Sin taxes for unhealthy food

Whether to impose excise taxes on unhealthy food – much like those on tobacco and alcohol – is a matter of continual debate in health-policy circles and state governments. Advocates assert that the increased cost of food with dubious nutritional value would reduce consumption of it. They have an attentive audience in state legislators, who legally must balance their budgets. Opponents argue that such a tax would be regressive, unduly penalizing low-income residents who spend a greater percentage of their household budgets on food.

Most states already tax soda sold in grocery stores and vending machines, but not at a level that significantly affects sales. A study of North Carolina young adults showed that a 10 percent increase in the price of pizza and soda was associated with a 7 percent decrease in calories consumed in soda and 12 percent decrease in pizza.

A U.S. Department of Agriculture analysis estimated that a 20 percent price increase in sugar-sweetened beverages – including some fruit juices – would decrease average consumption by 37 calories a day, lowering the adult incidence of obesity and being overweight by 10 percent each.

Scientists tested the effectiveness of “sin taxes” compared with price discounts for healthier food. A group of volunteers – all mothers – shopped at a simulated grocery store. First, they bought groceries at regular prices. Researchers then imposed taxes of 12.5 percent, then 25 percent on unhealthy items, or they decreased the prices of healthy food comparably. The result: Sin taxes were more effective than discounts in raising the nutritional value of the shopping basket.

Doctors are seething

Family doctors are mad. Who can blame them?

Primary-care physicians are the front line of medicine. They are the first stop for people who need care. They treat the patient as a whole person, not a body part or disease. They determine where to send the patient  for more care if necessary.

Their income essentially has stayed the same since the 1990s, while their practice expenses have steadily increased. After accounting for inflation, their average income fell 7 percent from 1995 to 2003. This obviously is an unsustainable business model.

Their workdays are brutal. A Philadelphia practice kept track of what its physicians did in a day’s time. The average doctor saw 18 patients, wrote 12 prescriptions, reviewed 14 consultation reports from specialists, studied 11 X-rays or other imaging reports, and wrote or answered 17 email messages.

Many patients do not get the recommended care. If everyone did, it would destabilize the U.S. primary-care system. A physician with a typical 2,000-patient base would have to spend more than 17 hours a day to meet all of the guidelines for preventive care and chronic-disease management.

Physicians have to fight for every dollar. Plumbers and attorneys do not have to call a third party to verify that they will be paid when they fix leaky faucets or draw up wills. Doctors must follow strict health-plan guidelines or they will not be reimbursed. State and federal health-insurance programs continue to squeeze the rates they pay physicians to compensate for rising costs. Many practices lose money when they treat Medicaid and Medicare patients.

Primary-care physicians’ share of the U.S. health-care dollar is only 7 cents. If payers cut reimbursement for physician services by 25 percent – certainly a doomsday scenario for doctors – the average rate of medical inflation would decrease from 6.2 percent to 5.7 percent.

However, primary-care doctors control 80 cents of every health-care dollar by sending their patients to hospitals, referring them to specialists and handing out prescriptions. This is a key paradox: Primary-care physicians arguably are the most powerful players in the health-care system but are underappreciated and comparatively undercompensated. In a 2006 survey, nearly 8 out of 10 characterized themselves as “junior partners” or “second-class citizens” in the health-care galaxy.

The threat of malpractice suits weighs heavily on physicians. Medical-liability system costs, including defensive medicine, represent less than 3 percent of total health-care spending. However, physician concerns are the same regardless of whether they live in states that have adopted medical malpractice reforms.

They are deeply suspicious of health reform. Two-thirds said their initial reaction to the law was negative. Almost 90 percent said primary care is on “shaky ground” or “is a dinosaur soon to go extinct.”

Lou Goodman, president of the Physicians Foundation and chief executive officer of the Texas Medical Association, predicts that physician practices will vanish because of market forces and the new law’s effects.

Health reform’s newly insured will be clamoring for physician services, which will become increasingly scarce because supply is not expanding with demand. The federal government soon will penalize physicians who do not use electronic health records, an expense and service disruption that many physicians cannot afford.  Many solo practitioners or small practices are banding together, selling themselves to hospitals or simply going away.

