Americans spent $3 trillion on health care in 2014, or about $9,523 per person. That’s up 5.3 percent from the previous year. That increase isn’t expected to slow down; for about the next decade, the U.S. government expects spending to grow 5.8 percent on average each year.
As policymakers look for ways to cut down this spending, one idea gaining traction is to incentivize consumer-directed health plans (CDHP). These high-deductible, low-cost plans are already growing in popularity. About 20 percent of people who are covered by employer-sponsored health insurance are enrolled in some type of CDHP.
In theory, CDHPs would reduce health-care costs because consumers would choose less expensive health care when they pay for it themselves. But does that theory pan out in practice? M. Kate Bundorf, an associate professor of political economy, examines the benefits — and the trouble spots. Bundorf is also a core faculty member at Stanford Health Policy.
How do consumer-directed health plans work?
A CDHP is one type of plan offered by an insurance company. The main idea behind CDHPs was, instead of putting decisions about cost and quality tradeoffs in the hands of the health plan, we’ll put them in the hands of the consumers. There are three features that are generally associated (with CDHPs): One is a relatively high deductible, the second is some type of a personal spending account, and the third is information tools for people to compare costs and quality when they’re choosing care.
People can make decisions that reflect their own preferences. Think about a person choosing between two different drugs to treat their condition. One drug is less expensive, but it has some side effects. Some people would be willing to pay the higher price for the drug without the side effects, and some people would prefer to spend less and be fine with the side effects. People might be very different in terms of the tradeoffs they’d like to make.
Read the full Q&A with the Stanford Graduate School of Buisness.
Please note: All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication.
Summary
In this talk I’ll provide a history of the breast cancer screening controversies and discuss the new guidelines from the US Preventive Services Task Force and the American Cancer Society.
Senior Fellow, Freeman Spogli Institute for International Studies
Professor, Management Science & Engineering (by courtesy)
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MD, MS
Douglas K. Owens is the Henry J. Kaiser, Jr. Professor, Chair of the Department of Health Policy in the Stanford University School of Medicine and Director of the Center for Health Policy (CHP) in the Freeman Spogli Institute for International Studies (FSI). He is a general internist, a Professor of Management Science and Engineering (by courtesy), at Stanford University; and a Senior Fellow at the Freeman Spogli Institute for International Studies.
Owens' research includes the application of decision theory to clinical and health policy problems; clinical decision making; methods for developing clinical guidelines; decision support; comparative effectiveness; modeling substance use and infectious diseases; cardiovascular disease; patient-centered decision making; assessing the value of health care services, including cost-effectiveness analysis; quality of care; and evidence synthesis.
Owens chaired the Clinical Guidelines Committee of the American College of Physicians for four years. The guideline committee develops clinical guidelines that are used widely and are published regularly in the Annals of Internal Medicine. He was a member and then Vice-Chair and Chair of the U.S. Preventive Services Task Force, which develops national guidelines on preventive care, including guidelines for screening for breast, colorectal, prostate, and lung cancer. He has helped lead the development of more than 50 national guidelines on treatment and prevention. He also was a member of the Second Panel on Cost Effectiveness in Health and Medicine, which developed guidelines for the conduct of cost-effectiveness analyses.
Owens also directed the Stanford-UCSF Evidence-based Practice Center. He co-directs the Stanford Health Services Research Program, and previously directed the VA Physician Fellowship in Health Services Research, and the VA Postdoctoral Informatics Fellowship Program.
Owens received a BS and an MS from Stanford University, and an MD from the University of California-San Francisco. He completed a residency in internal medicine at the University of Pennsylvania and a fellowship in health research and policy at Stanford. Owens is a past-President of the Society for Medical Decision Making. He received the VA Undersecretary’s Award for Outstanding Achievement in Health Services Research, and the Eisenberg Award for Leadership in Medical Decision Making from the Society for Medical Decision Making. Owens also received a MERIT award from the National Institutes on Drug Abuse to study HIV, HCV, and the opioid epidemic. He was elected to the American Society for Clinical Investigation (ASCI) and the Association of American Physicians (AAP.)
