over 16%.The larger effect of a sugar tax on nutrition comes despite the fact that it has the same effect on indirect utility as a soda tax. Dueto their negative income elasticities and the patterns of own- and cross-price elasticities we find, taxes on snacks and packaged mealshave very small effects on nutrition. Fat and salt taxes, on the other hand, have much larger effects, decreasing calories by 19% and 11%, respectively. SSB taxes, which can be thought of as a hybrid price policy that targets a set of products based on their nutritional content, also are quite effective, reducing caloric intake by over 8%. However, these taxes are less-effective and only slightly less-distortive than a broad-based sugar tax.

If this is so, the next steps should be to review the initial impact and explore wether new approaches could be more succesful. Unfortunately the article doesn't explains the details of how to implement their result...

PS. On sugar

Ben l'oncle Soul

European Union Health: in the middle of nowhere

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability

If there is an example of how one part of an organization can't speak with the other is the European Union and Health Policy. If we are talking about medical devices, health issues are at the back, industry is writing the regulations. If we are talking about options for improvement, economics unit  explains what health unit has to do. A perfectly designed mess.
Take the example of this week. A Joint report, that is an economics report with elementary mistakes for any health economist. Take this statement:

"Competition between hospital providers can lead to higher quality under strict price regulation." (p.70)

Does anybody know what does really mean strict regulation? Who is writing such things and being paid with our taxes?.
If you check another report on the topic by experts of the European Union you'll find an opposite recomendation.

"The conditions for competition to be a useful instrument vary across countries, health care subsectors and time. There is no golden rule or unique set of conditions that can be met to ensure that competition will always improve the attainment of health system goals." (p.4)

Definitely, the EU is in the middle of no judicious health policy.
In summary, an avoidable report that you can skip reading and devote your time to hearing Bob Dylan music for example, the new Nobel Prize.

 

The Times They Are A-Changin'

Bob Dylan

Come gather 'round people where ever you roam
And admit that the waters around you have grown
And accept it that soon you'll be drenched to the bone
If your time to you is worth savin'
Then you better start swimmin' or you'll sink like a stone,
For the times they are a' changin'!
Come writers and critics who prophesy with your pen
And keep your eyes wide the chance won't come again
And don't speak too soon for the wheel's still in spin
And there's no tellin' who that it's namin'
For the loser now will be later to win
For the times they are a' changin'!
Come senators, congressmen please heed the call
Don't stand in the doorway don't block up the hall
For he that gets hurt will be he who has stalled
There's a battle outside and it's ragin'
It'll soon shake your windows and rattle your walls
For the times they are a' changin'!
Come mothers and fathers throughout the land
And don't criticize what you can't understand
Your sons and your daughters are beyond your command
Your old road is rapidly agin'
Please get out of the new one if you can't lend your hand
For the times they are a' changin'!
The line it is drawn the curse it is cast
The slow one now will later be fast
As the present now will later be past
The order is rapidly fadin'
And the first one now will later be last
For the times they are a' changin'!

Written by Bob Dylan • Copyright © Bob Dylan Music Co.

A much-needed start: soda tax

Soda Politics: Taking on Big Soda (and Winning)

Obesity is a top concern on public health. Personal and collective responsibilities are linked. The concrete issue is the following one: government may require manufacturers to release information to consumers (about calories, composition, etc.), but is there anything else that he can do?
Current strategies fall short to achieve the goals of obesity reduction. Nutritional labels are not enough, are taxes an option?. Some countries have already implemented taxes on fizzy drinks, fat or salty foods. There are complex technical issues to be considered. However, The Economist says that taxes on fizzy drinks seems to work as intended. If this is really so, then there is a much-needed reason to start in this way.
Marion Nestle in her latest book "Soda Politics" provides the hole list of arguments. Any regulator should read in detail the book, specially part IX on "Advocacy: Soda caps, taxes and more", and take into account her recommendation:

 Let me acknowledge immediately that advocacy to reduce soda intake faces special challenges that distinguish it from advocacy for reduction of alcohol, tobacco, or junk foods. Like these other industries, the soda industry sells relatively inexpensive products that are available in almost every corner of the globe. Like them, this industry is extremely wealthy. Also like the others, health is the industry’s Achilles’ heel. But in sharp contrast to companies selling junk food, alcohol, or tobacco, Coca-Cola and PepsiCo consistently rank among the most admired, respected, and honored companies in the world. Health and environmental advocates must recognize the power of this favorable public perception when encouraging others to resist it.

