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.