13.2.07

by the numbers: the “wal-mart law”

the day before governor o’malley’s inauguration, the fourth circuit struck down the “fair share act,” which would have forced all employers with 10,000 or more maryland employees to spend at least 8% of their payroll on health insurance.

the act is also known, affectionately, as the “wal-mart law,” because its namesake comprises one-half of the companies it covers (which – if you didn’t catch that – number all of two). that, and everyone hates wal-mart.

our new governor has taken up a firm “waffle” position, his spokesman going only so far as to say, “we continue to believe that fairness is critical to making health care more affordable.” attorney general doug gansler has until april to appeal the decision, and my bet is that he’ll ride it for all its worth.

the act’s momentum owes itself to the popular sentiment that wal-mart is in some sense “at fault” for swelling medicaid rolls, because it “forces” employees onto subsidized health insurance, foisting insurance costs onto taxpayers.

but consider this: if our legislature suddenly decided to give everyone $100,000 a year, would you really blame employers for cutting salaries across the board? of course you wouldn’t – but that’s precisely what’s happening, here. our government is giving away health care, and yet it’s somehow the employer’s fault for not buying something that’s free.

you have to understand that benefits like health insurance are just a slice of the compensation pie that employees could cash out, if given the option. let’s say wal-mart is willing to pay someone $20,000 annually. it would then be equally willing to foot the bill for $5,000 of insurance and pay $15,000 in cash. but when paying that much for insurance, it would be crazy to pay anything more than $15,000 in cash, since that would bust the $20,000 cap. wal-mart’s only decision is how to divide the $20,000 pie, and if it can get a good deal on insurance, it will offer it because it can cut labor costs and increase profits.

the underlying problem at work, here, is that medicaid is a good deal, even when a better healthcare plan is available. let’s say wal-mart offers a plan worth $5,000, whereas medicaid is only worth $3,000. the employee will nevertheless want to take medicaid’s $3,000 and pocket the $5,000 in healthcare “savings.” and since the cost is no longer coming out of wal-mart’s pocket, it can pay out the full $20,000, bringing the employee’s total compensation to $23,000 of cash plus medicaid, rather than the $20,000 salary that includes private healthcare. the same holds true even if the group policy has cheaper rates – which it probably would – simply because it has rates, whereas medicaid is always free.

things work the same way when we zoom out. wal-mart may be willing to spend $1 million on payroll for all employees, who will then receive $150,000 in medicaid. all the “fair share act” would do – by forcing healthcare spending up to 8% – is reduce wages to $926,000 and benefits to $74,000. and even if there is a minimum wage, the act would just cause wal-mart to switch away from investments in labor, to investments that replace labor with robots.

leaving its employees on medicaid is just wal-mart doing what it does best – finding a cheaper product and passing on the savings.

so what’s really great about the “fair share act” is that it actually makes poor people poorer, by putting tax dollars back in your pockets and forcing them to buy health insurance they don’t want.

who saw that one coming?

1 comment:

Anonymous said...

I had an exceptionally well-rounded and fascinating oncologist give a lecture in a pathology class a couple days ago, his name is John Marshall. The reason I appreciated his talk is not only due to the amount of scientific information he presented but because of his understanding of Economics (he’s actually friends with Ken and Ursula Reitz, if you don’t know who they are http://www.360advantage.com/About360_rietz.php , Ken is friends with Manley, and several months ago before I meet Dr Marshall Ken promised me a dinner date with him because he’s at Georgetown and he’s fascinating)

I digress; he presented to us the adjuvant therapeutic treatment which would be given to a Stage II node negative colon cancer patient. I will expand on his ideas.

Ok, so let’s pause for some background information:

Colon Anatomy:
The colon has three main layers:
1. Inner layer made up of the epithelium, connective tissue, a little bit of muscle (herein referred as Mucosa for simplicity)
1a. Submucosa
2. Muscle Layer
3. Colon Wall

Staging Review:

*For reference - The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. (5SR)


Stage 0:
The cancer is in the earliest stage. It has not grown beyond the inner layer (mucosa) of the colon or rectum. It is very superficial, all you would do for this is excision. Survival rates are almost 100%, and scientists, including myself, don’t really consider this “cancer”.

Stage I:
The cancer has grown through the Mucosa into the submucosa, but has not passed the muscle or outer layers nor spread into nearby lymph nodes or distant sites. 5SR = 93%
.
Stage II
The cancer has grown through the wall of the colon or rectum into other nearby tissues or organs. It has not yet spread to the nearby lymph nodes or distant sites. 5SR = 70–80%

Stage III:
The cancer has grown through the wall of the colon or rectum or into other nearby tissues or organs and has spread to 1-3 nearby lymph nodes but not distant sites. 5SR = 44–64%

Stage IV:
The cancer but has spread to distant sites such as the liver, lung, peritoneum (the membrane lining the abdominal cavity), or ovary. 5SR = 8%

Now the facts:

A stage II patient after wide surgical resection will be treated with—a mix of three types of systemic/regional agents type 1 and 2 are chemotherapy drugs that kill any actively dividing cell and type 3 is a targeted therapy (i.e. antibodies) to specific proteins (some of the drugs: 5-FU, leucovorin, oxaliplatin, avastic, cetuximab)

The overall survival rate for stage II patients after surgery alone ranges from 70%–80%

The potential value of adjuvant therapy for patients with stage II colon cancer is very controversial since evidence is inconsistent that adjuvant 5-fluorouracil (5-FU)-based chemotherapy is associated with an improved overall survival compared to surgery alone. The value of therapy in increasing survival for stage III and above is well documented and the case is very different than stage II.

One month of treatment with different combinations of the drugs I described above costs 25,000 dollars, yes that is 25 thousand, you read it right. And patients are treated for 6 months.

Now to the economics and healthcare issue:

You already know the reasons for high drug prices and the roles that the health insurance industry, government subsidized drug purchases, public misconception, and drug companies play in keeping those prices high. So I won’t discuss that.

As you also know, patients don’t pay the $25K a month for their treatment, and due the unrealistic and pragmatic world that is created when you get something for free; you are not forced to weight the real value of your therapy.

Dr Marshall put it in words similar to these, “If you told me that after surgery 20% of patients die from this cancer within 5 years but 70% survive, and that you couldn’t tell me for certain that I would benefit from adjuvant therapy (because science is not quite advanced enough to do individualized cancer genetic profiles for response to drugs ) and in addition, the adjuvant therapy would cost me 25k a month for 6 months—I would decide that my cash savings of $200k for my kids’ college tuition are not worth giving up for a small uncertain increase chance in survival.”

Great example isn’t it? Of the consequences of removing the perception of real cost in personal choice.