PS. A must read. Understanding 25 years of health policy in Catalonia, released in this journal: Referent. You'll find an article that I have written for the occasion.

Being loyal to your health system

Entitats d’assegurança sanitària lliure de Catalunya 2014

Your country may have decided that publicly funded health coverage is mandatory for all citizens. Therefore, there is no opt-out posible. Your taxes or contributions will fund the system. What happens if you are not satisfied with the access or quality of services? You may complain, but unfortunately its impact will be negligible most of the times. This is the voice option in Hirschman terms. Voice is really a political and confrontational perspective, while  Exit is the alternative option.

While both exit and voice can be used to measure a decline in an organization, voice is by nature more informative in that it also provides reasons for the decline. Exit, taken alone, only provides the warning sign of decline. Exit and voice also interact in unique and sometimes unexpected ways; by providing greater opportunity for feedback and criticism, exit can be reduced; conversely, stifling of dissent leads to increased pressure for members of the organization to use the only other means available to express discontent, departure. The general principle, therefore, is that the greater the availability of exit, the less likely voice will be used.

Hirschman provides light to what is going on in our health system. Right now one fourth (24,9%, p.29) of the population has decided to "exit" the publicly funded health system. Well, really they can't exit, they pay twice, and this is the reason why it is said they have duplicate health insurance, the same services covered twice.
Hirschman  says that loyalty could reduce exit, however current health policy trends are exactly producing the opposite, reducing loyalty to the public system. And this could be the reason why every year there is an increase of departures. Well, really there are communication vessels and people switch between the systems according the services needed.
This is exactly what's going on, and somebody should ask: is this efficient in social terms?. My answer is absolutely not, you'll never pay twice if you want to buy a loaf of bread, why should be this the case for health insurance for 66% of Sarria district citizens, one third (37,5%) of Barcelona citizens or one fourth of catalan citizens?.
Beware of the warning sign of decline while health policy is encouraging hospital nationalization.

PS. Just to be clear, I'm not arguing for a formal opt-out system. It is unacceptable and outdated. I'm just asking for an efficient system that members engage in long-term loyalty relationships.

A central dilemma

Reconsidering the Politics of Public Health

These are difficult times for public health regulators. JAMA highlights the issue:

A central dilemma in public health is reconciling the role of the individual with the role of the government in promoting health. On the one hand, governmental policy approaches—taxes, bans, and other regulations—are seen as emblematic of “nanny state” overreach. In this view, public health regulation is part of a slippery slope toward escalating government intrusion on individual liberty. On the other hand, regulatory policy is described as a fundamental instrument for a “savvy state” to combat the conditions underlying an inexorable epidemic of chronic diseases. Proponents of public health regulation cite the association of aggressive tobacco control, physical activity, and nutritional interventions with demonstrable increases in life expectancy

The article presents 5 ways towards a solution. The fifth says:

Physicians may bear particular responsibility in addressing the problem that psychologists call “hyperbolic discounting”— the human tendency to discount the value of future conditions bya factor that increases with the length of delay. Physicians bear witness to regrets about prior unhealthy choices in poignant moments— for example, the ex-smoker who wheezes in trying to keep up with grandchildren—and work to prevent other patients from experiencing avoidable fates.Perhaps physicians and other health professionals, as a result, have a special duty to weigh in on how society mitigates the social and environmental conditions that lead toward unhealthy choices

Wishful thinking again?.
Why should physicians bear such huge responsibility? "Nanny physicians"? What about citizens?. As you know, my focus is on shared decision making. Unfortunately the article doesn't mention it.

PS. What's goign on in Catalonia? Have a look at WSJ today. This is not a dilemma, it's a fact.

PS. Are you willing to pay 12.380€ for an additional survival of 36 days -progression free in breast cancer- ?. NICE considers that cost per QALY of Eribulin is 91.778 €. Are you willing to pay this cost? Forget the question,  there is no dilemma, the social insurance will pay it for you as from today. We are rich enough to afford it.

PS. If somebody wants to know how neuromarketing is being applied, have a look at the following documentary: "Don't think, just buy". Public health regulators can learn a lot from this experience to counter commercial efforts on junk foods and beverages.

