Will insurers avoid the ACA's exchanges?

An insurer can choose not to offer any products in the exchanges--the do nothing scenario... It could also be prudent to stay out of the exchanges for a year or two, and then join and offer products after the dust has settled.  

From a Milliman analysis of "Ten critical considerations for health insurance plans evaluating participation in public exchange markets."  Consideration #10, on why plans might want to stay out of the exchanges, is of particular interest.  It mentions the possibility that the exchanges will attract "a population with unknown, and potentially unfavorable, risk characteristics."  This scenario would likely drive health populations away from the exchanges and lead to adverse selection within the exchange, a big worry for ACA supporters.

The Libertarian Vice

Excellent post from Tyler Cowen about the vices in libertarian philosophy:

The libertarian vice is to assume that the quality of government is fixed.  The libertarian also argues that the quality of government is typically low, and this is usually the bone of contention, but that is not the point I wish to consider.  Often that dispute is a red herring...

But sometimes governments do a pretty good job, even if you like me are generally skeptical of government.  The Finnish government has supported superb architecture.  The Swedes have made a good go at a welfare state.  The Interstate Highway System in the U.S. was a high-return investment.  In the area of foreign policy, we have done a good job juggling the China-Taiwan relationship.  Or how about the Aswan Dam for Egypt?  You might contest these particular examples but I assure you there are many others. 

I think this first sentence describes me very well:

It is possible to agree with the positive claims of libertarians about the virtues of markets but still think that improving the quality of government is the central task before us.  One could love markets yet be some version of a modern liberal rather than a classical liberal.

These posts about the liberal vice and the conservative vice are very good as well.

Numbers of the Week, Demography Edition

Britain is getting more diverse and less religious, via the Economist:
88 - Percentage of British people who described themselves as "white British" in 2001.
81 - Percentage of British people who described themselves as "white British in 2011.
661,000 - Number of British people of mixed identity in 2001.
1,200,000 - Number of British people of mixed identity in 2011.
15 - Percentage of British people who said they have no religion in 2001.
25 - Percentage of British people who said they have no religion in 2011.

From the CIA World Factbook:
91.5 - Percentage of ethnically German people in Germany.
87.4 - Percentage of ethnically Irish people in Ireland.
80.5 - Percentage of ethnically Dutch people in the Netherlands.
91.5 - Percentage of ethnically Han Chinese people in China.

Global population in 2050, via Photius:
397,000,000 - America's projected population in 2050.
1,462,000,000 - China's projected population in 2050.
1,572,000,000 - India's projected population in 2050.
2,181,000,000 - India's projected population in 2050 if Pakistan and Bangladesh were still a part of India.

The state's role in fighting obesity

This issue is well framed by the Economist, as usual:

For those (like this newspaper) who believe that the state should generally keep its nose out of people’s private affairs, obesity presents a quandary. “A millionaire may enjoy breakfasting off orange juice and Ryvita biscuits,” Orwell pointed out; “an unemployed man doesn’t…You want to eat something a little bit tasty.” If people get great pleasure from eating more than is good for them, should they not be allowed to indulge themselves? After all, individuals bear the bulk of the costs of obesity, quite literally. They suffer at work, too: their wages are often lower and, in America, some employers also make fat workers pay more for health insurance.

Yet in most countries the state covers some or most of the costs of health care, so fat people raise costs for everyone. In America, for instance, a recent paper estimated that obesity was responsible for a fifth of the total health-care bill, of which nearly half is paid by the federal government. And there are broader social costs. The Pentagon says that obesity is shrinking its pool of soldiers. Obesity lowers labour productivity. And state intervention is justified where it saves people from great harm at little cost to themselves. Only zealots see seat-belt laws as an affront to personal liberty. Anti-smoking policies, controversial at first, are generally viewed as a success.

And this is a good point about obesity being more than just a matter of personal responsibility:

Obesity is, at its heart, the result of many personal decisions. But the rise of obesity—across many countries and disproportionately among the poor—suggests that becoming fat cannot just be blamed on individual frailty. Millions of people, of all cultures, did not become lazy gluttons at the same time, en masse. Broader forces are at work. The government can try to influence them by discouraging overeating. But how?

And more here, on how, unlike climate change or cigarettes, there is no single big solution to obesity; rather that the state will need to pursue a number of smaller solutions in schools and communities:

Drugs and surgery can help in the most extreme cases. They do not, however, offer a solution to the wider problem. Economists, faced with behaviour they don’t like, tend to favour imposing “sin” taxes. But eating fatty and sugary foods is not a “sin”, even in the fiscal sense, for unlike cigarettes, fatty foods are not uniformly unhealthy. Moreover, since poor people spend a higher proportion of their income on food than rich people do, such a tax would be regressive. It would also be an administrative nightmare, as the fat content of each item of food would have to be measured. Denmark, which imposed a fat tax in 2011, abandoned it after a year.

