Sunday, February 26, 2017

Public Health Strategies Part 4B: Subsidies

In an earlier blog post I discussed taxation as a public health strategy, particularly related to the proposed tax on sugar sweetened beverages (SSBs) in Australia.  In this post I’m going to look at the opposite of taxation: subsidies.

Putting a tax on unhealthy foods would generate extra tax revenue and so the question becomes whether the government should reduce taxes in other areas (or use it to help pay off national debt) or put that extra revenue into something, and if so, what?  Generally I have seen calls to tax unhealthy foods being coupled to calls to subsidise health foods, like fruit and vegetables (F&V).  There are a few rationales for subsidising healthy foods like fruit and vegetables:

  • Reducing the cost of fruit and vegetables would increase the consumption of them and displace unhealthy foods, which will ultimately improve population health and reduce healthcare costs
  • Coupling a fruit and vegetable subsidy to a tax on unhealthy foods (like sugar sweetened beverages) is also a means to reduce the increase to cost of living as a result of the tax, provided people purchase fruit and vegetables 

However, there may be a few problems if a health food subsidy was put in practice

  • A recently published Australian modelling study estimated that a F&V subsidy ($0.14 per 100g of fresh and preserved F&V*) would increase F&V consumption by 42g (a serving of fruit and vegetables is considered 150g and 75g respectively).  However, it was estimated that the subsidy would also increase sodium consumption by 48mg and energy consumption by 236kJ (56.6 calories), because “however, using price subsidies or discounts as an incentive to purchase more fruits and vegetables may have the effect of increasing real income available to buy food, including unhealthy products, and could therefore lead to an overall increase in dietary measures such as saturated fat, sodium, or total energy intake”**.  As a result, their model predicted that a F&V subsidy would actually have adverse health outcomes [1].  The major benefit of food taxes is that they generate revenue [2].  This revenue should go towards initiatives that are at least cost effective, but with a F&V subsidy there’s this study says there’s a 89% chance that it wouldn’t be.  Not a great policy
  • A subsidy on F&V isn’t likely to offset the increase in cost of living from a tax on unhealthy foods such as SSBs.  The estimates show that there isn’t going to be much change in behaviour.  So the people who are already low SSB consumers and high F&V consumers are the ones who will benefit.  This got me thinking if the promotion of taxes + subsidies in some people (not all) is at least partly driven by financial self-interest, but you can defend this motivation in countries with socialised healthcare.  (By the way, my diet is very rich in F&V, with no SSBs and low added sugar, so I would benefit a lot from such policies) 

In my opinion as a stingy student currently on an unflattering income, many F&V are already very cheap as there’s a lot you purchase for < $4-5 per kg or even less.  I think the reason why so many people don’t consume the recommended intake of F&V [3] is because other foods simply taste better, the structure of their habitual meals is not conducive to eating many F&V (cereal for breakfast, sandwiches for lunch, etc), and they don’t value/are empowered about their health enough to change.  When people say cost is important, they are comparing apples with apples, and not apples with muffins.  The apple wins easily on cost, but the cafĂ© bought muffin wins on palatability and reward, and because most Australians have that money to spend, that’s what most people choose

A tax on unhealthy foods should be coupled with a subsidy or health initiative that is actually cost effective in itself.  An idea circulating around AHSNZ is that a tax on SSBs could be coupled to subsidy on dental health or free dental for children.  This would disproportionately benefit lower income families who are less likely to have private health insurance, see the dentist less often and more likely to have worse diets.  It is also likely to be more cost effective as healthcare spent in younger people has a greater return on investment, and dental health is one of the major health issues for children, and one (rampant tooth decay) that is potentially not reversible unlike obesity and type 2 diabetes.  Some people may be against the government using taxes and subsidies to save people from themselves, but may concede that something should be done as tooth decay is so common in children [4].  I would still like to see an estimate of the cost effectiveness of any policy, as good intentions do not necessarily create good policies

* For example, if a fruit or vegetable was priced at $4 per kg, this subsidy would cover 35% of the costs.  This method of subsidising has a greater effect on cheaper F&Vs such that it wouldn’t be practical as very cheap F&Vs like carrots would be almost free.  In fact, at the time of writing this Coles has a special on carrots at $1.20 per kg, so they would be paying the customer to purchase them, pretty crazy! (but don’t forget that F&V are expensive and cost of healthy foods is a limiting factor in population health…)

** I think this point is debatable.  Paying less for F&V would result in consuming more F&V and this may have the opposite effect on calorie intake as F&V are more satiating than most foods per calorie.  In addition, the sodium > blood pressure data they used was based on a large effect from observational studies [5] rather than the small effect in RCTs [6], although sodium could be a surrogate marker for highly processed foods and such foods are unhealthy for other reasons besides sodium.  That being said, if the estimates on calorie and sodium intake were ignored, increasing F&V intake by 42g alone isn’t going to have that impact on population health

