Errors de la medicina

Blind Spots. When Medicine Gets It Wrong, and What It Means for Our Health

 Aquest llibre, "Blind Spots", examina els errors comesos en medicina moderna i com la transparència pot millorar l'atenció sanitària. L'autor, el Dr. Marty Makary, un professor de la Facultat de Medicina de Johns Hopkins, argumenta que la medicina té "punts cecs", és a dir, àrees on es produeixen errors però que passen desapercebuts.

Un punt cec que s'aborda és l'ús excessiu d'antibiòtics, que pot tenir conseqüències negatives per al microbioma, la comunitat de bacteris que viuen al nostre intestí. Makary explica com l'ús d'antibiòtics en la infància s'ha relacionat amb un major risc d'obesitat, problemes d'aprenentatge, asma i malaltia celíaca.

El llibre també examina la història de la medicina, destacant com les noves idees sovint s'han rebut amb resistència. Makary ofereix exemples com el rebuig inicial de la teoria de la circulació sanguínia de Miguel Servet, la lenta adopció de la prevenció de l'escorbut amb cítrics, i la resistència a la idea que rentar-se les mans pogués prevenir la febre puerperal.

Makary argumenta que la medicina moderna pateix una "cultura d'obediència" que impedeix la discussió oberta i la crítica. Afirma que la revisió per parells, el procés pel qual els articles científics són revisats per altres experts, no sempre és fiable i que els errors en la investigació mèdica sovint no es detecten.

El llibre conclou amb una crida a una major transparència en l'atenció sanitària. Makary creu que els hospitals haurien de publicar les seves taxes d'errors mèdics, les taxes d'infecció i altres mesures de qualitat.

En resum, Blind Spots és un llibre provocador que desafia les creences convencionals sobre la medicina moderna. El llibre argumenta que la medicina té punts cecs i que la transparència és essencial per a millorar l'atenció sanitària.

La financialització com a determinant de la salut

The Financialization of Health in the United States 

Més d'una vegada he confrontat el professionalisme amb l'ineficàcia de l'Estat i els desequilibris del mercat al sector salut. El que es coneix com a tercera lògica que va dir Freidson. Les tres peces clau del professionalisme són: l'hegemonia del benestar del pacient, el principi d'autonomia del pacient i el principi de justícia social. La dinàmica dels incentius porta a conflictes d'interès on l'objectiu de benefici es contraposa als criteris anteriors, i especialment al primer.

A un article recent del NEJM podem veure com el professionalisme va de baixa als USA i es veu minoritzat fruit de la financialització de la salut, entesa com el procés d'influència dels mercats financers i les seves elits sobre el sector. La financialització implica la transformació d'empreses i productes sanitaris  en actius comercialitzables i transmissibles pels quals el sector financer pot acumular capital. La financialització representa una nova forma de propietat i control dels actius del sector sanitari en la mesura que els mercats financers demanen l'obtenció de beneficis a curt termini i la seva distribució a agents financers allunyats del sector salut.

Les dades que conté l'article demostren que la tendència ha estat i és creixent a hores d'ara. La financialització de la salut s'estén com una taca d'oli al USA. I alhora, això significa que hospitals, asseguradores i empreses farmacèutiques i biomèdiques es comporten com entitats financeres. Tal com vaig explicar, la teranyina que envolta la indústria farmacèutica ha convertit la innovació en noves molècules en actius financers, preocupa més l'extracció de valor que la seva creació. Allò que l'enyorat Uwe Reinhardt ja va apuntar sota el nom de "value shifting", quan el valor s'extrau dels membres d'una societat i és apropiat pels tenidors del capital.

Ho exemplificava amb aquest gràfic:

i ho explicava així:

In this exhibit, we assume that Acme Inc., possibly a pharmaceutical company, has developed a new product that is highly valued by the rest of society. Let us call that value “social value.” Measuring it is a methodological challenge. At the conceptual level, however, we may think of it as follows: Acme, Inc. can sell the new product to each individual, prospective customer at that individual’s maximum bid price – the monetary expression of the value that individual puts upon a unit of the product. That bid price naturally varies among individuals, because their income and wealth varies and also because their desire for the product—economists call it “taste” for the product—varies.