In the absence of a single big solution to obesity, the state must try many small measures. Governments, some of which already intervene a lot in the first few months of people’s lives, should ensure that parents are warned of the dangers of overfeeding their babies. Schools should serve nutritious lunches, teach children how to eat healthily and give them time to run around. Urban planners should make streets and pavements friendlier to cyclists and pedestrians. Taxing sugary fizzy drinks—which unlike fatty foods have no nutritional value—and limiting the size of the containers in which they can be sold may work. Philadelphia and New York, for example, have implemented a range of such policies, and have seen child-obesity rates dip ever so slightly.

I would say that the article is worth reading throughout, but I suppose I've linked to most of it already.

For what it's worth, I don't think that big solutions to obesity are inherently flawed.  The problem is that humans don't yet understand the areas of weight gain and weight loss well enough to design a policy that strikes at the heart of the obesity epidemic.  We understand on a broad level that there are a number of factors that are correlated with weight gain (lack of exercise, fatty foods, overeating, etc...), and so we try to design policies to reduce these behaviors.  But we don't fully understand, say, the biological process for how people lose weight.

I suspect that once we do understand this, there will be medications or surgeries that will do a better job of fighting obesity than any government policy.  In the meantime, government will probably be reduced to tinkering around the edges, as it has been doing in recent years.

Random Questions: Do people live in Antarctica? What is life like there?

According to a 2001 report from USA Today, there are between 1,000 and 8,000 people on Antarctica at any given time.  The number swells to around 8,000 people during the winter, and drops to about 1,000 for the other three seasons.  There are no cities, as we think of them, but rather people live on stations sponsored by country governments.  The U.S.'s McMurdy Station is the largest station on Antarctica, home to around 1,000 during the peak summer months.

Lonely Planet has more.  There has never been a native population in Antarctica, including today, since the current workers are only temporary residents.  As such, wildlife is still unafraid of people, which sounds pretty amazing.

Well-behaved visitors usually elicit no more than disinterested yawns from seals and penguins focused on rearing their young and evading predators.

Antarctica is governed by an international agreement, the Antarctic Treaty, signed by 46 countries, including the U.S., China, India, Brazil, Argentina, Russia, France, Germany, and the UK.  It is one of the few places on the plant where there has never been a war.

Landing a job there is quite difficult, according to Lonely Planet:

Antarctic workers must submit to a battery of physical and psychological tests – and most important, must possess advanced skills in one or probably several areas. 

One can apply to jobs through the several governments that conduct research there or through a private contractor.  About 600 people are employed in the service sector in jobs ranging from chefs to clerks to hair stylists and physicians, as well as in the trades and construction.

It is possible, though expensive, to visit Antarctica.  In fact, tourism is, by far, the continent's largest industry.  Most visitors arrive by sea, on cruise ships from Ushuaia, Argentina (the capital of Tierra del Fuego).  The cruise ships allow passengers to disembark and wander around landing sites.  Some wealthy people take private yachts.  You can also fly to the interior of Antarctica and take part in a tourism expedition, which might involve penguin watching or cross-country skiilng.  As of a few years ago, these trips cost in the range of $35,000-$60,000/person.

Will a society of millionaires push for better economic policies?

Scott Sumner thinks so:

So if Singapore ends up with a steady state of 25% to 30% millionaires, that steady state will imply that roughly half of all Singaporeans will be millionaires at some time during their lives.

This will make the Singaporean electorate much more “conservative” i.e. anxious to have government policies that preserve wealth.  It will also allow Singapore to get away with a smaller set of social welfare programs, and lower tax rates.  A virtuous circle of growth creating good economic policies, which will create even more growth.

I'm not so sure.  I normally wouldn't question Scott's economic expertise, but this statement seems to fly in the face of most of what I know about public choice economics and creative destruction.  It seems to me that a society of millionaires would push for policies that enshrine the economic status quo.  It is in the economic interest of these millionaires to restrict creative destruction and the resulting economic mobility.  Rather than "a virtuous cycle of growth creating good economic policies, which will create even more growth," I foresee growth eventually creating economic stagnation.  The entrepreneurial may then emigrate to other countries with more dynamic economics, creating a sort of leveling effect.

Novelty in Exercise

Really interesting thought from Henry Abbott at TrueHoop:

And here's a Joakim Noah story that's, amazingly, somewhat related. The story is that Noah has been in incredible shape after training in the offseason with, of all people, big-wave surfer Laird Hamilton. Now here's how that's related: As a runner I have put a ton of trust into the evidence-based insight of Jay Dicharry, who has written a book about running form and the like. I met Dicharry when I interviewed him at SXSW, and at that event he said that he thought one of the best things an athlete could would be to train like ... Laird Hamilton. The main reason he says that is that Hamilton goes to great lengths to put himself through new things, rather than spending all that training time perfecting well-known skills. Hamilton and Dicharry are also both very into working on balance, something that isn't a big part of most workout regimens, but that I've been working on for the past several months and that I believe has made big impact. I'm guessing Joakim would agree.