Health financing on the right track

The Changing Role of Government in Financing Health Care:An International Perspective

If you are looking for a paper that reflects all the issues sorrounding health care finance, you are in luck. A recent article in JEP covers the topics to understand what's going on in developed countries. For example,  I found this statement of interest with regard to our current situation:

The relative efficiency of different types of taxes used to finance health systems has been explored in the public finance and health economics literature. The equity and efficiency properties of general taxation (c.f. Auerbach1985) do not differ depending on whether the money is spent on health or education per se, although, if the level of government that collects revenue differs from the level of government that provides health coverage, there may be equity issues and issues about whether the level of taxation best meets local demand for the services required (c.f. Ahmad and Brosio 2006). Of course, the amount of deadweight loss associated with any revenue generation will depend on the balance and type of taxes  used to raise the revenue.

There are huge equity issues to address in our current system, and have to be corrected very soon. I hope we are on the right track and this is going to be solved in forthcoming months.

On sugar and taxes

Should We Tax Sugar-Sweetened Beverages? An Overview of Theory and Evidence

The real question is how to tax the addiction industry. Sugar is only one case. Right now, these are the guiding principles (for sugar):

1. Focus on Counteracting Externalities and Internalities, Not on Minimizing
Sugary Drink Consumption
2. Target Policies to Reduce Consumption among People Generating the Largest
Externalities and Internalities
3. Tax Grams of Sugar, Not Ounces of Liquid
4. Tax Diet Drinks and Fruit Juice If and Only If They Also Cause Uninternalized
Health Harms
5. When Judging Regressivity, Consider Internality Benefits, Not Just Who Pays the
Taxes
6. If Possible, Implement Taxes Statewide
7. The Benefits of Sugar-Sweetened Beverage Taxes Probably Exceed Their Costs

Furthermore, sugar-sweetened beverage taxes are not a panacea—they will not, by themselves, solve the obesity epidemic in America or elsewhere. But sin taxes have proven to be a feasible and effective policy instrument in other domains, and the evidence suggests that the benefits of sugar-sweetened beverage taxes likely exceed the costs

 Robert Frank

Els desori regulatori dels impostos sanitaris sobre l'alcohol

 Global report on the use of alcohol taxes 2023

Gairebé tots els països posen impostos d'una o altra manera sobre el consum d'alcohol. Ara bé n'hi ha molts que una vegada els han posat, no gosen tocar-ho. Encara que siguin ineficients, és a dir serveixin per recaptar però no per adoptar un consum responsable, segueixen allà pels temps dels temps.  Per això només un 23% dels països tenen sistemes de reajust automàtic d'impostos especials segons aquest informe de la OMS. 

Per altra banda, encara que els impostos especials sobre l'alcohol són generalitzats, hi ha 22 països, especialment europeus, que exclouen el vi, d'aquests impostos. Un desori regulatori.

Cada vegada que s'ha volgut modificar la fiscalitat de l'alcohol ha provocat un canvi de ministre o una crisi notable. El lobby de l'alcohol és especialment actiu i bel·ligerant . És justament per això que els nous ministres ja han entès que aquesta és una línia vermella que no poden creuar per la seva pròpia supervivència (com a ministres). A Europa no s'ha legislat sobre impostos especials des de 1992. Segueixen de vacances parlamentàries però no de cobrar el sou a final de mes. L'any 2022 va preparar-se una nova directiva que segueix en avaluació.

I si voleu saber per exemple què representen els impostos sanitaris sobre el preu de la cervesa, podreu comprovar que a Espanya, són un 6% del preu mitjà d'una cervesa. I són els menors de l'OCDE (excepte Luxemburg i Alemanya). I ja no tinc res a afegir.

Table 1. Excise Taxes as Percentages of Final Beer Retail Prices by Countries.