*** The study also modelled the effect of taxes on SSBs, sugar, saturated fat and sodium.  The study estimated that all these taxes combined, plus the F&V subsidy, would reduce 470,000 disability adjusted life years (DALYs, or years with chronic disease) and would reduce health healthcare expenditure by $3.4 billion.  These figures seem impressive, but need to be put in context.  The study used a population of 22 million, so this works out to average reduction of 0.0214 DALYs per person (7.8 days) and average reduction in healthcare costs of $155.55 per person across their lifetime (or a few dollars per year, depending on how long you think the average person will live for (e.g. 40 years = $3.86 per person per year)).  This magnitude of response is consistent with another Australian study I discussed previously.  Modest taxes on unhealthy foods are somewhat useful at generating revenue for the diseases they increase the risk of, and will very marginally improve population health, but they won’t come close to solving the obesity/chronic disease epidemic

Sunday, February 5, 2017

Health Associations and Censorship

In an earlier post I discussed education as a public health strategy.  In that post I levelled some criticisms against health associations, particularly that they should revise some of their content and offer more detail, depth and complexity than the bare minimum to sufficiently inform and empower the early majority.

I care about health associations because they strongly influence health policy and what the public thinks on health.  And I think they should.  The purpose of health associations is for a large number of experts to come together and arrive, and arrive at a consensus and publish their collective ideas in a centralised place.  As a result, statistically speaking, the average person is more likely to find information from health associations and this information is more likely to be accurate.

However, the rise of the Internet has resulted in increasingly more information that is decentralised, crowd-sourced, and diverse than ever before, the opposite form of information from health associations.  Much of this kind of information is likely to be of a lower quality than the former, but due to the great diversity of ideas in the latter, some of those ideas may be better.  The hope is that this crowd-sourced information undergoes a process akin to evolution wherein in the free marketplace of ideas, good ideas are generally promoted and bad ideas are generally discarded, and that the average person is able to discern this

This dichotomy was described by Tom Naughton as the vision of the anointed vs the wisdom of crowds (also see his four part series on the anointed and free speech regarding the call for retraction by the ironically named Centre for Science in the Public Interest (CSPI) on Nina Teicholz's BMJ article criticising the dietary guidelines)  And health associations, much like the 'anointed' that Thomas Sowell discusses in his book, are generally pretty dismissive of ideas that challenge their consensus, particularly when coming from non-experts.  Perhaps more importantly, there are few notable instances where health associations have attempted to censor people who promote opposing ideas:

Tim Noakes is a highly regarded South African emeritus professor in exercise science and recent advocate for LCHF diets.  After providing rather general and unindivdualised advice on Twitter, the dietitian Claire Strydom, president of the Association for Dietetics in South Africa, said it was “Dangerous to wean an infant onto #LCHF diet” (evidence for that claim?) and reported Tim Noakes to the Health Professional Council of South Africa (HPCSA) for unprofessional conduct [1], which lead to the HPCSA setting up a hearing.  Tim Noakes doesn’t practice medicine, so could easily give up his license, but wanted to put both conventional dietary advice on trial and defend LCHF.  If you want to learn more about the Tim Noakes trial I would highly recommend Marika Sboros’ coverage of the trial and the following article.  Meanwhile, veganism actually has a history of failure to thrive and (rare) child deaths [2], but you don’t hear about people promoting veganism in children being taken to court

Gary Fettke is an Australian orthopedic surgeon who had been advising his diabetic patients to eat a LCHF diet until a complaint led to an investigation by the Australian Health Practitioner Regulation Agency (AHPRA), where APHRA found he was not qualified to give nutritional advice and told him to stop doing so.  The case led to senate inquiry into the AHPRA (see link) [3] [4] [5] [6] [7] [8]

Jennifer Elliot is an Australian dietician who was giving advising people with metabolic syndrome and type 2 diabetes to eat a LCHF diet.  When an anonymous complaint was lodged with the Dietitians Association of Australia (DAA) the DAA deregistered her and then her employer fired her and stated that “Nutritional advice to clients must not include a low carbohydrate diet. Jennifer will be advised on the information that she may provide to clients…” [9] [10].  If dieticians are told what advice to give, then what’s the point, is their function just a meal plan generator?

Steve Cooksey was a type 2 diabetic who decided to manage/treat his condition with a low carb Paleo diet.  He started a blog, which included dietary advice in an advice column that the North Carolina Board of Dietetics/Nutrition deemed was illegal (giving dietary advice without a licence).  Steve Cooksey and the Institute for Justice, filed a free speech lawsuit against the board [11].  Fortunately, the case was successful [12]

Even if you disagree with some or all their ideas you should still defend their right to express them both on principle and in self-interest (taking away one person’s rights sets a precedent to take away everyone’s).  When someone aims to censor speech, they are communicating that they aren’t interested in having a conversation or that they are in the pursuit of truth.