Chair, Department of Health Policy, School of Medicine
Director, Center for Health Policy, Freeman Spogli Institute for International Studies
More than fifty experts met in Xi’an, China, for an international academic conference on demographic change and social development last week. Several scholars from the Freeman Spogli Institute for International Studies (FSI) spoke at the conference, including Karen Eggleston, Marcus Feldman, Jean Oi and Scott Rozelle.
The conference marked the 120th anniversary of Xi’an Jiaotong University’s founding and more than three decades of collaboration with Stanford scholars. Researchers at Xi’an Jiaotong University’s Institute for Population and Development Studies collaborate on policy-relevant research and educational activities with Stanford faculty at FSI as well as the Morrison Institute and Woods Institute.
For more information on FSI’s work in the areas of global health and medicine, please visit this page and the Asia Health Policy Program website.
Abstract: Industry, medical centers, academics and patient advocates have come together to create common standards for the representation and exchange of genomics information for both research and clinical use in The Global Alliance for Genomics and Health. Now GA4GH involves hundreds of organizations and individuals worldwide. The open source projects of our Data Working Group welcome participation by all individuals and organizations.
About the Speaker: David Haussler develops new statistical and algorithmic methods to explore the molecular function, evolution, and disease process in the human genome, integrating comparative and high-throughput genomics data to study gene structure, function, and regulation. As a collaborator on the international Human Genome Project, his team posted the first publicly available computational assembly of the human genome sequence. His team subsequently developed the UCSC Genome Browser, a web-based tool that is used extensively in biomedical research. He built the CGHub database to hold NCI’s cancer genome data, co-founded the Genome 10K project so science can learn from other vertebrate genomes, co-founded the Treehouse Childhood Cancer Project to enable international comparison of childhood cancer genomes, and is a co-founder of the Global Alliance for Genomics and Health (GA4GH), a coalition of the top research, health care, and disease advocacy organizations.
Haussler is a member of the National Academy of Sciences and the American Academy of Arts and Sciences and a fellow of AAAS and AAAI. He has won a number of awards, including the 2014 Dan David Prize, 2011 Weldon Memorial prize for application of mathematics and statistics to biology, 2009 ASHG Curt Stern Award in Human Genetics, and the 2008 Senior Scientist Accomplishment Award from the International Society for Computational Biology, the 2006 Dickson Prize for Science from Carnegie Mellon University, and the 2003 ACM/AAAI Allen Newell Award in Artificial Intelligence.
David Haussler
Distinguished Professor, Biomolecular Engineering
UC Santa Cruz Genomics Institute, University of California, Santa Cruz
Science and common sense tell us that the teenage brain is more vulnerable to peer pressure and susceptible to nicotine addiction than at any other stage of development.
That’s why California legislators recently voted to raise the legal age to buy cigarettes and tobacco products from 18 to 21. If Gov. Jerry Brown signs the bill, California will become the second state, after Hawaii, to raise the age limit on the unhealthy products.
Yet while more than 100 cities around the country have adopted such laws — including New York, Boston and Cleveland — New Jersey Gov. Chris Christie in January vetoed such a bill, despite strong bipartisan support from his state legislators.
Health policy advocates see the Christie veto as a setback in what they believe is an otherwise accelerating movement toward “Tobacco 21” laws as a new tool for curbing young people’s potential addiction to tobacco products and e-cigarettes.
Michelle Mello, a Stanford professor of law and health research and policy, and colleagues from Harvard University and Baylor College of Medicine argue in this New England Journal of Medicine article that there is new evidence to suggest these laws are effective, have great public support and have minimal economic impact in the short term.
“The vast majority of smokers begin smoking during adolescence, a period when the brain has heightened susceptibility to nicotine addiction,” they write. “Nearly everyone who buys cigarettes for minors in the United States is under 21 years of age; raising the sale age prevents high school students from buying tobacco products for their peers.”
