New health studies professor smokes out tobacco wars, health reform

Willard Manning isn't out to win popularity in the raging tobacco wars. The anti-tobacco lobby doesn't like his assertion that cigarette taxes aren't really necessary. Tobaccoists, meanwhile, aren't thrilled that his "it's-a-wash" reasoning hinges on the premature mortality of smokers. His theory: Although smokers may contribute to higher medical and insurance costs while living, they "pay back" society when they die because most don't live long enough to cash in their pensions or take advantage of subsidized nursing-home care. When he and his colleagues first took on this issue in a 1989 study published in the Journal of the American Medical Association, Manning says, he was motivated not by politics but by an economist's curiosity.

Manning, 52, joined the U of C last November as a professor in health studies in the Pritzker School of Medicine and the Irving B. Harris Graduate School of Public Policy Studies. In his new posts, he continues to indulge his curiosity about what influences Americans' health-care decisions, delving further into the costs of poor health habits like smoking and exploring health-care financing issues, another contentious arena he has entered, however unintentionally.

Previously the director of graduate studies in health services at the University of Minnesota, Manning earned his Ph.D. in economics from Stanford in 1973 and then joined Harvard with appointments in the School of Public Health and the John F. Kennedy School of Government. But it was as a senior economist for the RAND Corporation in Santa Monica, California, from 1975 to 1988, that he made his mark as a lead researcher on RAND's Health Insurance Experiment, one of the largest federally funded social research projects ever conducted. For nearly a decade, the HIE team of some 30 researchers gauged how different insurance arrangements affected the health of 7,700 patients and their use of health-care services. For Manning, the ambitious project was "the chance of a lifetime." The team ultimately determined that patients tend to use more services the less they have to pay out-of-pocket, even though using more services does not typically affect overall health. The team's findings-and its reams of health-insurance data-steered insurers to the use of deductibles and copayments and continue to influence debates on health reform.

Later, Manning took up smoking research, challenged by a lunchtime debate with colleagues over whether they could better document the habit's costs than a rival Canadian team. Joking that he's "into vice," Manning says he is now looking at whether cigarette taxes play into teens' decisions to start smoking; whether price affects how much alcohol people drink; and if there's any connection between how much alcohol people drink and their status in the labor market.

Manning has also crunched a lot of numbers related to services for the mentally ill, whom he calls a "vulnerable population too often treated as second-class citizens." Since 1991, he and other researchers from the Universities of Minnesota and Utah have been comparing the experiences of schizophrenic patients in Utah's new Medicaid managed-care program for mental-health services to those still in its traditional Medicaid program, which does not rely on the cost-containment policies of managed care. In an initial report sent last year to federal health regulators, Manning says, the team concluded that patients under managed care have not done as well as those in the traditional program. The researchers are still studying the cause of the disparity, which Manning speculates is the result of less care or less timely care. In the coming academic year, he hopes to get some related projects rolling on the effectiveness of existing treatment models for depression; the financing of mental-health services for children; and whether many people who qualify for disability remain employed. "It's not like we're going to run out of issues studying the organization and financing of health care," he notes.

As for whether any health-care legislation will come out of Washington this year, Manning doubts that major structural reforms are possible given the spread of special interests. He chalks up the recent debates over the rights of managed-care enrollees to election-year posturing. However, he does see a place for the curious academic in Capitol Hill debates. "So much of what goes on is based on anecdotes," he says, "whereas in research we can actually evaluate and assess whether programs work and do what their proponents claim."-C.S.