There are a perhaps two broad motivations for censorship.  The first is a concern that they won’t win in the free marketplace of ideas and so resort to censorship to protect the public from ‘dangerous’ ideas.  However, this motivation is based on a patronising belief that the public is too stupid to hear both sides of an argument and come to the right conclusion.  In addition, it may reveal some anxiety in how well they can express their ideas, how convinced they are of them and how convincing the ideas are to others.  You may be able to draw a parallel here between the political correct authoritarianism, which aims to censor ‘hate speech’ (which these days basically means anything someone finds offensive) and is associated with low verbal cognitive ability, high interpersonal disgust sensitivity, mood or anxiety disorder, and intolerance of nuance and the unknown [13].  As an unintended consequence, the act of censorship signals to others that they have something to hide or that their arguments are weak, and so the idea they are trying to censor gains more visibility and credibility than otherwise (the Streisand effect)

Secondly, the individual or organisation doing the censorship may have a conflict of interest.  Dietetic associations are particularly suspect here.  They function more like a trade union in that their primary function to benefit dieticians collectively rather than the health of the public [14].  They have an incentive to pass anti-competition laws to give them have a monopoly over dietary advice (Steve Cooksey’s case + other evidence [14]).  Also, dietetic associations receive sponsorship from the food industry (see ‘And Now a Word From Our Sponsors’ US [15] and Australia [16] + the conflicts of interest in the Tim Noakes trial [17]),  and the food industry also employs many individual dieticians.  Finally, and this applies to many organisations, they have an incentive to shut down opposing ideas so that the public perceives them to be the ultimate gate-keepers of knowledge, and that acknowledging other ideas or previous errors will cede the monopoly and make them appear less relevant, rather than more honest

With the internet providing increasingly more diverse ideas and information, the increasing partisan bias of the media and the rise of fake news, the solution cannot be to silence everyone you disagree with, as this will be both logistically challenging and counterproductive.  Instead the solution must be to teach people how to think, not what to think.  And instead of presenting an uninspiring version of conventional wisdom and dismissing/censoring opposing ideas, I would like to see health associations hosting debates similar to the Sugar and the State debate hosted by the Cato Institute The Protein Debate hosted by the Performance Menu

Sunday, January 8, 2017

Public Health Strategies Part 4A: Taxes

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into a political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.   In this post I’ll discuss the strategy of taxation/subsidies, which I thought fits nicely into the authoritarian left quadrant.  This is because this strategy holds the food environment primarily responsible for people not adopting healthy lifestyle behaviours rather than personal responsibility, and then uses government controls to manipulate the free market


Rationale

There are a few targets people have suggested to tax or subsidise.  There was the failed Danish tax on saturated fat, and sometimes there are suggestions that fruit + vegetables and even gym memberships (because you couldn’t possibly exercise without one) should be subsidised, but this isn’t very common.  At the moment, a tax on sugar sweetened beverages (SSBs) is far more commonly proposed and is actually being implemented in a few areas, so I’ll focus on that

There are two main rationales to support a tax on SSBs.  The first is that a tax on SSBs will increase their price and this would reduce the consumption of them, particularly in people on lower incomes, who consume more SSBs on average, as they are more sensitive to changes in price.  This is textbook supply and demand, as price goes up demand decreases.  In this respect, a tax on unhealthy food or a subsidy on healthy food could be seen as a form of nanny statism.  Generally, implicit in the support for a tax on SSBs is the belief that education programs haven’t or will not work on some people (the laggards).  This usually isn’t mentioned when a tax on SSBs is proposed (probably out of political correctness and not risking alienating others), but it is an important premise to justify taxes/subsidies, because otherwise why not use education instead?  And so a tax on SSBs appears necessary to reduce SSB consumption and therefore improve health, or, to save some people from themselves.  Or perhaps more importantly, to save the overweight/obese children with a mouthful of tooth decay from negligent parents.  But people who are against many forms of nanny statism argue that what right does the government have to control/influence individual choices that don’t adversely affect others?*  In addition, cigarettes are heavily taxed but plenty of people still smoke, and as David Gillespie points out, there is already a tax in Australia on many processed foods including SSBs in the form of the GST [1]

This leads into the second rationale for taxing SSBs which counters the previous argument.  In countries with a socialised healthcare system the consumption of SSBs creates a negative externality.  When people purchase SSBs they are paying the costs for the product but are mostly or totally externalising the increase in healthcare costs from SSB consumption increasing the risk of several chronic diseases.  As a result, it could be said that they are not paying the ‘true costs’ of a SSB.  Let’s say 1 litre of SSBs costs the consumer $1.50 but each litre of SSBs is associated with an increase in healthcare costs at about $0.30.  Therefore, in this scenario a 20% tax on SSBs is necessary to internalise the healthcare costs.  With this rationale of internalising externalities, a tax on SSBs could be considered a successful policy even if no one changes their behaviour as a result of the tax, and also doesn’t make it about nanny statism or a moral judgement (a ‘sin tax’)

Of course, the government (and health associations [2]) also has a motivation to tax things that are politically acceptable as a form of cash grab, particularly if they’re the kind of government that likes to spend money, which seems to be the main motivation for the Danish tax on saturated fat [3].  “A lesson learnt from this chain of events is that if a tax on fat is to survive it needs more than merely to be passed. It probably needs to be politically supported for health rather than fiscal reasons and to be supported or at least accepted by prominent actors in the food arena including researchers.” [3]

* This can also apply to laws against recreational drug use (that doesn’t expose people to second hand smoke for example), ‘unsafe’ playgrounds and bike helmet and seatbelt laws