In 2013, only eight U.S. municipalities had adopted Tobacco 21 laws. By March 2016, at least 125 localities and the state of Hawaii had done so, and California is on the cusp of following suit. In September 2015, the first federal Tobacco 21 legislation was introduced (Tobacco to 21 Act, S. 2100) by U.S. Senator Brian Schatz (D-HI).
The authors note an analysis of the effects of one such law adopted in Needham, MA, revealed a 47 percent reduction in the smoking rate among high school students, along with a reported decline in area retail tobacco purchases. The decreases were significantly greater than those in 16 comparison communities without Tobacco 21 laws.
And a 2015 report by an Institute of Medicine (IOM) committee provided evidence from two different simulation models that increasing the minimum age to 21 would lead to a 12 percent reduction in smoking prevalence. Another simulation study predicted that there would be an even larger effect: a nearly 60 percent reduction in adolescent smoking within seven years after nationwide implementation of a Tobacco 21 law.
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Two national public opinion studies published in 2015 found that 70 to 75 percent of Americans — including a majority of current smokers — support raising the minimum purchase age to 21. The authors themselves conducted a national survey of 1,125 American adults regarding their attitudes toward various public health laws.
“We found that three in four Americans support the adoption of a federal Tobacco 21 law,” they write. “Majority support extends across all major socio-demographic groups, including 68.3 percent support among young adults 18 to 24 years of age.”
Opponents of the federal and state bills — namely Tobacco interests, convenience store owners and e-cigarette manufacturers — say that states should not be in the business of policing public choice. Store owners contend raising the age limit would hurt sales, as snacks and soft drinks are typically ancillary purchases with cigarettes.
And some veterans’ organizations and Republican legislators have said it is wrong to take away the decision on whether to smoke from young people who are nevertheless old enough to marry, vote and join the military.
But Mello and her coauthors, Stephanie R. Morain, PhD, MPH, and Jonathan P. Winickoff, MD, MPH, say the long-term benefits of raising the age limit far surpass the near-term economic concerns, which they believe are overstated.
Research indicates that in the short term, raising the tobacco-purchasing age to 21 would result in a 2-3 percent annual decrease in total tobacco sales.
“Over the longer term, the revenue loss from decreased smoking prevalence will be substantial,” they concede. “But allowing future generations to become addicted to nicotine in order to preserve tobacco revenue fails the red-face test as an argument against Tobacco 21.”
If a federal law raising the legal age of purchasing cigarettes were implemented today, the Institute of Medicine estimates that would result in 249,000 fewer premature deaths, 45,000 fewer deaths from lung cancer, and 4.2 million fewer lost-life years among Americans born between 2010 and 2019.
“Local and state efforts have succeeded in extending Tobacco 21 protections to more than 16 million Americans,” the authors write. “We believe the time has come to expand this effective, broadly supported approach to a much greater share of the population.”
Nearly 100 health economists from across the United States signed a pledge urging U.S. presidential candidates to make chronic disease a policy priority. Karen Eggleston, a scholar of comparative healthcare systems and director of Stanford’s Asia Health Policy Program, is one of the signatories.
The pledge calls upon the candidates to reset the national healthcare agenda to better address chronic disease, which causes seven out of 10 deaths in America and affects the economy through lost productivity and disability.
