Image of the Week 2/25/2014

 

 

What does the radiograph show? What condition is associated with these findings?

To Ban or To Tax?

By Michal McDowell

In January 2013, the Massachusetts Congress moved to eliminate the state food products sales tax exemption from candy and soda.[1] In September 2012, the New York City Board of Health voted in favor of Mayor Michael Bloomberg’s ban on sweetened beverages in containers larger than 16 ounces. (However, in March 2013, the regulation was found “arbitrary and capricious” and the case is currently in the appeals process).[2] This paper will 1) compare the public health merits, 2) economic advantages, and 3) personal liberties considerations of taxation versus restrictive regulations.

Massachusetts’ Tax

Public Health Merits

            Massachusetts’ H.2634, which was introduced in January 2013 and had its latest hearing scheduled in September, aims to remove the “essential items” state sales tax exemption from candy and soda. The impetus of the bill is the state’s public health concern regarding obesity. “Half of the people [in Massachusetts] are overweight or obese,” warned the Massachusetts Health Commissioner, Dr. Lauren Smith.[3] Indeed, according to a 2012 report released by the Centers for Disease Control and Prevention (CDC), 59.3% of adults and 14.3% of adolescents were overweight in Massachusetts (23.0% and 10.9% were obese, respectively).[4]

The idea behind tax exemption removal from candy and soda sold in the state is both to send a message to consumers and to deter consumers from purchasing these items. With regard to the messaging, current law defines “soft drinks” as “food products,” and thus exempts these beverages from the Massachusetts sales tax. Supporters of the tax argue that the exemption currently in place supports, and in part subsidizes, these unhealthy options. With regard to the deterrence factor, policymakers hope that highlighting these products as unhealthy, compounded with the increased price, will dissuade consumers from purchasing candy and soda.

Lisa Powell, a professor of public health at the University of Illinois at Chicago said that applying the Massachusetts state sales tax to soda would cut soft drink consumption by 7% or 8%, based on consumption trends in the 35 states that tax soda.[5] Kelly D. Brownell and colleagues also explored sugar-sweetened beverage price elasticity (consumption shifts produced by price) in a New England Journal of Medicine article, explaining that for every 10% increase in soft drink price, there would be a corresponding 8-10% decrease in consumption.[6] In a separate paper, Fletcher notes, “typically imposed beverage taxes are neither large enough nor transparent enough to lead to meaningful behavior change.”[7] Although they may disagree on soft drink elasticity numbers,[8] many experts believe that more tax will lead to less consumption.

In an article published in The Journal of Public Economics, Jason M. Fletcher and colleagues investigated the potential of soft drink taxes to combat rising levels of child and adolescent obesity.[9] The paper concluded that each 1% increase in the soda tax rate correlated with a 0.003-point drop in Body Mass Index (BMI). The authors explain, “the [0].003 points is less than one thousandth of what a borderline obese person would need to lose to become borderline normal weight.”[10] Further, opponents of the tax argue that consumers could substitute another, equally deleterious, tax-exempt beverage in place of soda. This “substitution” would counter any positive health gains achieved by reducing soft drink consumption, as consumption would shift to other equally unhealthy beverages.

Regarding the substitution effect of the tax, the state’s move to reduce consumption of unhealthy beverages could be undermined if Massachusetts only taxes soft drinks, but leaves in place the exemption for fruit drinks, energy drinks, and sports drinks. Powell explained that consumers could simply substitute other untaxed sugary drinks for soda.[11] If people offset soft drink intake by consuming other high-calorie beverages, there would likely be no change in population weight and other health outcomes.

