The curious logic of Professor Adam Carroll

Last week, Indiana University School of Medicine professor Adam Carroll filed a piece for the New York Times with a provocative premise. Titled Preventive care saves money? Sorry, it’s too good to be true, it argued that investing in preventative care doesn’t actually yield savings. Here’s its opening and closing:

The idea that spending more on preventive care will reduce overall health care spending is widely believed and often promoted as a reason to support reform. It’s thought that too many people with chronic illnesses wait until they are truly ill before seeking care, often in emergency rooms, where it costs more. It should follow then that treating diseases earlier, or screening for them before they become more serious, would wind up saving money in the long run.

Unfortunately, almost none of this is true.

[…]

In the short term, less smoking would lead to decreased spending because of reductions in health care spending for those who had smoked. In the long run, all of those people living longer would lead to increases in spending in many programs, including health care. The more people who quit smoking, the higher the deficit from health care — barely offset by the revenue from taxing cigarettes.

But money doesn’t have to be saved to make something worthwhile. Prevention improves outcomes. It makes people healthier. It improves quality of life. It often does so for a very reasonable price.

There are many good arguments for increasing our focus on prevention. Almost all have to do with improving quality, though, not reducing spending. We would do well to admit that and move forward.

Sometimes good things cost money.

We can agree that good things usually do cost money, but this seems like especially curious logic to get to that conclusion. Yes, if fewer people smoke, more people will live longer to get sick of other things and die instead from that, requiring treatment along the way that might be expensive. But this is sort of like arguing that fire alarms don’t save money in the housing market because the homes that don’t burn down within one hundred years become more expensive to maintain.

True, it saved an awful lot of money when that New York State lottery winner put off going to the doctor till he found out he had stage four cancer.

Since he couldn’t afford to catch it earlier, he just straight up died, skipping right past all that expensive chemotherapy, hospital, and hospice care, for months or years of remission and return.

By Carroll’s reasoning, we really should count improved access to reproductive autonomy as monumental healthcare savings because it means you’re not only saving the cost of an unplanned pregnancy or abortion, you’re also saving the economy from a lifetime of future healthcare costs.

Euthanasia on demand, especially for people over 80, would involve lots of cost-saving, and what care could possibly be more preventative than making sure no one ever needs to use health services again?

So that’s just not a useful or really even an honest way to look at things, even if that’s what the studies he references were saying, and I’m not convinced they were, especially when it comes to emergency room visits increasing.

Massachusetts: The implementation of health care reform in Massachusetts was associated with a small but consistent increase in the use of the ED across the state. Whether this was due to the elimination of financial barriers to seeking care in the ED, a persistent shortage in access to primary care for those with insurance, or some other cause is not entirely clear and will need to be addressed in future research.

Oregon: We did not find that Medicaid caused a statistically significant decrease in emergency-department use for any of the conditions we considered; indeed, once again the vast majority of point estimates are positive. We found statistically significant increases in emergency-department use for several specific conditions, including injuries, headaches, and chronic conditions.

ACA overall: We found that total ED use per 1,000 population increased by 2.5 visits more in Medicaid expansion states than in nonexpansion states after 2014. … Among the visit types that could be measured, increases in ED visits were largest for injury-related visits and for states with the largest changes in Medicaid enrollment.

Although Oregon’s increase in ED visits appears to be permanent previous research suggests that the increase in ED visits may be temporary because of pent-up demand. Future research should revisit how ED visits continued to change beyond the first year of implementation in 2014.

‘When people can afford to go to the Emergency Room without bankrupting themselves, they’re more likely to.’ Well, yes, and an increase in people using the Emergency Room still seems entirely consistent with lowering healthcare spending overall because, for a lot of people, their preventive care is going in to get something checked out when it’s really hurting instead of about to kill them.

Indeed, expanding Medicaid meant more people with injuries requiring emergency care actually bothered to go get it.

Carroll dismisses a study that found that all sorts of preventative care would lead to savings in healthcare of ‘only’ $3.7 billion per year in 2006.

But it saves money to accomplish this each year:

What’s more, the increased costs of [investing in an evidence-based package of preventive services] would be recouped. Put differently, more than two million people would have been alive during 2006—or 780 people in a city of 100,000—if preventive care had been widely delivered in prior years, all without an increase in net cost.

‘People healthy enough not to die’ tends to involve cost-savings in the sense that a lot of money has been invested in a given person already in education and job skills. ‘People healthy enough not to be ill for extended periods of time or permanently disabled’ saves money, too. It might save money not to ever change your oil, but a car that no longer runs is considerably less useful as a car.

Somalia doesn’t spend very much on preventative healthcare, and the costs show up in people who are unnecessarily infirmed and need someone else to take care of them instead of engaging in productive economic activity.

Most suspicious is the fact that Carroll went about making his case by focusing on an uptick in emergency room visits and people surviving lung cancer to die of heart disease rather than a more straightforward look at how other OECD nations’ increased availability of preventative care seems to result in people living longer, healthier lives while their governments spend less on healthcare overall.

To be fair, Carroll is making only a soft sort of argument, but I don’t think his links support his claim, that his claim even makes sense on its own terms, or that even if those were valid, that’s the most sensible conclusion.

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