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.