Economic Considerations

With regard to economic advantages of the tax, according to Healthy People / Healthy Economy, a coalition in support of the bill, imposing the Massachusetts 6.25% state sales tax on candy and soft drinks would generate around $53 million in revenue for the state annually.[12] The bill directs this revenue to the Massachusetts Department of Public Health Wellness Fund. School districts would be eligible to apply for competitive grants through the Wellness Fund to increase physical activity within the school day.[13]

Personal Liberties Considerations

The “personal freedoms” consideration adds another level of emotion and subjectivity to the public health debate. Those who argue that the law infringes on personal freedoms consider any tax designed to change behavior (also called a “nudge” in some circles) to be beyond the scope of government. Opponents argue that the move violates personal freedoms, and that individuals should be free to pick and choose their beverage of choice without penalty. This personal freedoms argument is validated by the fact that for those with an overall healthy diet, little evidence shows that modest levels of soft drink consumption prove deleterious to health outcomes.[14] It is only when used in excess that sugary beverages are shown to increase weight, reduce health, and thus wrack up expensive health care use (medical costs for overweight and obesity alone are estimated to be $147 billion, or 9.1% of U.S. health care expenditures, half of which is covered by Medicare and Medicaid).[15] An ideal solution would, some opponents argue, dissuade consumption in excess without penalizing consumers who eat candy and drink soda “in moderation.”

Bloomberg’s Ban

            Last September, the New York City Board of Health approved Mayor Bloomberg’s proposed ban on sodas (not including diet sodas, beverages containing more than 70 percent fruit juice, and alcoholic drinks) larger than 16 ounces. The plans to limit soft drink size have been stalled in the court system since New York Supreme Court Judge Milton Tingling found the law invalid in a March 11, 2013 decision. The fate of the proposal now rests with the state’s Court of Appeals.[16]

Public Health Merits

            Mayor Bloomberg and other supporters of the ban argue that the purpose of the ban is to “save lives.”[17] Indeed, 40% of public elementary school children and 58% of adults in New York City are overweight or obese; the proportion of New York City adults who are obese increased from 18% to 23% between 2002 and 2010.[18] This presents a serious health concern, given that obesity is responsible for as many as 5,800 deaths per year in the city.[19]

Economic Considerations

The public health pros of the ban are obvious: soda is toxic in large amounts, and fuels the growing overweight, obesity, and diabetes epidemics. Absent from this pro list is, of course, the benefit of increased revenue associated with imposing a beverage tax. In addition, opponents of the ban note that the ban would hurt businesses, arguing that it would decrease profit margins for small businesses, and would not ultimately improve anyone’s health.[20]

Personal Liberties Considerations

            With regard to personal liberties, the cons of the ban are similar to those addressed in the Massachusetts tax debate discussion: many opponents find the ban an overreaching of government into the lives of citizens and an infringement on the personal liberties of New Yorkers.

To Ban or to Tax

            Policymakers have many options to address the looming obesity public health crisis, including bans, taxes, other policy levers, or nothing at all. With regard to the public health question, either of the “choice editing” strategies discussed could inure to the benefit of the public’s health if implemented properly. Both the tax and the ban would, in theory, curb consumption of whatever is targeted. The levels of the tax and the contours of the ban must be studied to be sure the desired public health result can be achieved. Considering personal liberties, both tax and ban have the disadvantage of triggering public ire at the government’s (ab)use of its power to tax and regulate consumption. Regarding economics, a tax includes the attractive advantage of generating revenue to fund state public health efforts.

            In order to orchestrate effective implementation of a public health ban or a public tax, government would need to ensure the measure comprehensively avoided loopholes (substitution to other unhealthy options or ways around portion control in the case of the ban). By implementing a comprehensive measure, government would impinge on individual freedoms, especially on the freedom of choice of the poor, in the case of a tax.

            In evaluating taxation, the case of the taxes on cigarettes in the United States is instructive. Tobacco taxation has been one of the most effective population-based strategies for decreasing smoking. The U.S. Congressional Budget Office (CBO) conducted a literature review and concluded that a 10% increase in cigarette prices would, on average, lead youth (under age 18) to reduce their smoking by 5-15% and adults to cut back by 3-7%.[21] A paper published in 2012 analyzed well over 100 studies regarding the impact of tobacco taxes on tobacco use and found that significant increases in taxes are “a highly effective tobacco control strategy and lead to significant improvements in public health.” The paper noted that the positive health impact “is even greater when some of the revenues generated by tobacco tax increases are used to support tobacco control, health promotion and/or other health-related activities and programs.”[22] Of course, the question of correlation and causation remains. Did use of tobacco products decrease directly because of cigarette taxes? Or did an increasing awareness of the harms of smoking come about at same time as cigarette taxes?