Some see primary care in a death spiral. Because it is so challenging and relatively underpaid, few medical students choose that route. This places greater pressure on existing practices, forcing even more to drop out. Primary-care doctors have little bargaining power. Their reimbursement from Medicare and Medicaid has remained relatively flat over the past decade, and private insurance plans have followed suit.

Even though the workload is expanding, physicians are slowing the speed of the treadmill. The average workweek decreased from 55 hours in 1996 to 51 hours in 2008. That is the equivalent of losing 36,000 doctors in a decade. The financial incentive to work harder, they say, is simply not there.

Only 1 out of 4 say that in three years, they will still work as hard as they always have. The remainder say they will cut back their hours, retire or seek nonclinical employment. The recession has prompted many to delay retirement. The health-care industry experience the largest decline in retirement rates  of all economic sectors. In 2009-2010, about 1.5 percent of full-time works retired, compared with 4 percent in 2004-2007.

The ABCs of prevention

There are three kinds of prevention.

Primary prevention focuses on community-wide efforts to reduce disease in everyone. This is usually called public health. Some examples are mass immunizations, air-pollution controls and public-service campaigns to reduce smoking and other risky behavior. So-called “sin taxes” on cigarettes and alcohol are a form of primary prevention.

Secondary prevention is primarily screening to detect diseases such as cancer and heart disease in their early stages, in an effort to reduce severity. But screening does not prevent them.

Tertiary prevention attempts to keep disease under control after it has developed. This is also known as chronic-disease management, and is the most expensive form of prevention. There is an entire chapter devoted to this subject later in this book.

The bottom line is that most preventive services do not save money immediately. But that might not be the point. Prevention advocates correctly argue that most medical treatment does not save money, and that holding prevention to the different standard is unfair. The larger issue, they say, is to determine the best way to allocate health-care dollars to improve Americans’ health.

 Steven Woolf, a physician and Virginia Commonwealth University professor, argues that health is a commodity, just like a new car or a loaf of bread. They are bought for their non-monetary value – in this case, transportation or nourishment. They are not meant to save money. But they are expected to provide good value.

How much should an additional healthy year of life cost? The rule of thumb seems to be $100,000 or less for what health-policy experts call a “quality-adjusted life year.” It is easy to spend far more than that when disease-prevention efforts include a mostly healthy, low-risk population.

Placing an economic value on life is a tricky business. The Environmental Protection Agency valued an individual American’s life at $9.1 million when it proposed more stringent air-pollution controls in 2010. That is up from $6.8 million, the figure the agency used during when George W. Bush was president. The Food and Drug Administration’s number is $7.9 million, up from $5 million in 2008.

It is likewise difficult to tote up prevention cost-effectiveness. For example, adult cigarette smoking causes multiple chronic conditions and sickens children in the household. Secondhand smoke affects the public in places where smoking is not banned. How do you account for the value of tobacco-cessation programs for the damage not caused by smoking?

Timing can also be an issue. Obese children almost inevitably become obese adults. If the condition could somehow be altered early in life, the personal and societal payoff would be enormous and compounded annually.

How much prevention costs depends on how it is delivered. An out-of-shape, overweight man can transform his health by deciding to change his diet and frequenting a local hiking trail. That cost is no more than an adjustment of the weekly grocery bill and a pair of sneakers, and it stays within the household. He profits by having a longer and healthier life. His insurance company pays less for his medical bills. His employer has a more energetic and engaged employee. Everyone wins, and the cost is peanuts.

If the man is not self-motivated, the costs start to mount and effectiveness becomes less certain. Perhaps his doctor has to spend time counseling him about potential health risks. Or his company has to offer him a cash incentive to work out.

Woolf contends that people often conflate the value of programs with the effectiveness of the behavior. The programs encouraging exercise cost money. But the resulting behavior likely saves money. This confusion can obscure positive public-health messages.

A final, and perhaps more cynical, point is that preventive services account for a tiny percentage of health-care costs. The big money is in treating disease. It is not that the health-care system wishes people ill. But most health-care marketing is about the wonders of medical technology and dealing with expensive conditions.