 This reminds me of the recent studies on deliberate practice, described as:

a constant sense of self-evaluation, of focusing on one’s weaknesses, rather than simply fooling around and playing to one’s strengths. Studies show that practice aimed at remedying weaknesses is a better predictor of expertise than raw number of hours; playing for fun and repeating what you already know is not necessarily the same as efficiently reaching a new level.

Tyler Cowen v. Ben Goldacre

Tyler Cowen reviews Ben Goldacre:

Goldacre’s policy recommendations would in general raise the costs of research and development, although they would  likely improve the accuracy of research results and reduce over-prescription and overuse of drugs.  It is quite possible they would lower the rate of return to pharmaceutical innovation, likely I would say.  These trade-offs are neglected, and, much as I admire many features of this book, I cannot help but, alas with trepidation, call some of its central features “Bad Science.”  Bad Economic Science.  The morality of the narrative and the Platonism of his vision distracts him from presenting the policy trade-offs clearly.

And Goldacre responds (in the comments):

The key argument of the book is that the results of clinical trials should not be withheld from doctors and patients. Industry spokespeople continue to deny that this happens at all, in the face of overwhelming evidence, in a testament to how easy they have found it to evade serious public discussion.

Sharing all trial results would not cost any more money, since the cost in a trial is in conducting it, rather than dissemination. The risk to industry is that doctors and providers of healthcare services would have a clearer picture of the absolute benefits of drugs, and of which is best, or most cost effective. So the downside would perhaps be that drugs might become more like commodities, as purchasers got better information.

I haven't read the book yet (though it's on my shortlist), but, for once, I think Goldacre has a stronger argument than Tyler here.  I'm sure that Goldacre probably could have moderated his tone a little bit, but if his book is, as he says, mostly about calling for greater transparency in pharmaceutical studies, then Tyler's response seems a bit weak.  Tyler basically seems to be saying that pharma companies should not have to publish their studies because they make a lot of money selling mediocre (but often unnecessary) drugs and the profits from these drugs allow them to create more drugs.  This seems akin to saying that it's okay for pharma companies to defraud the public because it's in the greater good.  It also seems to skew the incentives.  If a pharma company can turn a profit with either a mediocre product or a good one, there's not a whole lot of incentive to work extra hard to produce a good product. 

And as for Tyler's criticisms about tone, if your goal is to stir up public sentiment to push for reform, I'm not sure that moderation is the goal.  There is a place for moderate criticism and a place for outrage, and this book may fit the latter.  

Where is the best place to be born in 2013?

A View From The Cave has some thoughts about the Economist's index on where the best country to be born in 2013: 

According to the latest index from The Economist the answer is Switzerland followed by Australia, Norway, Sweden and Denmark. For those of you looking for the United States (16) and Britain (27) in the top ten. 

Of interest: 

Libertarian think tank the Cato Institute released its annual Economic Freedom of the World report which includes an index of countries ranked by economic freedom. It should come as no surprise that the index does not look favorably upon the United Sates who comes in ranked 18th in the world. There are some interesting points of similarity and divergence between the two indices  

Cato's 5 most economically free countries (Hong Kong, Singapore, New Zealand, Switzerland and Austria) are all in the top ten of the Economist's index. However, Mauritus and Bahrain, two nations considered to have high economic freedoms, do not make the list for The Economist. Also, Norway (3) and Sweden (4), are ranked 25 and 30 by the Cato Institute. 

I find that most interesting cases are the former communist countries: 

• Despite more than 30 years of spectacular growth, and more growth projected over the next two decades, China comes in at 49 out of 80, below every South American country other than Ecuador. 
• Despite a stifling lack of economic freedom, Cuba ranks 40th overall, ahead of several South American and Eastern European countries.  
• Russia ranks 71st out of 80, just ahead of Syria and below a number of countries with much lower GDP per capita. 

Will the ACA increase waiting lines for patients?

Brad DeLong has a question on ACA implementation:

What is your guess as to what will happen if the ACA works for access, works for quality, works for coverage--but the extra health-care workforce needed isn't there, and the lines start to get longer?

I have two thoughts: 

First, to answer the question directly: looking at the issue from a market-based standpoint, if his scenario comes true, I think the obvious answer would be that we need to graduate more doctors.  Doctors make a ton of money, meaning that there is probably an undersupply (although there are probably additional reasons) and there are loads of people who would like to be doctors, but can't get into medical school because there are not enough spots.

The problem, in my opinion, is that a lot of healthcare seems supply-sensitive, rather than demand-sensitive.  Which is to say that the more available doctors or hospital beds, the more doctors will prescribe more treatment, despite the fact that a lot of this treatment has very little effect on overall health outcomes.  It's possible that lines will start to get longer as a result of the ACA's provisions on access, quality and coverage, but it's possible that demand-side is a less significant factor than we believe it will be.  If nothing else, the studies on supply-sensitive care suggest that training more doctors would result in a spike in healthcare costs.