            In conclusion, as we have seen in the case of taxes on cigarettes, implementing a tax on candy, soda, and other unhealthy food products could successfully deter consumers from purchasing these items in harmful and/or excessive amounts, but the question of their effect on obesity remains. The 6.25% Massachusetts sales tax is likely not substantial enough to produce a significant deterrent to consumers. The more dramatic the tax, the better results the community will see. In addition, a tax would create a pool of proceeds to further address the public health impacts of obesity and its sequelae: diabetes, heart disease, stroke, arthritis, and some cancers. As policymakers develop and roll out “sin taxes” going forward, researchers must rigorously evaluate these interventions and their repercussions. With further research, taxes and other strategies can be developed into a comprehensive framework that effectively addresses the purchasing behaviors and health outcomes of Massachusetts citizens and New York City dwellers.

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[1] Bill H.2634, An Act to reduce childhood obesity. Available online at: https://malegislature.gov/Bills/188/House/H2634

[2] Wiesnerr, Daniel (Oct. 17, 2013). “New York court to hear Bloomberg’s appeal to restore soda ban.” Reuters. Available online at: http://www.reuters.com/article/2013/10/17/us-nycsodaban-appeal-idUSBRE99G0T620131017

[3] Martha Bebinger, “Mass. Weights Governor’s Plan To Tax Candy and Soda,” Kaiser Healht News. Available online at: http://capsules.kaiserhealthnews.org/index.php/2013/03/mass-weighs-governors-plan-to-tax-candy-and-soda/

[4] “Overweight and Obesity – Massachusetts: State Nutrition, Physical Activity, and Obesity Profile,” Centers for Disease Control. Available online at: http://www.cdc.gov/obesity/stateprograms/fundedstates/pdf/massachusetts-state-profile.pdf

[5] Martha Bebinger, “Mass. Weights Governor’s Plan To Tax Candy and Soda,” Kaiser Healht News. Available online at: http://capsules.kaiserhealthnews.org/index.php/2013/03/mass-weighs-governors-plan-to-tax-candy-and-soda/

[6] Kelly D. Brownell et al., “The Public Healht and Economic Benefits of Taxing Sugar-Sweetened Beverages,” NEJM. Available online at: http://www.nejm.org/doi/full/10.1056/NEJMhpr0905723

[7] Jason M. Fletcher, et al. “Taxing Soft Drinks and Restricting Access to Vending Machines to Curb Child Obesity,” Health Affairs. Available online at: http://content.healthaffairs.org/content/29/5/1059.full

[8] Roland Sturm et al. “Soda Taxes, Soft Drink Consumption, and Children’s Body Mass Index.” Health Affairs. Available online at: http://content.healthaffairs.org/content/early/2010/04/01/hlthaff.2009.0061.full 

[9] Jason M. Fletcher, et al. “The effects of soft drink taxes on child and adolescent consumption and weight outcomes.” Journal of Public Economics. Available online at: http://medicine.yale.edu/labs/fletcher/www/soda.pdf

[10] Sarah Kliff, “Why ban soda when you can tax it?” Washington Post. Available online at: http://www.washingtonpost.com/blogs/wonkblog/post/why-ban-soda-when-you-can-tax-it/2012/06/01/gJQAT27E7U_blog.html

[11] Martha Bebinger, “Mass. Weights Governor’s Plan To Tax Candy and Soda,” Kaiser Health News. Available online at: http://capsules.kaiserhealthnews.org/index.php/2013/03/mass-weighs-governors-plan-to-tax-candy-and-soda/

[12] “House Bill 2634: An Act to Reduce Childhood Obesity, sponsored by Rep. Kay Khan,” Healthy People / Healthy Economy. Available online at: http://bostonfoundation.org/subsites/content.aspx?ID=18728

[13] “House Bill 2634: An Act to Reduce Childhood Obesity, sponsored by Rep. Kay Khan,” Healthy People / Healthy Economy. Available online at: http://bostonfoundation.org/subsites/content.aspx?ID=18728