If we added up these maximum bid prices across all individuals potentially interested in the new product, we might call that sum the product’s “social value.” In the exhibit, it is shown as the value-flow in pipe A. In many instances, the true social value might even be higher, if there are spill-over effects from the individual user of the new product to other members of society. That would be the case, for example, if the products cured an infectious disease.

Usually, in the real world, firms cannot extract from society all of the social value their products create. Even drug companies with government-granted monopolies usually capture only a fraction of total social value in the form of the firms’ sales revenue. That captured value is shown in pipe B of the chart. The firm distributes that captured value to its employees (pipe C), to its suppliers of other productive inputs and of credit (pipe D), and to government in the form of taxes (pipe E). The residual that is left over accrues to the firm’s shareholders (pipe F). It is the source of the wealth the firm bestows on them.

A major point to take away from the preceding discussion and the accompanying exhibit is that a firm adds net social value to society as a whole only through pipe A. If a firm’s policies do not add net social value, but its shareholders nevertheless are enriched by the firm’s decisions, the firm merely has redistributed already existing value from some members of society (for examples, customers or employees) to its shareholders.

Normally, neither politicians, nor the media, nor the general public pay much attention to the fraction of total social value (pipe A) that firms can capture as revenue (pipe B). In health care, however, that fraction can be quite controversial, as was seen in the public’s reaction to the pricing of high-value specialty drugs such as Gilead Sciences Inc.’s new drugs Solvadi and Harvoni.

En Reinhardt ja apuntava el 2016 a que els preus excessius dels medicaments representaven una extracció de valor. Malgrat no citava el terme financialització com a causa, a hores d'ara podem afegir i confirmar que la financialització també és un determinant de la salut. Una financialització que esvaeix el professionalisme en la medicina. Cal estar-ne atent, entendre com actua i tractar de moderar el seu impacte. Malauradament, en sabem encara poca cosa del que passa per aquí a prop. Caldria una anàlisi en profunditat, i crec que ens trobaríem amb més d'una sorpresa.

PS. Aquí podeu trobar un exemple d'avui de com els lobbys treballen per la financialització de la salut.

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

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.

The health funding crisis (ten years after)

 Despesa sanitària a Catalunya

In a decade (2008-2018) the nominal growth of health expenditure has been 7,6%, 811m€ in absolute terms (!). If we apply de CPI to deflate such figure (14,6%), then  we conclude that we have reduced our expenditure in 887m€ after  10 years (!). In 2018, we were spending 8,3% less than in 2008 in real terms (!).  If we add a demographic growth of 3,3%, then the reduction in per capita terms is 11,6% (!). This is our "funding" for population health. The nominal growth in taxes during the same period has been 17,8%. Where is the money?

That's all folks, and now you can ask why Catalonia is asking for independence and why our politicians are not answering the outcry for a better funding for health.

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

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.

 

How much do countries spend on health?

‌Health at a Glance 2019: OECD Indicators

The european country that spends the most is Switzerland 12,2% over GDP. In Catalonia this figure was 7,6% in 2016 (less than Greece). Per capita income in 2016 was 35% more in Switzerland than in Catalonia, while health expenditure was 60% more in Switzerland.  Where have the catalan taxes gone?. You know it and I know it. And everybody is aware that there is only one solution to have the appropriate public health expenditure. We have to say good bye as soon as possible.

Eurohealth

Everything you always wanted to know about European Union health policies but were afraid to ask

I have to say that I am not afraid to ask about health policies in EU because EU is basically a market. Therefore nothing to ask. Social policy is out of the real scope of EU.However, as a regulator of the market for health has clear examples of disfunctioning. For example, implantable medical devices regulation currently applied was enacted in 1990. New regulation will be applied next year, after 30 years of regulatory vacation. Nothing to add. Taxes haven't been on vacation. Shame on Europe. By the way, you'll not find minor details like this one in the book.

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

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.

Welfare State apocalypsis

WILL POPULATION AGEING SPELL THE END OF THE WELFARE STATE?