Book review: Why Calories Count

Why Calories Count: From Science to Politics (University of California Press, $29.95) is far from a diet book. Authors Marion Nestle and Malden Nesheim do an outstanding job of evaluating how a simple unit of energy becomes a confusing mess in the hands of diet purveyors, food manufacturers and unrealistic consumers.

Most of us do not know how much we eat and how many calories we expend. However, the authors use science to show how most people underestimate the number of calories ingested, and how few calories are expended during exercise. Even nutritionists, the authors find, are poor judges of the aggregate number of calories in a given meal. That does not bode well for the rest of us.

The U.S. has created an “eat more” culture with super-sized portions because the U.S. food supply has grown from 3,200 in 1980 to 3,900 calories per person now. Not coincidentally, most peg the date of the beginning of the obesity epidemic at 1980.

The authors state plainly that weight loss is portion control rather than gimmicks. Calorie balancing – not low-fat or low-carbohydrate diets – dictates weight control.

Reform spares small business

Health reform spared smaller companies from mandates. Employers with fewer than 50 workers will not have to offer health insurance to their employees.

Companies with 50 or more workers may face financial penalties if they do not offer affordable insurance. Their employees will receive subsidies to buy insurance on the exchanges instead. Most large companies already offer affordable insurance and are least likely to be affected, although more employees probably will participate because of the individual mandate.

Analysts have differed widely concerning the law’s effect on workplace enrollment. The Urban Institute predicted a slight increase at companies with more than 1,000 employees, and little change in smaller companies. Consulting firm Market Strategies forecast a 10 percent decrease in the number of workers offered health insurance by 2014.

Companies are weighing whether to continue offering health insurance or simply to pay the $2,000 penalty for each employee. The decision to discontinue health insurance might be prudent for industries with high turnover, such as hospitality, restaurants and retailers. Larger companies are more likely to conclude that offering insurance is too critical for employee recruitment and retention to abandon.

During the health-reform debate, President Obama repeatedly promised that people would be able to keep their current insurance coverage if they wished to. That is unlikely to be the case.

The law exempted, or “grandfathered,” health plans in place on March 23, 2010, when the law was signed. However, that exemption places tight restrictions on changes that companies can make to their existing plans. These restrictions include no increases in cost-sharing or coinsurance, and limits on deductible increases and employer-contribution decreases. These are tactics businesses typically use to blunt the impact of medical inflation.

The Obama administration expects 39 to 69 percent of employers to relinquish their exemptions by 2013.

Employers are also concerned about the tax implications of offering high-cost insurance policies to their employees. The so-called “Cadillac” or “gold-plated” plans have low deductibles and generous premium contributions. High-cost plans are defined as annual premiums costing more than $10,200 for an individual or $27,500 for a family, including worker and employer contributions. Employers would have to pay a 40 percent excise tax on the value above those thresholds beginning in 2018.

The law targets executives with cushy benefits. However, union and public employees also have generous health insurance. Reformers believe these expensive policies encourage overuse of the medical system. Businesses and governments likely will respond by offering fewer benefits to lower premiums, and raising deductibles and co-payments for employees.

Expect Congress to revisit the Cadillac plan thresholds. A May 2010 survey by Mercer found that this was the No. 1 employer concern regarding health reform. A Towers Watson analysis predicted that more than 60 percent of large-employer plans will be taxed in 2018.

In contrast, companies with 25 or fewer workers will be eligible for temporary tax credits of up to 35 percent. They will also be able to rely on their own health-insurance exchange, called the Small Business Health Options Program (SHOP), to offer standardized, comprehensive coverage at more affordable prices. This should improve their ability to compete with larger companies for employees.

However, health-reform critics say the tax credits are too complex to attract small businesses and probably will help only those companies already offering coverage. A survey of small California businesses found that more than half were unaware of the tax credits or the SHOP exchange. The CBO estimated that the tax credits would reduce the cost of premiums for small businesses by 8 to 11 percent, which translates into a weak incentive.