Efficacy

Danish tax on saturated fat: some people in public health have praised the Danish fat tax because it reduced the intake of saturated fat [3].  However, simply implementing a well-intentioned policy doesn’t mean it’s necessarily going to have good outcomes.  The most important outcome of such policies should be related to health rather than consumption, and in this respect even diet-heart diehards should judge it to be a failure.  Based on ecological data, the Danish tax on saturated fat appears to have reduced SFA, MUFA and PUFA by 0.3%, 0.2% and 0.1% of total calories respectively (this is because foods high in SFA are often high in MUFA and PUFA on a grams per weight basis).  As a result, LDL-C would be expected to decrease by 0.008 mmol/l and HDL-C would be expected to decrease by 0.005 mmol/l, and this would be expected to increase the risk of CHD by 0.2% (-0.3% for LDL-C +0.5% for HDL-C) [4].  While it’s ideal to be able to judge the efficacy of the tax based on actual changes in population health rather than modelling, the estimated effect size here is probably too small to notice and would likely be drowned out by noise.  The Danish fat tax also had the issue where consumers could avoid the tax by purchasing heavily taxed foods in neighbouring countries without such a tax

SSB tax in Australia: a tax on SSBs hasn’t been implemented in Australia but one study in particular has estimated effect of a 20% tax on SSBs in Australia, and found the following [5]:


Males
Females
Consumption
141g/d to 124g/d
76g/d to 67g/d
Total energy intake
-16 kJ/d
-9 kJ/d
Change in BMI
-0.10
-0.06
Weight loss
0.32 kg
0.06 kg
Obesity prevalence
2.7% (0.7 percentage points)
1.2% (0.3 percentage points)
Health-adjusted life years
112,000 (4.54 d/per capita)
56,000 (2.27 d/per capita)

The estimated change in BMI as result of the tax is similar in magnitude to other studies in the US [6].  The tax is expected to cost 27.6 million AUD upfront, but generate 400 million each year and reduce healthcare costs by up to 29 million per year (savings are expected to increase over time and plateau at 29 million) [5].  This is a decrease of just ~0.024% in total healthcare expenditure (29 million/121.4 billion [7]) and is why it’s important to put those kinds of figures in context

Given that the revenue generated equates to about 0.329% of total healthcare expenditure, and that SSB consumption is likely responsible for at least a 1% of total healthcare expenditure (not aware of an estimation for this, but 1% seems like a reasonably conservative estimate), if the rationale for taxing SSBs is to internalise externalities then the tax would need to be substantially higher.  This is also true if the goal is to meaningfully improve population health

One of the problems with this model is that the health outcomes are based on BMI, which in turn are based on the very small estimated reduction in calorie intake, and doesn’t look at any effects of SSB intake independent of calorie intake and BMI.  And of course it looks at adults, whereas if it also included children the estimated effects would be greater because the analysis would include more people and because the expected health benefits are larger for younger people.  That being said, a modest (~20%) tax on SSBs in an affluent country like Australia (where the economic effect can be largely ignored by almost everyone) is certainly not going to be a silver bullet.  The food industry has a point when they say that SSBs only contribute about 3% on average to total energy intake.  ‘Extra’ foods contribute about 36% on average to total energy intake in Australia [8], so there’s a lot wrong with the average Australian diet.  Therefore, one could argue a lot of potential targets to tax, but also that there’s a lot more that needs to be changed by even a 10% reduction (~3 percentage points) in ‘extra’ foods as a result of a broad taxation policy

Other Objections

Some people argue that a tax on SSBs is a tax on the poor, as poorer people on average consume more SSB and are more motivated by changes in price, but there are a few issues with this objection.  (1) They are confusing intent with outcome.  This is a mistake many people make related to other issues where there is a race/sex/etc disparity.  The tax is not discriminatory (except against SSBs) as it’s not intended to disproportionately tax poorer people, but it’s simply that the people who consume more SSBs happen to be poorer.  It’s not like this is a tax on renting or living in apartments, which actually has more of a causal relationship with being poorer (2) People are free to purchase SSB or not.  There’s nothing forcing poorer people to consume more SSBs on average.  If they don’t want to pay the tax they can choose not to purchase them, after all SSBs are very discretionary food items.  (3) While the tax is estimated to cause large relative differences in total household expenditure (consumption multiplied by income differences), the actual increase in expenditure for low income earners is very modest (~0.2% household income, ~1% of food budget) [9] (4) A tax on SSBs is likely to disproportionately benefit the health of poorer people.  People in public health usually try to engage and improve the health of low SES people disproportionately.  After all, no one in public health is really advocating for a subsidy on salmon, avocado, blueberries and quinoa.  (5) Who do you suppose the tax revenue is likely to disproportionately benefit, almost regardless of what it’s used for?