A better solution, as my doctor friend Dylan notes, is to expand the Nurse Practitioner workforce: "Non-urgent medical screening can be handled by NPs, and physicians can see sicker patients. Many clinics already do this. There's no reason a doctor has to perform a screening pap-smear for example." 

How to Make Aid Work: Don't give to local-decision-makers

The Economist cites a World Bank report warning that giving aid to local decision-makers is less useful than had been hoped:

Channelling development aid directly to local decision-makers sounds like a good plan. Empowering local groups like community clubs and school boards means decisions can reflect actual needs on the ground. It should mean fewer bureaucratic hands in the pot, too. But a new report by two World Bank economists warns against relying on decisions made at the most local level of government. Entrenched elites, bribery and fraud are as much of a problem in village life as they are in big emerging-market bureaucracies.

Also this:

The first problem is corruption. A study based in Madagascar, for example, found that central government was actually a relatively safe steward of development cash, with more of it siphoned off at local-government levels.

Why did homosexuality evolve?

Really interesting article from the Chronicle about why homosexuality may have evolved, despite being such a seeming weakness from an evolutionary perspective.  

The short answer is that we don't know, but several good theories are presented.  My two favorites are the "sexually antagonistic selection" theory and the "nonadaptive byproduct" theory.  

Here's the sexually antagonistic selection theory: 

What if one or more genes that predispose toward homosexuality (and with it, reduced reproductive output) in one sex actually work in the opposite manner in the other sex? I prefer the phrase "sexuallycomplementary selection": A fitness detriment when genes exist in one sex—say, gay males—could be more than compensated for by a fitness enhancement when they exist in another sex.

Anyone prefer any of the other theories?  I'm skeptical of the group selection and social prestige theories.  It seems like there would have to be a pretty enormous benefit conferred upon one's relatives to offset not having children of one's own.  

Breast cancer screenings

The Lancet reports on the findings of the independent UK Panel on Breast Cancer Screening:

The Panel found that routine breast screening leads to a 20% relative risk reduction compared with no screening. This means for every 235 women invited for screening, one breast cancer death will be prevented, representing 43 breast cancer deaths prevented per 10 000 women aged 50 years invited to screening for the next 20 years.

Additionally, the Panel found that some overdiagnosis occurs. 19% of breast cancers diagnosed in women invited for screening would not have caused any problem if left undiagnosed and untreated (a rate of 129 per 10 000 women). However, owing to the scarcity of reliable data in this area, more research is needed to accurately assess the magnitude of overdiagnosis. The Panel also considered how women feel about the available evidence: many women believe the balance of benefits to risks is worthwhile.

I'm not sure that this is conclusive, as the article's title suggests, but it seems like a strong evidence point in favor of continuing screenings in women 50 and above.

Marijuana Legalization

The New York Times looks at the significance of Colorado and Washington's new marijuana laws:

As soon as the laws are certified, it will be legal under Colorado and Washington law for adults 21 years and older to possess up to an ounce of marijuana. In Colorado, people will be able to grow as many as six plants. In Washington, users will have to buy their marijuana from state-licensed providers.

Bringing marijuana production under the control of state-licensed providers seems incredibly logical, both from a regulatory and a revenue-maximizing standpoint.  It also seems like the best way to reduce the illicit drug trade caused by the "War on Drugs" that has done so much harm in countries like Mexico and Guatemala.  The big question now is whether or not the Obama administration will allow it:

In a statement on Wednesday, a spokesman for the Drug Enforcement Agency said the Justice Department was reviewing the ballot measures and declined to comment directly on how officials would respond to them. But he said the agency’s enforcement of federal drug laws “remains unchanged.” The United States attorneys in Denver and Seattle responded with nearly identical statements, offering no clue on whether they would sue to block the measures from being put into effect.

It is a murky landscape now, one that potentially pits voters who supported President Obama and legalization against the president’s own Justice Department. In 2010, weeks before California voted on an unsuccessful initiative to legalize marijuana, Attorney General Eric H. Holder Jr. announced that authorities would still aggressively prosecute marijuana laws.

It would be a huge disappointment to see the Obama administration continue to enforce drug laws.

On a related note, Alex at MR has linked to a study showing that states with medical marijuana laws have seen  an 8-11 percent decrease in traffic fatalities.  If true, this is a significant development for public health and safety.

 

Links I liked

• Statistical analysis - coming to politics (and health policy?) next 
• How not to write a personal statement 
• The Borat of the Central African Republic
• Development in Bangladesh 

Longevity Project, the power of relationships

According to David Brooks' recent column, the capacity for intimate relationships might be linked not only to life success, but maybe to longer lives as well:

 Body type was useless as a predictor of how the men would fare in life. So was birth order or political affiliation. Even social class had a limited effect. But having a warm childhood was powerful. As George Vaillant, the study director, sums it up in “Triumphs of Experience,” his most recent summary of the research, “It was the capacity for intimate relationships that predicted flourishing in all aspects of these men’s lives.” 