Price Level	% of Max Price		% of Mean Price		% of Min Price
Countries	Mean (SD)	Trend β(SE)	Mean (SD)	Trend β (SE)	Mean (SD)	Trend β (SE)
Australia	0.19 (0.01)	0.02***(0.00)	0.25 (0.01)	0.00* (0.00)	0.35 (0.05)	−0.03* (0.01)
Austria	0.07 (0.01)	−0.02***(0.00)	0.09 (0.01)	0.00 (0.00)	0.13 (0.02)	0.01+ (0.01)
Belgium	0.05 (0.00)	0.01(0.003)	0.07 (0.00)	0.01* (0.00)	0.11 (0.01)	0.01** (0.00)
Czech Republic	0.07 (0.02)	−0.01(0.02)	0.08 (0.02)	−0.02 (0.02)	0.09 (0.03)	−0.03 (0.02)
Denmark	0.11 (0.06)	−0.11***(0.01)	0.13 (0.05)	−0.08***(0.01)	0.14 (0.04)	−0.06*** (0.01)
Finland	0.19 (0.04)	−0.05***(0.01)	0.24 (0.02)	−0.01+(0.01)	0.32 (0.06)	0.04** (0.01)
France	0.05 (0.02)	0.04 (0.03)	0.07 (0.03)	0.04+ (0.02)	0.10 (0.04)	0.04 (0.02)
Germany	0.04 (0.01)	−0.03***(0.00)	0.05 (0.01)	−0.03*** (0.00)	0.07 (0.01)	−0.04*** (0.00)
Greece	0.10 (0.05)	0.09***(0.01)	0.11 (0.05)	0.09***(0.01)	0.12 (0.06)	0.09*** (0.02)
Hungary	0.14 (0.02)	0.01(0.01)	0.17 (0.01)	0.002 (0.01)	0.21 (0.01)	−0.01 (0.01)
Iceland	0.50 (0.18)	−0.13***(0.02)	0.51 (0.18)	−0.13***(0.02)	0.59 (0.18)	−0.14***(0.02)
Ireland	0.24 (0.02)	0.01 (0.01)	0.26 (0.02)	−0.01 (0.00)	0.30 (0.02)	−0.01* (0.01)
Italy	0.10 (0.02)	0.01 (0.01)	0.12 (0.02)	0.01 (0.01)	0.16 (0.04)	0.003 (0.02)
Japan	0.29 (0.02)	−0.02***(0.00)	0.35 (0.01)	−0.01 (0.00)	0.42 (0.02)	−0.01* (0.00)
Luxembourg	0.04 (0.00)	0.00(0.00)	0.04 (0.00)	−0.01*(0.00)	0.05 (0.00)	−0.02** (0.01)
Netherlands	0.09 (0.01)	0.01 (0.01)	0.11 (0.01)	0.005(0.00)	0.17 (0.03)	−0.01 (0.01)
New Zealand	0.17 (0.02)	0.02* (0.01)	0.22 (0.02)	0.01*(0.01)	0.29 (0.02)	0.01 (0.00)
Norway	0.23 (0.04)	0.02 (0.01)	0.33 (0.05)	−0.00 (0.01)	0.49 (0.07)	−0.02 (0.02)
Poland	0.09 (0.03)	0.07***(0.01)	0.12 (0.03)	0.04***(0.01)	0.18 (0.02)	−0.01 (0.01)
Portugal	0.07 (0.01)	−0.02+ (0.01)	0.09 (0.01)	−0.02***(0.00)	0.12 (0.02)	−0.04*** (0.01)
Slovak Republic	0.11 (0.02)	−0.05*** (0.01)	0.14 (0.03)	−0.05*** (0.01)	0.19 (0.04)	−0.04*** (0.01)
Spain	0.05 (0.00)	0.00 (0.00)	0.06 (0.00)	−0.00(0.00)	0.07 (0.00)	−0.002 (0.00)
Sweden	0.22 (0.01)	−0.00+(0.00)	0.25 (0.01)	0.01(0.00)	0.29 (0.03)	0.02** (0.01)
Switzerland	0.07 (0.04)	−0.11***(0.02)	0.08 (0.05)	−0.09***(0.02)	0.10 (0.05)	−0.08*** (0.02)
United Kingdom	0.22 (0.01)	0.00 (0.01)	0.29 (0.03)	0.00 (0.00)	0.39 (0.08)	−0.01 (0.02)
United States	0.23 (0.02)	−0.02***(0.00)	0.28 (0.03)	−0.03***(0.00)	0.28 (0.03)	−0.04***(0.00)

Note: SD: standard deviations. SE: Standard Errors. +p < 0.1, * p < 0.05, ** p < 0.01, *** p < 0.001. Trend: changes over time (decrease (−) or increase (+)).

Fig. 1 presents the trends of excise taxes as a percentage of final beer retail prices at three different price levels during 2003–2018. The percentages of excise taxes in beer prices at the maximum and average price levels are less than 10 % and stay the same in most countries during the study period. The percentages of excise taxes are less than 1 % at all three different price levels in France, Japan, Poland, and the United States. The percentages of excise taxes are highest at the minimum price level in all countries and do not change much over time except for Iceland, Ireland, and Netherlands.