Another objection is that a tax on SSBs will reduce sales and as a consequence some employees will have to be laid off (if the food industry objects to the tax for this reason, then you know they think it will work to some extent).  The goal isn’t (and shouldn’t be) to punish the food industry as they are reacting to consumer demand for the most part (but they should be punished when they distort science, and there are numerous examples of this).  But the food industry and their employees shouldn’t get upset that in countries with socialised healthcare, the government at some point may tax unhealthy food to improve health and/or internalise externalities, after all there is a rationale and incentive for it to do so.  While it’s unfortunate that a very small number of people may lose their jobs, it’s important to recognise that there are other jobs out there, and that changes in the world will always create winners and losers (the internet is a great example), and part of life is setting yourself up to manage such likely changes well

While I thought taxes/subsidies and bans fit nicely into the authoritarian left quadrant, a modest (~10-20%) tax on SSBs isn’t really that authoritarian.  However, a major concern, particularly from libertarians, is that a tax on SSBs sets up a precedent for governments to tax other things, where these other things may be quite inappropriate targets for improving population health, while also leading to a progressive loss in individual freedom.  This should also be of concern to people in ancestral health, low carbers and other, regardless of political opinion, as by adopting such dietary practices we acknowledge that the government and mainstream isn’t always right.  A good example of an inappropriate target is the Danish tax on saturated fat, as saturated fat is not associated with coronary heart disease in meta-analyses of observational studies [10], replacing saturated fat with polyunsaturated fat does not reduce coronary heart disease in adequately controlled randomised controlled trials [11], and reducing fat intake is hardly the best strategy for weight loss [12].  Similarly, total fat is a potential target, but increasingly less likely.  (Red) meat is another potential target for taxation for health or environmental reasons, despite evidence to the contrary [13] [14] [15].  Salt is another potential target because people in public health seem to have an almost pathological hatred of salt, despite the relationship between salt intake and mortality being on a U-shaped curve [16] and that reducing salt intake doesn’t affect blood pressure much but does have some undesirable side-effects [17].  Being in academia and around nutrition students hasn’t alleviated these concerns, it has strengthened them

This post is already quite long so I’ll simply list a few more papers if you’re interested:

  • Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study [18]
  • Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption [19]
  • Using price policies to promote healthier diets [20]
  • Modelling the potential impact of a sugar-sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa [21]

And finally, if you want to follow me on Facebook you now can.  Just follow this link​ and like the page

Friday, December 30, 2016

Public Health Strategies Part 3: Education

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into the political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.   In this post I’ll discuss the strategy of education, which I thought fits nicely into the libertarian left quadrant.  This is because this strategy holds a lack of education and empowerment primarily responsible for people not adopting healthy lifestyle behaviours rather than character defects, and then ultimately leaves the adoption of healthy lifestyle behaviours up to individuals once these educational needs are met

Role of Education

In earlier blog posts I discussed how one of the weaknesses of relying on individual personal responsibility is that that strategy depends on individuals having reasonably easy access to reliable information that when implemented would improve their health, substantially reduce their risk of chronic diseases (which I consider as >80-90%), and better treat or even reverse the chronic diseases they currently have

The whole point of improving health is a (reasonable) belief that poor health and chronic disease substantially impairs quality of life, whereas the sacrifices to quality of life in adopting healthy lifestyle behaviours is/should be very small or improves quality of life as early as the day you make them or the following day.  Otherwise, if the costs of adopting healthy lifestyle behaviours exceed the benefits of good health and reducing the risk of chronic disease, then education as a public health strategy is simply one big con

If we assume for the moment that humans are rational creatures, we would therefore make decisions based on objective cost-benefit analyses, and so this shift in favour of healthy lifestyle behaviours in theory should be quite automatic and shouldn’t be too difficult.  However, these analyses depend on our perception on the costs and benefits of various behaviours and our perception is based on our knowledge of the world (perceived cost-benefit).  Therefore, the rationale of education is that providing information regarding the efficacy and implementation of healthy lifestyle behaviours, and the consequences of good health and chronic disease, would shift peoples’ perceived cost benefit analyses in favour of adopting behaviours that improve their health and reduce their risk of chronic disease

You could break down this information to along simple-complex lines and along theoretical-practical lines.  The dietary guidelines are actually a fairly good example of this as they include both a complex 100s of pages long report, and a summary report including how to implement these guidelines.  I’ve included another example of what I’m thinking of below, using the scenario of vitamin K2 for osteoporosis:


Simple
Complex
Theoretical/justification
Stating that vitamin K2 helps put calcium in bones
RCT evidence with effect sizes, mechanisms
Practical/implementation
What foods are rich in K2?
Eat X serves of Y
Supplementation, blood tests to measure vitamin K2 status

Health Associations

Here’s the problem, Osteoporosis Australia doesn’t have content on vitamin K2 alongside their content for calcium and vitamin D, and the information they do have only satisfactory checks the simple-theoretical box.  They don’t provide RCT evidence from the vitamin K2 supplementation trials, they say what foods are rich in vitamin K2 but don’t give an indication on how much you should aim for with prevention and treatment (like what they did with calcium and vitamin D), and they don’t inform people on possible blood tests to check for vitamin K2 status.  Osteoporosis Australia also doesn’t have a section for protein (alongside their sections on calcium and vitamin D) which I would think is important considering the popularity of the debunked hypothesis that high protein intake contributes to osteoporosis due to the acid load of protein, despite higher protein intakes actually improving bone mineral density