Of the 31 men in the study incapable of establishing intimate bonds, only four are still alive. Of those who were better at forming relationships, more than a third are living.

The right to self-medicate?

Interesting argument presented by Alex at Marginal Revolution about the liberalization of prescription drugs:

Citizens have rights of self-medication for the same reasons that they have rights of informed consent. The prescription drug system has bad consequences and it privileges regulators’ and physicians’ judgements about a patient’s health over the patient’s judgement about her overall well-being. Most troublingly, the prescription drug system violates patients’ rights.

Instead, I propose that prohibitive pharmaceutical policies, which are a kind of strong paternalism, be replaced by nonprohibitive policies that enable patients to obtain whatever medicines they choose while promoting informed consumer choices by making expert advice readily available.

I'm not sure that I disagree with this argument, but I found it a bit shocking how lightly Ms. Flanagan shrugs off concerns over addiction.

Since addicts are autonomous and able to give informed consent for treatment, including their drug of choice, they ought to be given similar authority to access treatment, including their drug of choice. One way to mitigate the potential harm of addictive pharmaceuticals would be to designate some addictive drugs as "behind the counter" and enable addicts who do not wish to use addictive pharmaceuticals to precommit to not using by enrolling in a voluntary programme. 

I don't feel comfortable saying that, "well, there is a study saying that addicts are able to give informed consent; therefore we can dismiss concerns about increased access to highly addictive drugs leading to increased addiction rates."  This brings up an interesting argument about whether public health laws (and other laws, for that matter) should be designed for the lowest common denominator or the highest. I like a lot of libertarian ideas, but the place where the most hardcore libertarian ideas often lose me is when they seek to legislate for the highest common denominator, with little regard for the lowest.

Healthcare - the French system

French NHI is more generous than what a “Medicare for all” system would be like in the United States, and it shares a range of characteristics with which Americans are well acquainted—fee-for-service practice, a public–private mix in the financing and organization of health care services, cost sharing, and supplementary private insurance.

And yet it still costs significantly less than our healthcare system.  One big reason:

The number of nonphysician personnel per bed (in France's hospital system) is higher in public hospitals than in private hospitals; in the aggregate, it is 67% lower than in US hospitals

From the American Journal of Public Health's series comparing health systems.  The article is old, but nevertheless quite interesting.

Healthcare Price Databases

Kaiser reports on the trend in healthcare price databases.  According to the All Payer Claims Database Council's map, there are now nine states with such databases and several others that are on the verge of implementing their own.  

As the Kaiser article discusses, these databases are expected to help reduce some of the wild variations between the cost of different procedures: 

The price of a knee MRI in Colorado varies from $350 to $2,336...

The eight-fold range in MRI prices stands out, as does a four-fold difference in spending per health plan member between nearby counties. It ranges from a low of $1,000 per year in Hinsdale County to a high of just over $4,000 in Pitkin County. 

The databases themselves seem to vary in their degree of user friendliness, and publicizing their existence may be difficult.  Nevertheless, this innovation has the potential to significantly improve the functioning of our healthcare markets.  Ultimately, it may even be of more use than the ACA's much-touted health benefit exchanges.  

Escaping the tyranny of cultural choice

Dorian Lynskey's column on the tyranny of cultural choice rang a bit too true for me:

In the most heartfelt chapter of his book Retromania, the music critic Simon Reynolds admits to a strange nostalgia for the boredom of his youth. "Today's boredom is not hungry, a response to deprivation; it is a loss of cultural appetite, in response to the surfeit of claims on your attention and time." One of the many ways in which technology leaves the human brain gasping to keep up is in its provision of almost limitless choice, because time remains as limited as ever. "Life itself is a scarcity economy," writes Reynolds. "You only have so much time and energy."

Technology has birthed new versions of the bedside pile of books: the neglected links stacking up in my Twitter Favourites column; the high-minded Netflix queue compiled by a tired parent who has somehow mistaken himself for a film-studies undergraduate; the earnest documentaries waiting in silent accusation on my DVR, like an unused gym membership, until the day the device mercifully crashes. At the same time, the digital buffet can erode your ability to commit to one thing at a time. The main reason I don't own a Kindle or iPad is my suspicion that, without the firm anchor of a physical book, I will get restless and float away in a sea of options.