[14] Jason M. Fletcher, et al. “Taxing Soft Drinks and Restricting Access to Vending Machines to Curb Child Obesity,” Health Affairs. Available online at: http://content.healthaffairs.org/content/29/5/1059.full

[15] Kelly D. Brownell et al., “The Public Health and Economic Benefits of Taxing Sugar-Sweetened Beverages,” NEJM. Available online at: http://www.nejm.org/doi/full/10.1056/NEJMhpr0905723

[16] Michael M. Grynbaum, “New York Soda Ban to Go Before State’s Top Court,” The New York Times. Available online at: http://www.nytimes.com/2013/10/18/nyregion/new-york-soda-ban-to-go-before-states-top-court.html

[17] Daniel Wiessner, “New York court to hear Bloomberg’s appeal to restore soda ban,” Reuters. Available online at: http://www.reuters.com/article/2013/10/17/us-nycsodaban-appeal-idUSBRE99G0T620131017

[18] Susan Kansagra, “Maximum Size for Sugary Drinks: Proposed Amendment of Article 81,” New York City Department of Health and Mental Hygiene. Available online at: http://www.nyc.gov/html/doh/downloads/pdf/boh/max_size_sugary_drinks_BOH.pdf

[19] Susan Kansagra, “Maximum Size for Sugary Drinks: Proposed Amendment of Article 81,” New York City Department of Health and Mental Hygiene. Available online at: http://www.nyc.gov/html/doh/downloads/pdf/boh/max_size_sugary_drinks_BOH.pdf

[20] Douglas Stanglin, “NYC hears pros, cons on banning large sugary drinks.” USA Today. Available online at: http://content.usatoday.com/communities/ondeadline/post/2012/07/nyc-holds-hearing-today-on-banning-large-sugary-drinks/1#.UqItd426kzc

[21] Chuck Marr et al. “Higher Tobacco Taxes Can Improve Health and Raise Revenue,” Center on Budget and Policy Priorities. http://www.cbpp.org/cms/?fa=view&id=3978#_ftn7

[22] Frank J. Chaloupka et al., “Tobacco taxes as a tobacco control strategy,” Tob Control. Available online at: http://tobaccocontrol.bmj.com/content/21/2/172.full

Didactic 2/19/2014

Situational monitoring was the topic of didactic session this past Wednesday, a continuation of the TeamSTEPPS program, which is an evidence-based national initiative to develop teamwork in healthcare professionals.

Situational monitoring involves medical professions at all levels of care, including administration, medical assistants, nurses, doctors, etc. When care providers at all levels engage with patients and aren't afraid to speak up if a situation seems out of the ordinary, patient safety nets are created. It encourages healthcare teams to check-in with each often, to communicate and ask questions when unsure, and to increase accountability within the team.

Some of the students present tonight gave examples of situational monitoring from their own experiences. One talked about doing surgical prerounds early in the morning and discovering a patient had aspirated overnight. The patient was able to be quickly transferred to the ICU. Another talked about an ICU nurse who had talked extensively with a patient and discovered some undocumented medical allergies. She was able to prevent a drug from being given that would have been detrimental to the patient's health.

Our final case of the night centered around a patient with a history of two heart attacks who presented to CCC clinic and was visibly short of breath and uncomfortable in the waiting room. When asked how the team would proceed, students were in agreement about disregarding the regular order of clinic nights and taking the following measures to make sure the patient received prompt care: 1) contacting the attending immediately, 2) evaluating vitals to make sure patient was stable, 3) rushing the patient to the ED if needed.

Some final clinical pearls for risk factors of high-risk patients who present with atypical heart attack signs:

1) diabetic/ patient with hyperlipidemia

2) males, younger than age 70

 Some of these atypical signs may be: abdominal pain, dyspnea, indigestion, and syncope.

-Yun Xue MSII

Image of the Week 2/18/2014

A patient presents with the following bumps on the arm. What disease could cause this condition?

Image of the Week 2/11/2014

A patient presents with pale conjunctiva, pale palms, and reveals that he switched to a strict vegan diet a few years ago. What might be the cause of his pallor?