I’m not targeting Osteoporosis Australia specifically as you could level similar criticisms against just about every other health association.  Many of these health associations provide the earthshattering information that their disease is caused by genes and environment, spread information that is outdated or based solely on observational studies, feature a disproportionate number of recipes for deserts if they have a recipe section, don’t discuss any science beyond the most basic, don’t mention that their disease was historically near absent and near absent in various populations prior to adopting a western diet and lifestyle.  For example, on the Diabetes Australia website you will be told that type 2 diabetes is a progressive disease and see a disproportionate number of recipes for desserts, but won’t be told about superior strategies to manage type 2 diabetes such as a low carbohydrate diet or strategies that have a good chance at reversing type 2 diabetes such as the very low calorie Newcastle diet.  On the Heart Foundation website you will be told that salt is a meaningful factor in the development of hypertension and that saturated fat increases your risk of heart disease, and once again you will see a disproportionate number of recipes for desserts, but you won’t see much on the Mediterranean diet, the PREDIMED Study or the Lyon Diet Heart Study.  On the cancer council Australia website you will be advised to eat a low-fat diet and that red meat increases the risk of colorectal cancer.  You will read about the evils of sun exposure, but won’t be told that vitamin D reduces the risk of other cancers or the possibility of a ketogenic diet potentially improving cancer prognosis.  (I wouldn’t include dietetic associations on this list, as it is clear that their primary goal is to benefit dieticians as a group rather than the health of the general public (they function much like a trade union in this respect))

Suffice to say, I think information regarding health and disease can be substantially improved, and this is a reason why I’ve gone down this path.  I think health associations should:

  • Remove things that aren’t correct
  • Provide information that allows people to increase the number of methods by which they can improve their health and reduce the risk of chronic disease
  • Justify these approaches with evidence, particularly from RCTs
  • Add some clinical information in case that their doctor doesn’t know about the latest research, because otherwise this will be limited to online forums
  • Provide more information regarding the probable causes of disease.  We may not know everything, but we certainly know more than the obvious genes + environment 

Education is not Always Sufficient

That being said, we don’t live in an ideal world where education/knowledge is sufficient to cause behaviour change.  I’m sure each of us could identify at least one area of our lives where this is the case.  But most importantly, it’s clear the education has worked in a sense that people know the basics of a healthy lifestyle (fruit and vegetables are healthy and that soft drink and desserts are not, walk regularly and do some moderate to vigourous physical activity each week, and get enough sleep) and have some understanding of their importance (one could hardly go through life and not be exposed to health information via school and the media at least).  However, that so many people are failing at the basics suggests that simply restating the basics won’t achieve much (the anointed strategy of ‘if it fails, just do the same, but bigger’) and also that education is not always sufficient to change behaviour

Some of the reason for this is that we are wired to be more like instant gratification monkeys rather than deeply logical and rational robots.  In fact this acknowledgement of our own irrationality and impulsivity is something I think that’s missing from health education and education in general*.  Many healthy lifestyle choices require a sacrifice of instant gratification now for a larger payoff in the future.  The way that that health information is presented doesn’t help this as the benefits of a healthy lifestyle is discussed in terms of risk while rarely providing information regarding the magnitude of risk reduction.  Our environment doesn’t help either, as maintaining good health and a healthy weight requires consistently making more effortful and less hedonistic choices such as the purchase of blander and less well marketed foods rather than hyper palatable, high reward and well marketed foods, as well as doing some exercise, meditation or going to sleep when something on the computer or TV is more engaging, etc**

* Something else I think that’s missing from health education is dispelling people’s beliefs that they are healthy when they’re not, although I appreciate that telling people that they’re fat, sick, instant gratification monkeys is a hard sell, but it’s probably necessary.  A recent report found that about 50% of Australians heave a chronic disease and 63% are overweight or obese, but 85% said they were in good or excellent health [1]

** I consider the environment to be the most important factor regarding health.  Remember, I don’t believe in free will, and consider everything to be a consequence of genes + environment, and our genetics haven’t significantly changed in the last few decades.  But I don’t think that a substantial change in the environment (like a regression back to the 1950’s or earlier) is a feasible public health strategy because we want cheap delicious food, labour saving devices and entertainment.  We can make some changes to incentivise healthy lifestyle behaviours (such as a user pays healthcare system and taxes/subsidies) and ban the worst offenders that no one really wants (industrial trans fats).  Beyond that, it’s really up to education and having people create their own micro-environment that promotes health

Targeting the Early Majority

In addition, while it’s probably politically incorrect to say so, some people just don’t care about health, and all the health education in the world isn’t going to change that.  Smoking has had many strategies used against it (education, taxation, bans, stigma, graphic images to invoke disgust, nicotine patches, support for quitting, etc) but people still smoke anyway, much like how people know various crimes are wrong but still commit crime anyway

The following graph is the prevalence of number of healthy behaviours in the US (not smoking, ≥7 hours of sleep, moderate or no alcohol, met physical activity recommendations, normal BMI) [2].  It may not seem too bad, but diet isn’t included, and “76% did not meet fruit intake recommendations, and 87% did not meet vegetable intake recommendations” [3] (similar to “…95 per cent of Australians did not eat the recommended servings of fruit and vegetables” [1]).  There is an explanation for everything, in this case, our high incidence of overweight/obesity and chronic disease.  We are only as good as our weakest link so unless you won the genetic lottery, you will need to do them all


I think you could draw a parallel between the theory of diffusion of innovations (see picture below), the prevalence healthy lifestyle behaviours, and health consciousness and consequently the receptivity to health education/information


Innovators + early adopters = highly motivated by health (4/5 – 5/5).  These people will seek out health information beyond what is provided by health associations.  Public health doesn’t need to target these people, but providing more complex information will make their research more convenient