The RAND Corporation has a much different outlook. Its analysis showed that the number of workers offered insurance at businesses with 50 or fewer workers will rise from the current 60 percent to more than 85 percent. The researchers say the individual mandate and lower-cost insurance on the exchange will fuel employee demand for insurance.

Polypharmacy: Too much Rx

The consumption of all these drugs inevitably has created problems for the health-care system.

The drug-induced deaths of Michael Jackson and Anna Nicole Smith are high-profile examples of larger problems. In 2008, 1.9 million people were hospitalized because of adverse drug events (ADEs), which is more than a 50 percent increase from 2004.

That does not include the 838,000 treat-and-release emergency-room patients affected by ADEs, a number that doubled from four years earlier. More than a third of those were for misuse of prescription painkillers.

The 28,000 prescription overdose deaths in 2007 are five times more than in 1990. Most of those deaths have been from painkillers. The Obama administration has called the current prescription overdose epidemic worse than those of crack cocaine in the 1980s and heroin in the 1990s. The White House launched an anti-abuse plan in April 2011 to cut the rate of abuse by 15 percent in five years.

A study at Pennsylvania-based Geisinger Health System found that more than one-third of patients treated for chronic pain with painkillers met the criteria for addiction. Between 20 and 40 percent of U.S. adults have persistent pain that lasts more than six months.

Seven out of 10 who abuse prescription painkillers got them from a relative or friend. However, physicians have been quick to reach for the prescription pad when patients complain of aches and pains. Spending on prescription painkillers tripled from 1996 to 2006.

The elderly have a particularly difficult time juggling multiple prescriptions. Researchers examined prescription use by people with chronic heart disease, using CVS Caremark data. Patients filled prescriptions for an average of 11 medications during a 90-day period. One in 10 used 23 prescriptions during that period. Each medication a patient takes causes an average of 10 percent additional adverse drug events in a hospital setting.

Dr. Jerry Avorn, in a commentary in the Journal of the American Medical Association, said, “The use of medications in older patients is arguably the single most important health care intervention in the industrialized world.”

However, the Harvard professor listed a number of factors that hamper medication management in the elderly. The fragmented health-care system causes patients with several chronic conditions to see multiple prescribing physicians, most of whom do not communicate with each other. That, Avorn said, creates “pharmacological chaos.”

Clinical drug trials rarely include many over 80 years old, so safety and side effects are less well known among that group. This population may metabolize drugs differently than younger patients and may experience more side effects. Overmedication, also called “polypharmacy,” can increase the risk of falls, cognitive decline and depression. All of that, of course, calls for more prescriptions.

Taking so many drugs is complicated. According to one study, only 15 percent of older adults could consolidate seven drugs into four doses a day correctly. People with less formal education performed even more poorly.

People with chronic conditions consume a prodigious amount of prescription drugs. They account for $3 of every $4 spent on pharmaceuticals. Those with five or more conditions filled an average more than 57 prescription medications a year.

Taking so many drugs, also known as “polypharmacy,” can create problems. A patient may not react to one drug on its own. When drugs are used together, the risk of adverse consequences increases exponentially. Unfortunately, health-care providers often react to these events by adding still more drugs to the mix – called “prescribing cascading” – which can increase the chance of additional adverse reactions.

On the other hand, about half of people who have three or more conditions do not take medicines as directed – often because of cost. Therefore, the risk of taking too many or too few medications is high for those with chronic illness.

U.S. cigarettes a relative bargain

Two significant recent steps should bolster the anti-tobacco effort. First, the federal cigarette excise tax increased from 39 cents to $1.01 in April 2009. Despite that price increase, U.S. cigarettes are among the most affordable in the world.

Second, the U.S. Food and Drug Administration (FDA) can now regulate the manufacturing and marketing of cigarettes and other tobacco products. The U.S. surgeon general declared tobacco a health hazard in 1964. However, over the next 45 years, the No. 1 preventable cause of death remained virtually the last unregulated consumable U.S. product. The regulation likely will have more impact than the 1971 ban against tobacco advertising on radio and television. It probably will eclipse the industry’s $206 billion settlement with the states in 1998.