L'informe de la OMS diu clarament:

Alcohol consumption is one of the leading risk factors for population health worldwide. While historically predominantly used to raise revenue, excise taxes are an effective tool to decrease the affordability of alcoholic beverages and reduce alcohol consumption and related harms. However, existing taxes on alcoholic beverages differ widely in terms of design and level, and most are not optimized to pursue health goals.

Aquest és el missatge per guardar i que qui en sigui responsable que llegeixi l'informe i faci alguna cosa.

Robert Doisneau

Aprés tout (3)

Publicly funded health expenditure reached 9,162m € in 2012, although the initial budget was 8,756m €. Therefore, the size of the budget deviation was  406m €(10% of total public deficit, health care is 38% of total public budget), and we have to remember that in 2011 the deviation was 582m€ .
Let's say it differently, in 2012 we have roughly accomplished the budget of 2011 (!) , or being more precise we have reduced the 2011 budget in 26 million .
The most interesting figure is always the per capita expenditure, in 2012 the final number is 1,205 € per inhabitant. A reduction of 2 € if we compare to 2011 budget (p. 45), or 77€ per capita of cutbacks in current terms.
The level of expenditure is right now close to what we were spending 5 years ago. Surprisingly, the size of population also went back to the figure of 5 years ago.(!)
Meanwhile, citizens wonder if there is a limit in the shrinking trend. The rumor these days is that the 2013 budget may be reduced by 9%. I can't imagine that this is possible to accomplish in 6 months, given that we have reduced 12% in two years(!!!).
And finally, don't forget that we are in a country that only 43% of our taxes come back, the remaining amount we'll retrieve it the day that we all agree in the creation of a new state. Then we'll not discuss again about cutbacks in the health budget, because we'll decide how much to devote to health services with our taxes.

PS. Video: Our politicians in the Parliament, a review of health policy in 2012.

PS. Today at 19:30 h. free broadcast of GET2013:  Genomics in the Practice of Medicine

PS. Otherwise at 22:00 h you may be interested in:  Genetics in Hollywood: Inspiring Writers and Producers to Create Storylines that Improve Health Worldwide 

PS. Recovery room from cutbacks: Must listen to Ben l'Oncle

Against Labor Tax funding for health

The Case Against Labor-Tax-Financed Social Health Insurance For Low- And Low-Middle-Income
Countries

Adam Wagstaff laid out a strong case against labor-tax financing for health insurance,

based on analyses of the potential revenue generation, the distributional implications, the impact on the labor market, and the potential for universality in service coverage

A key problem with labor-tax social health insurance is that it can actually redistribute resources toward the wealthy, not the poor. This occurs when general revenues subsidize labor-tax social health insurance institutions that predominantly serve upper-income groups instead of having those subsidies be used to extend coverage to the rest of the population. When expenditures on health care for the eligible workers in the formal sector—already higher than expenditures for the general population—exceed their contributions, the resulting subsidy is financed through taxes levied on the entire population (for example,value-added taxes), which is a form of upward redistribution.

 

The weirdest health financing system of the world (2)

Tracking Universal Health Coverage: 2017 Global Monitoring Report

If I had to summarise the best outcome of health policy in the last century in western countries, I would say mandatory health insurance. No doubt. And the joint report by WHO and WB reminds us that there is still a long way to achieve such goal for the whole population in the world.  Mandatory insurance is the most efficient way to solve the failures of the health insurance market. We al know the details and difficulties that arise as a result of information asymmetries and opportunistic behaviour.
Therefore the recommendation is clear, for those that already have a mandatory system, keep on it. This is precisely what hasn't happened here. In 2012 the system changed from universal towards a social security based membership funded by taxes. The weirdest health financing system of the world.