In this article, I consider what a casual observer can see of a notorious product’s primary place of fabrication. Few products have been criticized in recent years more than cigarettes. Meanwhile, around the world, the factories manufacturing cigarettes rarely come under scrutiny. What have been the optics helping these key links in the cigarette supply chain to be overlooked? What has prompted such optics to be adopted and to what effect? I address these questions using a comparative approach and drawing upon new mapping techniques, fieldwork, and social theory. I argue that a corporate impulse to hide from public health measures, including those of tobacco control, is not the only force to be reckoned with here. Cigarette factory legibility has been coproduced by multiple processes inherent to many forms of manufacturing. Cigarette makers, moreover, do not always run from global tobacco control. Nor have they been avoiding all other manifestations of biopolitics. Rather, in various ways, cigarette makers have been embracing biopolitical logics, conditioning them, and even using them to manage factory legibility. Suggestive of maneuvers outlined by Butler (2009) and Povinelli (2011) such as “norms of recognizability” and “arts of disguise,” cigarette factory concealment foregrounds the role of infrastructural obfuscation in the making of what Berlant (2007) calls “slow death.” Special focus on manufacturing in China illustrates important variations in the public optics of cigarette factories. The terms cloak and veil connote these variations. Whereas tactics currently obscuring cigarette manufacturing facilities generally skew toward an aesthetic of the opaque cloak in much of the world, there are norms of recognizability and arts of disguise applied to many factories across China that are more akin to a diaphanous, playful veil. I conclude with a discussion of how this article’s focus on factory legibility gestures toward novel forms of intervention for advocates working at tackling tobacco today, offering them an alternative political imaginary in what is one of the world’s most important areas of public policy making.
The threat of a pandemic claiming millions of lives and devastating economies around the world is as serious as the potential perils of global climate change, renowned economist Larry Summers told a Stanford audience during a recent visit to campus.
The world is taking dramatic and costly steps to prevent the calamitous impact of climate change on the economies and national security of most countries. Yet preparations for a worldwide pandemic on the scale of the 1918 flu are vastly underfunded and ill-formed.
“My biggest fear is that the world is way short of focus on all the issues associated with pandemic,” said Summers, former treasury secretary in the Clinton administration and Harvard president emeritus, who in recent years has focused on the economics of global health care.
“We are talking about something that could kill surely tens of millions and perhaps 100 million people, and the Stanford football program is substantially more expensive than the WHO budget for pandemic flu,” he said. “It’s just crazy that we are so underinvested and underprepared.”
Summers, the Charles W. Eliot University Professor at Harvard, also served as director of the White House National Economic Council in the Obama administration. He was in conversation with Stanford Health Policy’sPaul Wise for the March 8 event co-sponsored by the Stanford Institute of Economic Policy Research for faculty and students.
The World Health Organization budget for outbreaks and crisis response has been reduced by nearly 50 percent from 2012 to 2015. Some global health experts blame these cuts in part for its slow response to the Ebola outbreak in West Africa and the ongoing Zika crisis in Brazil.
In Brazil, Zika has been linked to a spike in cases of microcephaly, a birth defect marked by small head size and underdeveloped brains. Brazil has confirmed more than 640 cases of microcephaly and is investigating an additional 4,200 suspected cases. Puerto Rico is now preparing for an expected outbreak there.
Summers said the mortality rate from the great flu pandemic was far greater than the recent Ebola outbreak in West Africa, which killed some 11,300 people mostly in Sierra Leone, Liberia and Guinea. Some 50 million people died worldwide during the 1918-1919 flu pandemic.
‘I don’t want to minimize in any way the significance of Ebola, but there are things to worry about that are vastly larger,” said Summers, who gave the keynote address for the January unveiling of the National Academy of Medicine’s report on global health risks.
That report by the Commission on a Global Health Risks Framework for the Future found that, compared with other major threats to global security, the world has “grossly underinvested” in efforts to prevent and prepare for the spread of infectious diseases. The commissioners — some 250 independent experts in health, governance and research and development — estimate $60 billion in annualized expected losses from pandemics.
“Pandemics cause devastation to human lives and livelihoods much as do wars, financial crises and climate change,” the report said. “Pandemic prevention and response, therefore, should be treated as an essential tenet of both national and global security — not just a matter of health.”
Summers estimates that pandemic flu risk is in the same range of global climate change in terms of expected costs over the next century. Yet a potential pandemic is getting only 2 percent of the attention and resources that global climate change has today.