Early majority = fairly motivated by health (3/5 – 4/5).  These people are fairly receptive to health information but health education may need to be improved to sufficiently inform, motivate and empower them (such as changes suggested here, plus others I haven’t thought of).  Since the theory of diffusion of innovations suggests targeting the early majority and this group is fairly receptive to health information, I don’t think health associations/etc should be too concerned with providing more detail, depth and complexity than the bare minimum

Late majority: not very motivated by health, but not a disaster either (2/5 – 3/5).  Once the early majority has adopted more healthy behaviours and become healthier, and such things have become normalised, the late majority will see that such behaviour change is both feasible and a net benefit to their life.  We might then see a social contagious model of health rather than one of obesity [4]

Laggards = doesn’t really care about health (0/5 – 2/5).  This group can get some rare and awful health scares, but these health scares rarely change behaviour.  Other strategies are probably more productive if you want to improve the health of these people (see next post)

Tuesday, December 27, 2016

Will a User Pays Healthcare System Improve Population Health and Reduce Healthcare Costs?

We have a problem.  In Australia and other Western countries we are spending an increasingly significant amount of our GDP on healthcare [1].  This trend is expected to continue as healthcare spending is increasing at a faster rate than GDP (due to an ageing population and the increasing prevalence of certain diseases such as type 2 diabetes).  This is particularly concerning as Australia is in progressively higher amounts of national debt.  Clearly something needs to change


I find the arguments that ‘healthcare creates wealth’ and that ‘it isn’t necessarily an issue because economies can be flexible’ to be like the ‘broken window fallacy’.  Our ‘sickcare’ system really just patches up broken windows.  There is an opportunity cost in that those resources could be spent on other projects if the window wasn’t broken in the first place.  My aim is to reduce broken windows

As I mentioned in the previous post, the efficacy of relying on personal responsibility (which every public health strategy does to some extent except holding out for miracle drugs and simply banning everything that’s unhealthy) as a public health strategy would be improved if our healthcare systems are structured in such a way that individuals are more incentivised to be in good health.  One way to do this is to have individuals bear more of the financial costs of diet and lifestyle diseases rather than the government

* In 2009-10 Australia spent 9.4% of total GDP on healthcare [2], with 121.4 billion spent on healthcare (~$5,000 per person) [2].  Federal, state and local governments contribute 70% towards healthcare [2], and federal, state and local governments received a combined total of 333.336 billion in tax revenue [3], therefore 25.5% of taxes went towards healthcare in 2009-10

Advantages to a User Pays Healthcare System

There are advantages and disadvantages to more socialised healthcare systems and to user pays healthcare systems.  For this blog post, I’ll just mention some advantages to a user pays healthcare system that has some potential to reduce healthcare costs for most people

Individuals would be more incentivised to improve their diet and lifestyle, rather than face the financial costs of developing and/or poorly managing lifestyle diseases, that could otherwise be prevented or treated through changes in diet and lifestyle.  This would particularly be the case if pharmaceutical drugs for lifestyle diseases were not subsidised through policies like the Pharmaceutical Benefits Scheme we have in Australia (which we seem to be paying too much for [4]).  This will shift cost-benefit analyses in favour of diet and lifestyle, much like how renewable energy would be more cost effective sooner if fossil fuels were no longer subsidised.  For example, someone with type 2 diabetes has a few options: they could either continue what they’re doing and take insulin and Metformin to try and manage their glucose levels; they could simply reduce the amount of carbohydrates they’re eating; and they could try to reverse their diabetes by using the Newcastle diet or other dietary approaches that lead to a short-term spontaneous reduction in calorie intake.  If diabetes drugs and health care associated with diabetic complications becomes more expensive then people will see less value in drugs, while changes in diet and lifestyle (which are more effective anyway) would become more appealing.  As a result, there may be a shift in the culture from popping pills and seeing them as miracle drugs, and more towards a normalisation of healthy diet and lifestyle behaviours.  However, this depends on improving access and dissemination of more than just basic health information such as: the costs and benefits of various pharmaceutical drugs, measured in both relative risk and the number needed to treat; and strategies to prevent and manage many chronic diseases (the focus of the next post)

A major cost for the healthcare system is end-of-life care [5], but quite often end-of-life care prolongs the suffering of the patient, sacrificing quality of life for a few extra months.  Some people would not value it as much as it costs and would prefer to opt out and have that money go toward things they place more value on or toward their families (this should be coupled with voluntary euthanasia).  Similarly, healthcare costs could also be reduced by people opting out of things that offer marginal benefits.  This is basically the idea that individuals are best placed to maximise their utility (↓ money, ↑ value), but standard of care and subsidies distort this

When the cost of something is low (particularly when it’s free) there is a higher demand for it and it isn’t valued as much.  There are obviously many doctor’s visits and hospital admissions that are extremely important, but there are also some trivial ones such as seeing a doctor for the common cold to get a prescription for antibiotics (which won’t work anyway because a viral infection is causing the symptoms)

There are also some minor areas where costs can go down such as lower administrative costs, less bureaucracy, competition driving costs down, being able to shop around for a particular doctor or standard of healthcare, and not needing to see a doctor to get a blood test