Maya Fadeeva with Club des Belugas

The healthcare funding conundrum (once again)

Fiscal Sustainability of Health Systems. Bridging Health and Finance Perspectives

Forget economic forecasts, most of them have failed many times. You don't need to be precise about the size of the GDP devoted to health in 2030, it will definitely be more expenses than now. The OECD tries in a new report to review these forecasts and to spread fear in the near future. I think that our societies before the great recession, were able to manage to some extent fiscal deficits. Now it is different, the size of the deficit for future generations is unacceptable.
The report reviews former approaches to supply side and demand side measures for cost-containment. A well known story on the macro-prescription for governments.  My view is not reflected in the document. I have highlighted many times the importance of organizational change, the micro-perspective, i.e. the changes in the structure of incentives and coordination mechanisms in the health system.
This is the most challenging effort for any government, because organizational change and prioritisation represents an attempt to modify the current status quo. Governments are affraid of it, but in my opinion somebody has to handle this conundrum and tell  the population exactly that unless we change current health care organizations, taxes will not be sufficient to pay the bill. Then two options will be open to us: out of pocket or no access. This is the message that this report is unable to explain clearly and now it's time for somebody to disseminate it.

PS. Read the Fiscal Sustainability of Health Systems: Policy Brief 

A healthcare expenditure mess, and nobody cares about it

Let's imagine an alleged State. All its citizens pay taxes under the same Tax Code. Health Benefits are the same under the Health Act. And spending on health care according to geography, can reach 52% more in Basque country compared to Andalusia. This is not new. Many decades having the same figure and nobody cares about it.

This is an easy table to understand health policy making in a failed state. Catalonia spends 4,7% of GDP on health, other sources say 5,5%. Anyway, you'll not find an OECD country with similar figures. After a decade we are spending the same amount per citizen than in 2006, 1.120 €. I will not add anything to this mess. There is only an increasing need to disconnect. Is there any MP in the room?

 

PS. I'm not arguing that every country has to spend the same, I'm just saying that it is not legally possible to deliver the same benefits with such different budgets. Therefore we are unequal before law. This is the usual legal uncertainty of a failed state.



Private health insurance subsidies: the case of Ireland

Unwinding the State subsidisation of private health insurance in Ireland

Taxes may distort individual decisions and hence resource allocation. Subsidies may have the same effect. Ireland had large subsidies for private health until 2013.

In Budget 2014, announced in October 2013, the Minister announced that charges for all beds in public hospitals would be levied on insurers from 2014, raising € 30 m in 2014. Also in Budget 2014, the Minister for Finance announced that the amount of health insurance premium subject to tax relief would be capped at €1000 for an adult and € 500 for a child. This was expected to yield € 94 min savings in 2014 and € 127 m per year thereafter.

The article explains the concrete situation and policies. Its impact on one statement:

Despite the fears about the effect thes emeasures would have on the private health insurance market, the measures do not appear to have caused significant damage to this market. This may be partly due to the introduction of Lifetime Community Rating by the Government in May 2015, and consequent moves by insurers to innovate at the lower-priced end of the market in advance of this.

Ireland is the closer market to us, we share similar features.

Years behind the leader

U.S. Health in International Perspective: Shorter Lives, Poorer Health

This latest report of IOM-NAS highlights the outcomes of a health system and poor health behaviours. The concern about the US population health is growing. I was astonished by this statement:

Demographers refer to this measure as 35q15, or the probability of dying in the 35 years following one’s 15th birthday. For females in the 16 peer countries, 35q15 was around 2 percent in 2007 but was approximately twice as high—4 percent—in the United States. This means that the probability of a 15-year-old U.S. female dying within 35 years was double the average for 16 peer high-income countries.
In all high-income countries, including the United States, 35q15 has been declining for more than half a century. But the relative position of the United States has deteriorated since the late 1950s, when it was near the average of its peers. These countries, on average, had reduced their 35q15 for females to the U.S. 2007 level of 4 percent almost 40 years earlier. In this sense, one can say that, in 2007, the United States was 40 years behind the average of its peers (and 50 years behind the leading peer country).

Forty years behind the leader! that's a lot. A great effort is needed to balance such situation. An important sailors alert: those that want fierce and unregulated competition without mandatory insurance should have these results in their mind. Is this really what they want?

PS. The cheapest ad for a company is the one you may watch on TV3,  i.e. yesterday on TN about prenatal genetic screening. Why do all the citizens have to pay for this advertisement through our taxes?

Health reform zombies (2)

 THE NEXT GENERATION of HEALTH REFORMS

Three years ago in a OECD Health Ministerial meeting, everyone accepted the statement on the criteria for next health reforms. Now, 3 years later, we can confirm that nothing happened about it.

Inside the document there was also a recommendation on health data governance. And the same, nothing happened.

That's it, an extraordinary built narrative that leads to nowhere. Death and taxes remain as only truths.

Banksy