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Summers also chaired the Lancet Commission on Investing in Health, an independent group of 25 leading economists and global health experts from around the world. Their landmark report, Global Health 2035, provides a specific roadmap for this achieving “a grand convergence” in health within our lifetimes. Ahead of the U.N. General Assembly last fall, Summers led a joint declaration together with economists from 44 countries calling on world leaders to prioritize investments in health.
Wise, in the Department of Pediatrics at Stanford and senior fellow at the Freeman Spogli Institute for International Studies, asked Summers how one plans for pandemics when faced with so many failed governments and conflicts around the world.
“One of the central challenges that I worry about a lot in the deliberations of pandemic control is that many of the (regions) of greatest concern are characterized by chronic political instability, conflict and very weak governance,” said Wise, who for more than 30 years has been traveling to rural Guatemala to provide medical care to children there for his Children in Crisis project.
Summers said the world has been fortunate that there are so many brave and devoted medical workers who are trained to go into these conflict regions to try and contain outbreaks.
“But I think it would be disingenuous of me to say that you can solve these problems without in some way containing the failed state,” he said.
Wise then asked Summers what sort of advice he would give to the Stanford students who were trying to decide between a career in which one might use economics to make a fortune on Wall Street, or use economics for the greater good.
“I have always believed that you can count — and you can care,” Summers said. “There is nothing about counting and using numbers and analyzing the math that means you don’t care in a moral way.”
When a physician works with a patient and saves her life, he said, that has a profound and direct impact on both the patient and physician. But working on a vaccination program that has the potential of saving thousands of lives one day comes with delayed gratification.
“But the impact of making the world a better place and enabling people to survive and avoid grieving the loss of of a family member is as great — or greater,” he said.
The Walter H. Shorenstein Asia-Pacific Research Center (APARC), in pursuit of training the next generation of scholars on contemporary Asia, has selected three postdoctoral fellows for the 2016-17 academic year. The cohort includes two Shorenstein Postdoctoral Fellows and one Developing Asia Health Policy Fellow; they carry a broad range of interests from hospital reform to the economic consequences of elite politics in Asia.
The fellows will begin their year of academic study and research at Stanford this fall.
Shorenstein APARC has for more than a decade sponsored numerous junior scholars who come to the university to work closely with Stanford faculty, develop their dissertations for publication, participate in workshops and seminars, and present their research to the broader community. In 2007, the Asia Health Policy Program began its fellowship program to specifically support scholars undertaking comparative research on Asia health and healthcare policy.
The 2016-17 fellows’ bios and their research plans are listed below:
Shorenstein Postdoctoral Fellows
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Aditya "Adi" Dasgupta is completing his doctorate in the Department of Government at Harvard University. At Stanford, he will work on converting his dissertation on the historical decline of single-party dominance and transformation of distributive politics in India into a book manuscript. More broadly, his research interests include the comparative economic history of democratization and distributive politics in emerging welfare states, which he studies utilizing formal models and natural experiments. He received a Bachelor of Arts from Cambridge University and a Master of Science from Oxford University and has worked at the Public Defender Service in Washington D.C., his hometown.
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Dong Zhang is a political scientist whose research interests include political economy of development, with focus on the economic consequences of elite politics, and on the historical origins of long-run economic development. His dissertation examines the political logic of sustaining state capitalism model in weakly institutionalized countries with a primary focus on China. At Stanford, Zhang will develop his dissertation into a book manuscript and pursue other research projects on comparative political economy and authoritarian politics. He will receive his doctorate in political science from Northwestern University in 2016. Zhang holds bachelor’s degrees in public policy and economics, and a master’s degree in public policy from Peking University, Beijing.
Developing Asia Health Policy Postdoctoral Fellow
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Ngan Do is strongly interested in health system related issues, especially health financing, human resources for health, and health care service delivery. Do implemented comparison studies at regional level as well as participated in fieldwork in Cambodia, Lao, the Philippines, Korea and Vietnam. At Stanford, she will work on the public hospital reforms in Asia, focusing on dual practice of public hospital physicians and provider payment reforms. Do achieved her doctorate in health policy and management at the College of Medicine, Seoul National University. She earned her master’s degree in public policy at the KDI School of Public Policy and Management in Seoul, and her bachelor’s degree in international relations at the Diplomacy Academy of Vietnam (previously the Institute for International Relations).