I've spent the past few years tweaking my media consumption so that I can capture all the most interesting knowledge (twitter, instapaper, google reader, evernote, etc...).  A few months ago, I finally got the formula right, to the point that I could now spend all day on the internet and never run out of interesting stuff to read, which is to say that I've gotten a little bit too good at capturing potentially interesting information.  My book list is impossibly long, and catching up with my twitter feed and my google reader often seem more like chores sometimes.  Finding a fun new article seems more exhausting than anything else.  So, after the reading this article, I decided that some new rules are in order.  Some ideas to experiment with over the next few weeks:

• Limit myself to two media consumption sessions per day, one the morning, one in the evening.  During those two sessions, I can check my twitter feed, go through my google reader feed and browse articles from my instapaper, but I'm not allowed to go back in time, so I will accept that anything that I don't feel like reading during those two session was not enough of a priority, and shall be remorselessly x-ed out of my browser.  If there was something that I was truly excited to read, but that I ran out of time for, I can save it to my instapaper.  
• Spend more time on books.  I spend too much time in front of a computer as it is.  Books require more mental discipline; I cannot just sit mindlessly in front of a book.  And they do not require me to sit in front of a computer, a position that is becoming bad for my back.  
• Find a non-computer-based hobby.  A musical instrument seems like the best bet.  
• Be more disciplined.  This, as ever, is probably the greatest struggle.  

Annual checkups and the overconsumption of healthcare

Naomi Freundlich has a terrific post on annual checkups:

It sounds like heresy, but recent evidence challenges the long-held belief that the annual physical is beneficial for healthy adults. Researchers at the Nordic Cochrane Center in Copenhagen wrote last week that although a regular check-up with multiple screening tests might seem to offer the advantage of catching problems like heart disease and cancer early, their review of studies involving some 180,000 adults actually found no benefit. People who had annual check-ups were no less likely to be admitted to the hospital, become disabled or miss work than those who did not have regular physicals. Even more surprising, they were no less likely to die from heart disease, cancer or any other illness.

The study's authors offer a compelling theory for why this might be the case:

In fact, subjecting healthy adults to this yearly battery of tests may do more harm than good. The authors write, “One possible harm from health checks is the diagnosis and treatment of conditions that were not destined to cause symptoms or death. Their diagnosis will, therefore, be superfluous and carry the risk of unnecessary treatment.”

I'm increasingly starting to believe that overconsumption of healthcare is a bigger issue than previously realized.

Looking at the minimal differences in longevity between rich and poor countries only strengthens this theory.  We spend much more on healthcare than many middle-income countries, but receive very similar results in life expectancy.  The U.S. spends $7,000/person on health; Mexico spends $800.  But U.S. life expectancy is only two years longer than Mexico's (78.2 in U.S. versus 76.2 in Mexico).  And that's despite the fact that violence and traffic accidents kills 7% of Mexico's population versus only 3% in the U.S.

Links I liked

Robin Hanson on the impatience of idealism
More from Ta-Nehisi Coates on language learning
Good news
Probably good news

The 70 year theory

Is 70 years about the maximum that one party can stay in power in a given country?  Some intellectuals think it might be:

Hu Xingdou of the Beijing Institute of Technology says it has become common among intellectuals to wonder whether 70 years is about the maximum a single party can remain in power, based on the records set by the Soviet Communist Party and Mexico’s Institutional Revolutionary Party. China’s party will have done 70 years in 2019.

What are the counter-examples?  Should colonialism count?  Royal families?  What makes parties different?  Or is it not that parties are different, but rather this era of history is different?  

ACA Cost Estimates: Rising or Falling?

John Goodman has a misleading post over at his blog, claiming that the Cost for ObamaCare Soar:

When the [Affordable Care Act] passed in June 2010, the Congressional Budget Office projected the budget cost between fiscal 2012 and fiscal 2019 to be $462 billion. By June 2012, the cost for these same years had jumped to $574 billion, an increase of nearly 25 percent.

This is true, but it's very misleading.  CBO's estimates for the ACA's insurance subsidies have indeed increased, but Goodman and the American Action Forum fail to note that the CBO estimates that the overall cost of the ACA's health coverage expansions has dropped.  According to the CBO report, "the net costs of the coverage provisions of the ACA will be $84 billion less over the 2012-20122 period than they estimated in March 2012."

The entire CBO report is here.  

Flaws in the patient-doctor relationship

More excellent insight from John Wennberg's Tracking Medicine, this time on the patient-doctor relationship:

Social scientists had long recognized that the “exchange relationship” between the physician and the patient was radically different from the exchange relationship that determines the demand for other goods and services in most markets. The doctor-patient relationship is different because of the asymmetry of information. The patient, as a layman, does not know what he or she truly needs; it is the physician who knows the nature of the patient’s illness and can select the right treatment. For these reasons, many social scientists thought it was rational for patients to do something they would not dream of doing in most markets—that is, to delegate decision making to the seller of services, the physician, who by virtue of his special knowledge and skill, could act as their “rational agent” in health care purchasing decisions. 

From the patient’s point of view, the agency model was believed to be rational on the basis of several assumptions. First, it was assumed that clinical decision making is grounded in medical science; physicians have evidence-based knowledge to diagnose illness accurately and estimate the risks and benefits for the treatments they prescribe. Second, physicians make accurate judgments concerning the treatments patients want: they choose the treatment the individual patient would prefer, if only they were themselves physicians, and therefore knew the facts and better understood their own “true” wants and needs. This assumption is implicit when a patient says to his or her physician, “What would you do if you were me?” Third, the ethics of professionalism protects the trust that is the basis for the patient’s willingness to delegate decision making to the physician. Despite the fact that the physician benefits financially from higher utilization of his services, professional ethics ensure that he or she will choose what is best for the patient. Finally, egregious behavior by the few unethical physicians who induce patient demand for self-serving motives is detected and controlled through utilization review and other methods the profession adopts to discipline “outlier” behavior.

