Tuesday, September 15, 2009

Metrics for success

Should some version of healthcare reform be signed into law, I'd like to have a well-defined set of metrics to measure how successful it is at achieving its stated goals and objectives.

Clearly, a central objective is to increase the number of people with medical insurance. Democrats have bandied about the number 46 million as the current number uninsured, a number taken from a census bureau report. However, that number includes about 11 million illegal immigrants, who we are assured will not be covered. It also includes 15 million who were temporarily between coverages. The actual number of American citizens who are uninsured in the long term is around 20 million. Reducing that number significantly ought to be one metric. I would propose as a target that within ten years of Obamacare being enacted, the number of uninsured people be reduced to 5 million.

The percentage of America's GDP which is spent on health care is cited as a reason to reform our medical system. Obama has repeated that America spends 16% of GDP on health care, while Canada spends 10% of GDP and covers everyone. France spends 11% of GDP on health care. I propose 12% as a target.

Obama assures us that Obamacare will be deficit neutral, and that the public option will not be subsidized by the government. Measuring the deficit impact of a program is difficult. It is easy to falsely claim that costs have been offset by spending cuts if cuts are defined loosely. Stating that a program plans to increase spending by 10% and then only increasing it by 8% is not a 2% cut which can be used to offset Obamacare spending increases. Neither is the end of a short-term spending program a cut. For instance, the fact that we spent $800 billion on bailouts and stimulus this year and will only spend $300 billion next year does not equate to a $500 billion cut which can be used to offset Obamacare. Also, moving spending from one program to another is not a cut from the one. I propose this metric: for Obamacare to meet its goal of being deficit neutral, total entitlement spending must not grow faster than inflation times population growth. In addition, the public option (if included in the bill) must be self-supporting and not subsidized.

We are told that Obamacare will not reduce the quality of medical care in America. There is not one good metric for quality of medical care, so we have to track several metrics: infant mortality rate, life expectancy, and survival rates for various diseases all should do no worse than to continue on their current trend. "Quality-adjusted years of life" is a metric used by some countries. I don't fully understand how it works, but it sounds promising.

Obama campaigned on bringing transparency and accountability back to the political process. One way to accomplish that would be to build meaningful metrics into health care reform so that we will know if it delivers on the many promises made in the effort to sell the plan to the public.


Garrett said...

I agree about the important of transparency and legitimate reporting of the details behind the programs. I also agree with your metrics as being reasonable sounding as well, however... realize that the health of the country has HUGE inertia and changes now likely will not affect the numbers in a statistically significant fashion for likely 10 years. The sad part is by that time the next president might claim the benefits sowed now as his own...

Don Dodson said...

I just thought of another one: percentage of people in the public option who were uninsured prior to the passage of Obamacare. That percentage should be high if the public option is working like it was intended.

Garrett, you are right that these metrics change very slowly. Changes in life expectancy could take 20-30 years to fully emerge.

Colin said...

What a reasonable comment. I must say, I agree with you -- we need good metrics. I may quibble with your numbers around the margins, but we're on the same page.

I disagree about the number uninsured. It's hard to get a hard number, but that 46 million comes from the Census -- 2007 was their latest data. So it's not made up.
DeNavas-Walt, C.B. Proctor, and J. Smith. Income, Poverty, and Health Insurance Coverage in the United States: 2007. U.S. Census Bureau., August 2008.

There's a lot of research backing it up, however:

"The Agency for Healthcare Research and Quality, using the Medical Expenditure Panel Survey (MEPS) estimated that the percentage of uninsured Americans under age 65 represented 27 percent of the population. According to the MEPS data, nearly 54 million Americans under the age of 65 were uninsured in the first-half of 2007."
Chu, M. C. and J. Rhoades, The Uninsured in America, 1996-2007: Estimates for the the U.S. Civilian Noninstitutionalized Population Under Age 65, Medical Expenditure Panel Survey, AHRQ, Statistical Brief #214, July 2008.

The other thing that's clear is that the recession has increased these numbers, by at least 7 million and growing as a result of job losses: "A recent study shows that based on the effects of the recession alone (not job loss), it is projected that nearly seven (7) million Americans will lose their health insurance coverage between 2008 and 2010."
Gilmer, T. P. and R. G. Kronick, Hard Times And Health Insurance: How Many Americans Will Be Uninsured By 2010?, Health Affairs Web Exclusive, May 28, 2009.

"Urban Institute researchers estimate that if unemployment reaches 10 percent, another six (6) million Americans will lose their health insurance coverage. Taking these numbers together, it is conceivable that by next year, 57 to 60 million Americans will be uninsured.
The Urban Institute estimates that under a worse case scenario, 66 million Americans will be uninsured by 2019."
Holahan, J., et. al, Health Reform – The Cost of Failure. Robert Wood Johnson Foundation and the Urban Institute, May 21, 2009.

"Nearly 90 million people – about one-third of the population below the age of 65 spent a portion of either 2007 or 2008 without health coverage."
Families USA. Americans at Risk: One in Three Uninsured, Familes USA, March 2009.

The goal of this reform is 0% uninsured. Whether or not they can get there in a year is doubtful, but we should be on the right track by then at least.


Don Dodson said...

Colin, I said that it came from the Census. But the same report breaks the number down. Not all 46 million are long-term uninsured American citizens.