In addition, it would remove almost all the rationale for fat shaming or other shaming related to health or health related behaviours

Insurance

You could hardly discuss the costs of healthcare without talking about health insurance.  In my opinion health insurance, much like other forms of insurance, doesn’t make economic sense in most contexts.  That is because a healthcare system based on health insurance involves the average individual not only covering their costs in the health insurance premiums, but also paying for the overhead costs of running an insurance company, the profit the insurance companies need to make, and the additional admin costs at the doctor’s office.  So not only is the average person not getting their money back, but healthcare itself is made more expensive.  A healthcare system based on health insurance is probably a fair part of the reason why the US healthcare system is much more expensive.  It makes more economic sense, for both the individual and society, for people to self-insure the things they can by saving and investing that money for a rainy day or simply adopting universal healthcare [6]

Some of the contexts where health insurance makes sense include: (1) Where an individual doesn’t have enough capacity to save to self-insure themselves (so insuring your house is more likely to make sense).  (2) If the government subsidises health insurance through income tax concessions (an odd policy that really only benefits middle-upper income earners, who have more capacity to self-insure themselves anyway).  (3) If the government mandates that health insurance companies can’t charge women, older people and people with chronic diseases more (because everything else being equal, these people receive more healthcare on average*).  In this situation your health insurance policy will suffer because young healthy men will refuse to subsidise everyone else and opt out of the system, and only get insured when they’re old and sick.  This will either cause the system to run out of money, increase premiums and/or reduce payments beyond which was previously promised (sound familiar?)

* If you accept this, but you don’t think they should be charged higher health insurance premiums, then do you also think that young men shouldn’t have to pay more for car insurance?

Universal Basic Income

This raises the question of what to do with the extra tax revenue if a user pays health care system is implemented, and also how will low income earners and/or sick people be able to afford healthcare?

With the extra tax revenue, the government could either lower taxes by a quarter or could use that revenue for other projects, and could potentially further reduce total healthcare expenditure by putting money into project that would improve population health.  One possible project is to make public transport free.  There’s a saying in business that you can pick only 2 of the following 3 attributes: fast, good, and cheap.  Public transport is neither, because unless you’re catching a train into the city, driving is faster, cheaper and more pleasant.  Free public transport would at least give it one advantage over driving (cost) while likely being a good form of wealth distribution and improving congestion, population health and the environment

Another option that may addresses both issues well is the implementation of a universal basic income (UBI) or at least one solely for the purposes of a health savings account.  A UBI is basically where every adult citizen receives a regular small parcel of money from the government.  It is attractive to some on the left because of economic security and providing and minimum standard of living, and is attractive to some on the right because it would reduce bureaucracy and current welfare systems can be abused and don’t adequately incentivise employment.  In the future a UBI might become more attractive as there is a great potential for advances in technology leading to more automation and therefore job losses

But how much should the UBI be?  I think it should be set at a level that makes it very difficult to near impossible to live on the UBI alone indefinitely, so that some work is generally necessary.  Some articles mention a UBI of $40,000 per year (~$800 per week or a $20 per hour job) [7], which is simply far too much as it alone would require ~$720 billion (40,000 x ~18,000,000 adults), much more than current tax revenues ($446 billion for 2014-2015 [8]) while providing little incentive to work and causing massive inflation.  With the government spending ~$5,000 on healthcare per person per year, this equates to ~$100 per person per week, but the part of the UBI used for the health can be invested in a health savings account, and total healthcare costs may be reduced as explained above, therefore it may only need to be ~$50-75.  The federal government spends 154 billion on social security and welfare [9], so a UBI for living and healthcare (~275 billion) could be distributed at about $15,000 per year for each adult or ~$300 per week.  At a minimum of $200 for living ($100 maximum going to a health savings account) people won’t be starving in the streets, but won’t be living comfortably on the UBI alone.  The government would then consider the UBI to be part of someone’s income and tax their total income as normal, which addresses an objection to UBI that high income earners really don’t need extra money.  So for people in Australia almost half of the UBI would be taxed for those making over $180,000, compared with 19% being taxed for those making between $18,201-$37,000.  These taxes could go towards disability pensions, people who had a bad accident they couldn’t pay for, and people who lost the genetic lottery regarding health, although if more was needed the UBI might be a bit smaller

The incentive part of a health savings account is that it can be used for family members and whatever is left can become part of your estate (much like the Singapore’s healthcare system [8, 9, 10]).  You could further incentivise good health from the health savings account by allowing a dividend of sorts to be paid yearly based a small proportion of what is left at the end of the year.  But you would want to save most of the health savings account in the event of an accident and because most people receive more healthcare as they get older.  In addition it’s better if this was a system where the health saving account was forced as a default (but something you could opt out of if you signed something that future healthcare is dependent on your ability to pay) because otherwise too many people wouldn’t save for future healthcare (because we are wired to be instant gratification monkeys), much like how superannuation is a somewhat idiot-proof method (but one that’s a tax concession that quite disproportionately benefits high income earners) to have people save for their retirement to avoid the government paying pensions 

I don’t consider myself to be that knowledgeable in healthcare and economics but I think these are some ideas worth considering.  My thoughts on this may change with time as outcomes > ideology and intentions