It seems that all four assumptions are flawed.

1) Medical science is evidence-based, of course, but that evidence is notoriously complex, and oftentimes deeply flawed.
2) Physician-patient communication also has a reputation for being quite poor, with overwhelmed doctors often not having the time to properly discuss options with patients.
3) Professional ethics is probably a fundamentally flawed concept.  I would argue that the concept is important in physician training and education on a micro-level, but that the healthcare system is unwise to rely on this concept on a macro-level scale.
4) And most evidence seems to indicate that our utilization review system is not working.

All that being said, I'm at a loss for solutions on how to change the nature of the patient-doctor relationship.

Theories of entitlement spending

John Goodman has a post on "grand bargains" in which he discusses entitlement reform.  I certainly agree with his analysis that raising tax has historically been easier than cutting entitlement spending, and that this should be a cause for concern.  Of more interest, however, were his positions on entitlement reform, which seemed a bit extreme for me.

Fundamental reform of Medicare and the elderly portion (which is most of the total) of Medicaid needs to proceed in much the same way. Young people need to start saving right now to pay for their health care and their nursing home needs during the years of their retirement. We also need to create more private sector options so that seniors have access to the same kind of health insurance the rest of the nation has access to (a la Paul Ryan).

The Democrats, however, will have none of this. Their idea of Social Security reform is raising the retirement age, reducing the rate of growth of benefits, raising the maximum wage subject to the payroll tax, etc. In other words, they want to tinker around the edges. And while they are perfectly willing to allow increasing the payroll tax on higher-income taxpayers immediately, all the spending reductions must only apply to future retirees, not current ones.

While cutting entitlement spending seems necessary, I prefer the idea of tinkering around the margins, since I support the basic concepts behind them.  Social Security should provide financial security for people who are too old to work or who have outlived their usefulness in the labor force.  Raising the age for Social Security is justified because people live longer and healthier lives than they did when it was originally enacted.  By raising the minimum age, we would be keeping the Social Security closer to the fundamental purpose of the law, tweaking an old law to fit our changed world.

Is Goodman's position--eliminating Medicare almost entirely--the mainstream libertarian position?  Am I misreading his argument?

The island where people forget to die

From the New York Times Magazine, on an island in Greece where people regularly live into their 90s and 100s without heart diseases or dementia:

The researchers followed subjects for an average of six years, measuring their diets, physical activity and how much they napped. They found that occasional napping was associated with a 12 percent reduction in the risk of coronary heart disease, but that regular napping — at least three days weekly — was associated with a 37 percent reduction. She also pointed out a preliminary study of Ikarian men between 65 and 100 that included the fact that 80 percent of them claimed to have sex regularly, and a quarter of that self-reported group said they were doing so with “good duration” and “achievement.”

Also seemingly important: a Mediterranean plant-based diet and a social lifestyle.

Added to my lexicon: Supply-sensitive care

Fascinating sentences from John Wennberg's Tracking Medicine: A Researcher's Quest to Understand Health Care:

Supply-sensitive care is not about a specific treatment per se; rather, it is about the frequency with which everyday medical care is used in treating patients with acute and chronic illnesses. Here I am talking about physician visits; referrals for a consultation, home health care, and imaging exams; and admissions to hospitals, intensive care units (ICUs), and skilled nursing homes... 

This category, which accounts for roughly 60% of Medicare spending, may be difficult to grasp because it runs counter to the widespread belief that medical interventions are driven by explicit medical theories and scientific evidence. Most of us, including most doctors, believe that a physician makes decisions such as when to schedule a patient with diabetes for a follow-up visit, for example, or when to hospitalize a patient with chronic heart failure, or when to call in an infectious disease specialist for a patient with a fever, on the basis of medical science, augmented by some combination of experience and wisdom. As it turns out, medical science is virtually silent on such matters.  

There is another factor that influences such decisions. As Figure 1.3 illustrates and the book will demonstrate, physician decisions regarding supply-sensitive care are strongly influenced by the capacity of the local medical market—the per capita numbers of primary care physicians, medical specialists, and hospital or ICU beds, for example. (In the jargon of economics, the market is in disequilibrium—supply pushes demand or utilization.) This may seem deeply counterintuitive, and the effect of supply on professional behavior by and large goes unrecognized by physicians, who are unaware of the effect that capacity has on their decisions. But in the absence of a constraining professional consensus on best practices, and under the cultural assumption that more care is better care, available resources are used up to the point of their exhaustion.

Only on chapter 2, but this book has been full of eye-opening arguments and data so far.  

