The consumption of loose tobacco and cigars increased a remarkable 123.1 percent from 2000 to 2011 despite an overall downward trend of tobacco consumption, according to the Centers for Disease Control and Prevention.

Annual cigarette consumption declined each year during 2000–2011, but the amount of loose pipe tobacco sold last year was enough to make 17.5 billion cigarettes, suggesting that certain smokers have switched from traditional cigarettes to other tobacco products in the wake of the 2009 federal law that created tax differences between product types:

This analysis shows that cigarette consumption continues to decline in the United States, a trend that has persisted since the 1960s. However, recent changes in consumption patterns, particularly increases in large cigar and pipe tobacco use, have resulted in a slowing of the decline in consumption of all combustible tobacco, and indicate that certain cigarette smokers have switched to using lower-taxed noncigarette combustible products. Moreover, a 2012 Surgeon General’s report found that youths and young adults had even higher rates of cigar use and simultaneous use of multiple tobacco products.

Tobacco companies have always had a knack for adapting. In the 1950s and 60s, as a wave of new research began to show the harmful effects of smoking, Camel coined the “more doctors smoke camels” refrain to ease consumer fears. According to the report:

Recent analysis of excise tax data for pipe tobacco, roll-your-own cigarette tobacco, small cigars, and large cigars reveals that the tobacco industry is adapting the marketing and production of cigars and roll-your-own tobacco products to minimize federal excise tax and thus reduce these tobacco products’ prices compared with cigarettes. [...] The Government Accountability Office (GAO) recommends modifying federal tobacco taxes to eliminate large tax differentials between roll-your-own and pipe tobacco and small and large cigars. In addition, because Food and Drug Administration (FDA) regulations currently do not apply to cigars and pipe tobacco, these products can be produced with flavoring, can be labeled with misleading descriptors such as “light” or “low tar,” and can be marketed and sold with fewer restrictions than apply to cigarettes.

Marketing a tobacco product as “light” or “mild” is blatantly misleading. Under the 2010 FDA rule, it’s now illegal for the tobacco industry to do so: Marlboro Lights are now “Marlboro Golds” and Camel Lights are “Camel Blue.” As the CDC report notes, though, these regulations do not apply to “roll your own” type products — which are much cheaper than packaged cigarettes but just as deadly. The solution, according to the report, is to increase prices, which “has been one of the most effective ways to reduce tobacco use and prevent youth smoking initiation.”

– Steven Perlberg

Rep. Paul Ryan’s (R-WI) proposals to control health care spending by slashing the federal government’s contribution to Medicare and Medicaid and shifting that spending on to future retirees or the states, has dominated Washington’s conversation about entitlement reform.

But on Thursday morning, a group of health care economists and former Obama administration officials laid out an alternative approach that could achieve health savings by encouraging providers to deliver care more efficiently.

“Mr. Ryan has had too much running room to go out with proposals that neither will reduce overall health care costs nor will help individual beneficiaries simply because there has not been enough of an alternative put forward by those who believe that we really need to focus on the incentives and information for providers,” Peter Orszag, former director of the Office of Management and Budget under President Obama, told ThinkProgress in an interview at the Center for American Progress.

Republicans have offered a plan that would “shift risk on to consumers” rather than examining whether doctors are prescribing the most effective and efficient treatments. “I would challenge Mr. Ryan and others who support a premium support approach to show an analysis done by an objective entity, like the Congressional Budget Office, in which that type of approach reduced overall health care costs.”

The alternative — which Orszag described as a “centrist proposal” that would “keep the basic structure of the current system” while dramatically improving it — would among other changes, promote privately negotiated payment rates between insurers and providers, increase transparency in prices, and reduce the risk of malpractice claims for physicians. Read the full plan here.

The proposals compliment the delivery system reforms and administrative simplifications included in the Affordable Care Act and have attracted bipartisan support in the past. These changes seek to reimburse providers for delivering care more efficiently rather than paying a separate fee for individual services. They “are all very doable,” Orszag said, adding, “If I had to pick out two or three things to do immediately, I would pick the accelerated towards bundled payments and non fee-for-service payment. We already have the structure in place, the challenge is to kind of ramp it up and accelerate it,” he said. “The second thing, which might be a little more controversial, both substantively and politically is to put forward a more agressive medical malpractice reform.”