Too many people argue over the end of the welfare state. There are reasons for concern, but apocalyptic views are unnecessary. A new book reviews the ageing process and the implications for the welfare state. The message is a balanced perspective:

Upon closer inspection, available evidence suggests that caring for a growing older population may not be so costly to finance and that older people provide significant economic and societal benefits, especially when healthy and active:
– Population ageing has a modest and very gradual effect on health expenditure forecasts, compared
to traditional cost drivers such as price growth and technological innovation.
– Demand for long-term care is expected to increase substantially due to population ageing but it is coming from a low baseline currently. However, projected increases in long-term care spending do not account for the economic cost of informal long-term care, as this is not captured in international statistics (nor fully understood).
– Many older people continue to provide paid or unpaid work beyond official retirement age and continue to make a positive economic and societal contribution. The value of unpaid work provided by older people is considerable but not regularly quantified.
– While in Europe older people's consumption is mainly financed by public transfers, many older people pay for (part of) their consumption from private sources, including from incomes from their own continued work or from accumulated assets.
– Accumulation of asset wealth also benefits the economy indirectly through its contribution to productivity growth; health is a key predictor of asset accumulation.
– Older people, even if not in paid employment, continue to pay consumption and other non-labour-related taxes, and thus contribute to public-sector revenues.

 Mostly, I agree with this view. The retirement funding issue is the largest challenge for the welfare state and our politicians are playing with fire.

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 weirdest financing of a health system in the world

Alternative Financing Strategies for Universal Health Coverage

This article from WHO by Joe Kutzin provides a deep analysis of the implications of financing universal coverage. Today I would like to highlight this statement:

There is a general trend toward greater diversification of revenue sources, including a diminishing role for payroll tax funding. This is a practical consequence of the “ideology” of UHC. With the move toward UHC, entitlement to health coverage is being delinked from employment, and from direct contributions more generally. On the practical side, wage-linked contributions cannot generate a sufficient revenue base, both in high-income countries (because of aging populations and macroeconomic concerns regarding increasing wage-based taxation) and also in low- and middle-income countries (LMICs) (because of low participation rates in formal sector employment).

Spain has decided exactly the opposite. Coverage entitlement comes from social security membership, while funds come from taxes. The weirdest financing of a health system in the world.

La capsa entròpica

Voluntary health insurance: fulfilling expectations

Memòria entitats d'assegurança lliure 2015
Regulació de l'assegurança voluntària de salut

Let's take one country that has a mandatory social security system for the whole population, though its funding comes from taxes (?). If 25% of the population in this country voluntarily buy  duplicate coverage for the roughly the same benefits, what would you say?. The potential answer is that the public system is not fulfilling people expectations and has a big problem. Unfortunately, politicians don't recognise the situation. Imagine that in the capital more than one third of the population hold private insurance, you would say indeed that the problem is larger. This is the case of Barcelona.
Somebody should review the situation. Both public and private systems have their drawbacks. If public mandatory funding is not providing an efficient system, than a prescription is needed. If voluntary health insurance solves the unfulfilled expectations, then a close relationship should be established, and this is not an option by now.
I wrote a paper some time ago on the required new regulation for voluntary health insurance. My impression is that nobody read it. Maybe now it's the time.

PS. Right now 735.997 patients are waiting for a surgery, a visit or a diagnostic procedure.

 

 

Richard Estes. Galeria Marlborough

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

On sugar as a toxic substance. How little is still too much?

THE CASE AGAINST SUGAR

Last book by Gary Taubes takes a difficult way, how to demonstrate sugar as a toxic substance for our health. Although he tries to show evidence for his words, he finally concedes the following conclusion:

Ultimately and obviously, the question of how much is too much becomes a personal decision, just as we all decide as adults what level of alcohol, caffeine, or cigarettes we’ll ingest. I’ve argued here that enough evidence exists for us to consider sugar very likely to be a toxic substance, and to make an informed decision about how best to balance the likely risks with the benefits. To know what those benefits are, though, it helps to see how life feels without sugar.

The "very likely" expression is crucial. Unfortunately we don't have a explicit causal explanation of the impact of sugar on metabolic syndrome, for example. I think that epigenetics will provide neew perspectives on the issue, however we will have to wait. Meanwhile reducing exposure is the best advice.

PS. On the sugar sweetened beverage taxes. And in this blog

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.

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.