The regulation bans the use of the terms “light” and “low tar,” as well as the use of fruit and candy flavorings to make products more palatable to children. Advertising and store displays will be restricted to stark black-and-white text. However, the bigger impact is the disclosure and regulation of the estimated 60 carcinogens and 4,000 toxins emitted by cigarette smoke. The FDA will have the ability to make the products less deadly for current users.

The Congressional Budget Office predicted the law would decrease youth smoking by 11 percent and adult smoking by 2 percent, independent of the effects of higher excise taxes and public smoking restrictions.

A 2009 Gallup poll indicated that more than half of Americans disapproved of the FDA regulation. The reasons for lack of support are unclear. However, even many nonsmokers oppose public smoking bans because they place a higher value on freedom of choice than on combating health risks.

Book review: The Blood Sugar Solution

Diabetes may well be the fastest-growing non-communicable epidemic in world history.

From 1983 to 2008, diabetes increased seven-fold from 35 to 240 million worldwide. From 2008 to 2011 alone, 110 more people became diabetics.

Dr. Mark Hyman does a good job of explaining how this is happening in The Blood Sugar Solution: The UltraHealthy Program for Losing Weight, Preventing Disease and Feeling Great Now (Little Brown, $27.99).

He describes “diabesity” as a continuum of health problems from overweight and mild insulin resistance to obesity and diabetes. It is almost entirely caused by environmental and lifestyle factors and, therefore, preventable. About 1 out of 4 cases of diabetes remains undiagnosed, as well as nearly all of those with prediabetes.

Hyman points to the usual dietary suspects that contribute to the problem: excess sugar consumption, processed food and sodium. However, he expands the culprits to include environmental factors such as pollution, pesticides, hormones and antibiotics in food.

The book includes a six-week “action plan” to lower blood sugar and the requisite recipes section. Buyers beware: While the book contains valuable information, it is also a Trojan horse for a website that sells his expensive “recommended” supplements.

Book review: The Ultimate Volumetrics Diet

The Ultimate Volumetrics Diet (Wm. Morrow, $27.50) is the latest in a series of books involving the highly regarded weight-control plan developed by Penn State professor Barbara Rolls.

Unlike the charlatans whose books populate the diet-plan shelves in bookstores, Rolls’ volumetrics is based on solid science and common sense. The idea is to consume foods that are filling, but low in calories. These typically contain lots of water and fiber, such as soups, salads, fruit and low-fat dairy products. The diet does not limit any particular foods and does not promote calorie-counting. However, it provides a context for evaluating the effect of what people consume.

The book contains updated research, as well as a 12-week weight-loss plan and strategies to cope with temptation when eating out and more than 100 new recipes. The goal is to train the reader to think in terms of the calorie density of food, and to track food consumption and physical activity. The book’s calorie comparisons are not unlike those of the Eat This, Not That genre.

Volumetrics practitioners will not find much groundbreaking content in this latest edition. It mostly expands on the franchise.

Studies: Tobacco still stinks

Research on tobacco’s effect on health continues to be popular, even though the results rarely surprise.

The surgeon general’s office issued its 30th report on tobacco in December 2010. The 704-page document describes in detail how tobacco damages every organ in the body, resulting in disease and death. It noted that tobacco smoke contains more than 7,000 chemicals, of which hundreds are toxic and at least 70 cause cancer.

Cigarettes alter a smoker’s DNA within 30minutes of the first puff. The immediate genetic damage raises the short-term risk for cancer. Smokers’ arteries stiffen with age twice as fast as those of nonsmokers. Stiff arteries are more prone to blockages that promote stroke, heart attacks and other cardiovascular disease.

A 55-year-old smoker has the same chance of dying in the next 10 years as a 65-year-old nonsmoker. The number of cigarettes smoked dictates how swiftly health-related quality of life deteriorates, even in those who eventually quit the habit.

Pipes and cigars have an impact on health similar to that of cigarettes, especially on lung function. While cigarette smoking has decreased in the past four decades, pipe and cigar smoking have increased in popularity.