Infant deaths in Massachusetts for much of the 1800s accounted for more than 20 percent of all deaths, many due to diarrhea, cholera and other gastrointestinal disorders.
But from 1870 to 1930, the infant mortality rate plummeted from around 1 in 5 white infants to 1 in 16 for both Massachusetts and the entire United States.
Studies have shown that the dramatic decline was due to the impact of a clean-water system in Boston and other major U.S. cities at that turn of the 20th century.
Now, new research by Stanford Health Policy’s Marcella Alsan indicates that effective sewage systems installed in Boston and surrounding municipalities complemented the water treatment plants and had a significant role in protecting the lives of children.
“We were motivated to investigate this because there was a watershed moment when infant mortality began to decline in the U.S. and Massachusetts that we wanted to understand,” said Alsan, an assistant professor in the Department of Medicine, and the country’s only physician who is a tropical disease expert and economist.
“In retrospect, the daunting challenges these engineers and medical professionals faced in designing, financing and executing such a massive project is incredible,” Alsan said in an interview. “It was really inspiring to read the history of how it all came together.”
She and co-author, Claudia Goldin of Harvard University’s Department of Economics, analyzed about 200,000 of infant death certificates in Boston and 54 other Massachusetts municipalities spanning the years 1880 to 1915.
The impetus behind the creation of the Metropolitan Sewerage District was complaints regarding the stench of sewage among Boston’s upper-class citizens.
“The first of a series of hearings was given by the sewerage commission at the City Hall on Friday night,” read a story in an 1875 edition of the Boston Medical and Surgical Journal. “From the statements made it would appear in various parts of the district including most of the finest streets, the stench is terrible, often causing much sickness.”
A joint engineering and medical commission was appointed in 1875 to devise a remedy and a massive drainage project got underway.
Alsan and Goldin found that an overwhelming number of deaths in the greater metropolitan area were due to gastrointestinal disorders, but that this improved significantly when sanitation canals became part of the overall water systems.
“We find robust evidence that the pure water and sewerage treatments pioneered by far-sighted public servants and engineers in the Commonwealth saved many babies,” they write in a working paper. “It must also have enhanced the quality of life for the citizens of the Greater Boston area even if it did not reduce the non-child death rate by much.”
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They acknowledge that the interpretation of their results is intuitive. But it’s an important one to promote because many developing countries today have yet to heed the lesson of combining safe drinking water and improved sanitation systems.
“Without proper disposal of fecal material, the benefits of clean water technologies for the health of children are likely limited,” they write. “Such a result has relevance for today’s low-and middle- income countries.”
The Millennium Development Goal Target 7.C — to halve by 2015 the proportion of the population without sustainable access to safe drinking water and basic sanitation —was only met for water, but not sanitation. Between 1990 and 2015, 2.6 billion people gained access to improved drinking water sources.
Yet despite that progress, one-third of the global population is still using unimproved sanitation facilities, including nearly 1 billion people who are still forced to defecate in the open. This often leads to cholera, typhoid, hepatitis, polio, and worm infestation.
Diarrhea is the third-largest killer of children under 5 in sub-Saharan Africa, and 44 million pregnant women are infected with worms each year due to open defecation, according to the United Nations. Every minute, 1.1 million liters of human excrement enters the Ganges River in India.
The problem of waste disposal likely will be compounded by rapid urbanization occurring in the developing world, said Alsan, and lack of sanitation and the practice of open defecation costs the world’s poorest countries $260 billion a year.
“We think our findings underscore how complementary these infrastructure investments are, and hope that holds lessons for the developing world,” said Alsan. “In all practicality, it’s very hard to ensure the municipal water supply is not contaminated if the sewage infrastructure is neglected.”