“When I go out and talk to heath care groups, if you start out with the fact that you acknowledge that whatever the academic literature says, that it would be beneficial if we could provide more clarity to doctors, the conversation changes. And I think it would be beneficial for supporters of the Affordable Care Act to change the conversation in that way,” Orszag claimed.

Rep. Jeff Flake (R), a sixth-term GOP congressman and current Arizona senate candidate, has confirmed he is not among the 82 percent of Americans who think insurance companies should be banned from denying coverage to people with pre-existing conditions.

In fact, during a recent debate on an Arizona NBC affiliate, Flake explained that doing so would end the industry as we know it:

If individuals are allowed to access health care services only when they are sick or injured, there is no reason for anyone to have insurance. If insurance companies are required to accept all pre-existing conditions, insurance is no longer insurance.

Since the Affordable Care Act requires everyone to purchase coverage and prevents people from gaming the system by buying insurance only when they fall ill, insurers can (and have themselves proposed) providing coverage to everyone who applies. As many as 129 million Americans currently suffer from pre-existing health conditions.

Flake is not alone in arguing that insurers can’t help but deny coverage to those who need it. Recently Sen. Ron Johnson (R-WI) told ThinkProgress that businesses should be allowed to deny health insurance to cancer patients, echoing earlier sentiments from Indiana senate candidate Richard Murdock. GOP presidential candidate Rick Santorum made the same argument while hoping to defeat Mitt Romney in the primary.

– Steven Perlberg

While the Affordable Care Act included an array of regulations to lower administrative costs and encourage more efficient delivery of care — and the CBO’s score of the reform law may have undershot its potential to reduce the debt — more can and should be done to lower health care spending. Even with the Obamacare, the nation’s health care spending as a whole is predicted to rise from 18 percent of the economy to 25 percent by 2037.

Since government health care programs like Medicare and Medicaid purchase care from private providers, this will drive up their costs as well — increasing the government’s spending, its debt, and crowding out other programs. To counter the increases, the Center for American Progress has released a report detailing a host of new reform proposals for the government to reduce its own health care costs, as well as encouraging private providers to do the same.

Most of the reforms recommended by Republicans and conservatives control costs by concentrating risk on individuals, and thus price many who need care out of being able to purchase it entirely. But there are alternative reforms which can increase awareness of prices for consumers and encourage insurers and providers to deliver quality care for lower cost. Here are a few the report recommends:

Promote privately negotiated payment rates between insurers and providers: The federal government should award grants to states to encourage programs that bring payers and providers together — along with economists and business and consumer representatives — to self-determine a ceiling on payment rates. The ceiling would limit growth in per capita health spending to the average growth in wages, and would apply to all public and private payers in a given state. This would prevent cost-shifting between public and private payers, and between large and small ones.

Require all state exchanges to actively promote better care at lower cost: Instead of just passively offering any insurance plan that meets the minimal standards, the exchanges should also actively promote better care by awarding bonuses to plans that meet higher measures of quality care and patient experience. These plans would then be highlighted for consumers shopping on the exchanges.

More steps to ensure transparency in prices: In America’s health care market as it stands, consumers almost never receive price information before treatment, even though the cost of services can vary widely in the same area. The state exchanges should collect, audit, and publicly report data on prices and claims. Aetna, a private insurer, and the state of New Hampshire already provides similar information through the internet. Government should also prohibit “gag clauses” in contracts between providers and insurers, which forbid the release of price information to an insurer’s customers.

Expand the use of non-physician providers: Restrictive state laws often prevent non-physician health care workers such as nurses to practice to the full extent of their training, or to practice without physician oversite. This decreases the supply of workers, which reduces competition and drives up costs. The federal government should award bonuses to states to encourage the adoption of more nimble scope-of-practice standards as set down by the Institute of Medicine.

Reduce the risk of malpractice claims for physicians: Fear of malpractice suits can drive physicians to engage in “defensive medicine,” which drives up the cost of care. Unfortunately, the Republicans’ preferred solution of capping damages would have a negligible effect on spending and would limit consumers’ ability to discipline genuine malpractice. Instead, “safe harbor” standards should set — drawing upon health information systems and evidence-based guidelines — which physicians could adhere to and then use as an affirmative defense in the early stages of litigation. This would provide physicians a concrete target to both ensure efficient care and preemptively guard against the risk of lawsuits.

There are six other reforms included in the report, which range from speeding up the use of delivery and payment systems other than the fee-for-service model, to bringing the health insurance plan for federal employees on board with the reforms already scheduled in Medicare and the exchanges.