More on Prop 37

The LA Times reports that most scientists don't believe that genetically modified crops have negative health effects:

Genetically engineered crops have been extensively studied. Hundreds of papers in academic journals have scrutinized data on the health and environmental impacts of the plants. So have several in-depth analyses by independent panels convened by the National Academy of Sciences.

The reports have broadly concluded that genetically modified plants are not only safe but in many respects friendlier to the environment than nonengineered crops grown via conventional farming methods.

For instance, a review this year of 24 long-term or multigenerational studies found that genetically modified corn, soy, potato, rice and wheat had no ill effects on the rats, cows, mice, quails, chickens, pigs and sheep that ate them. Growth, development, blood, tissue structure, urine chemistry and organ and body weights were normal, according to the report in Food and Chemical Toxicology.

Meanwhile, the positive effects include fewer pesticides, more targeted insect control, fewer toxic chemicals, and less soil erosion.  

Wellness tips

Laugh more; it is a form of exercise:

And in Dr. Dunbar’s experiments, pain thresholds did go up after people watched the funny videos, but not after they viewed the factual documentaries.
The only difference between the two experiences was that in one, people laughed, a physical reaction that the scientists quantified with audio monitors. They could hear their volunteers belly-laughing. Their abdominal muscles were contracting. Their endorphin levels were increasing in response, and both their pain thresholds and their general sense of amiable enjoyment were on the rise.

 And humans are social creatures, so remember to exercise (or laugh) in groups:

Laughter is an intensely infectious activity. In this study, people laughed more readily and lustily when they watched the comic videos as a group than when they watched them individually, and their pain thresholds, concomitantly, rose higher after group viewing.
Something similar may happen when people exercise together, Dr. Dunbar says. In an experiment from 2009, he and his colleagues studied a group of elite Oxford rowers, asking them to work out either on isolated rowing machines, separated from one another in a gym, or on a machine that simulated full, synchronized crew rowing. In that case, the rowers were exerting themselves in synchrony, as a united group.
After they exercised together, the rowers’ pain thresholds — and presumably their endorphin levels — were significantly higher than they had been at the start, but also higher than when they rowed alone.

Hospitals must stay the course on EMRs

NYT has an article about the ups and downs of electronic health records, in which it publicizes many complaints about the transitions:

Dr. Brailer encouraged the beginnings of the switch from paper charts to computers. But in an interview last month, he said: “The current information tools are still difficult to set up. They are hard to use. They fit only parts of what doctors do, and not the rest.”

Long before computers, many hospitals and doctors charged for services in ways that maximized insurance payments. Now critics say electronic records make fraudulent billing all too easy, and suspected abuses are under investigation by the Office of the Inspector General at the Department of Health and Human Services. 

Based on error rates in other industries, the report estimates that if and when electronic health records are fully adopted, they could be linked to at least 60,000 adverse events a year.

This is important information, and it's vital that these problems be addressed, but I don't think it presents an argument for slowing down implementation.  It doesn't make sense to continue with paper charts forever simply because the transition to EMRs will be messy.  The potential gains from this transition are too big, and hospitals are already several years behind the curve on health IT.

Africa Fact of the Day

New funds will pay for so far non-existent infrastructure on a continent with a land mass equivalent to that of China, India, Japan, America, Mexico and Europe combined

And an optimistic take from the Economist.

Prop 37

I think I agree with Tyler Cowen on this issue.  I like Michael Pollan a lot more than Monsanto too, but it is not at all clear what genetically modified crops are and why they need to be labeled.  Aren't all foods genetically modified?  Why is this all of the sudden a bad thing?  How are we defining genetically engineered foods, anyway.  Is there some magic date before which it was okay to modify foods (seedless grapes and watermelons), but after which it became evil?

At least the polls are moving in the right direction.  

The joys of learning a second language

Ta-Nehisi Coates writes about the joys of learning a second language:

And you even start to understand the differences in how you think about the world and how they think about the world. The Frenchmen doesn't so much "wake up" as he "wakes himself up." (Or some such.) I can detect subtle differences in psychology and culture, perceptions of the self, but I'm not yet prepared to analyze. 

This was the best part of learning French -- seeing how the differences in culture manifest themselves through language.  In French, one doesn't say, "you can't do that," but rather, "that is not done." ("ca ne se fait pas").  It's not merely the case that you should not start eating at a BBQ before everyone has been served; no one may do it, it is unthinkable.

4.) The feeling in the brain is itself interesting. My brain will cut on the "French" portion and sometimes I'll start to say something, the thought fully formed, and realize I don't have the words to express it. It's as if I got on a speeding train only to discover that the tracks weren't yet finished. 

When I was learning French, I used to say that speaking was like trying to maneuver through an obstacle course while driving a big clunky bus.  I would try to say something, realize that I didn't have the words, and have to back up and try to find another route through.  The more French I learned the more, the smaller and more agile my car got, so that I could maneuver through previously treacherous sentences with ease.