Why government health policy fails

Austin Frakt links to a qualitative study on why evidence-based policy so often loses out:

I’m pleased to write that an ungated PDF of “‘Developing Good Taste in Evidence’: Facilitators of and Hindrances to Evidence-Informed Health Policymaking in State Government,” by Christopher Jewell and Lisa Bero, is available. Anybody interested in why evidence often fails to penetrate the policymaking process should read it, though it is depressing. Here are some quotes, some of which are from interviews conducted by the authors:

• One official observed that in assessing the effectiveness of a new medical procedure, “I just did exactly what . . . everyone . . . is hoping I’m not. I talked to my brother-in-law and I Googled it.”
• In reference to medical malpractice reform, one official discussed the problem with having a legislature with a large contingent of trial lawyers: “Right now you’ve got a bunch of people who could care less about the evidence unless they can manipulate it. . . . They know where their economic interests are . . . and that will trump any kind of evidence.”
• “And you can always find somebody on the committee that’s had some bad experience and so they’re perfectly willing to tell their story, and then fifteen lobbyists stand up and talk about how different people have been harmed by this sort of legislation. . . . And they aren’t studies . . . the lobbyists even lie . . . I mean they make up stories that don’t exist.”
• An effort to institute a system to use encrypted state health data to analyze variations in medical practice—an issue that does not affect consumers directly—met with significant opposition on the grounds that “even if you don’t identify the individual, you somehow have violated the person because you were looking at the medical record.”
• “If the leadership in your governing body believes that government should have as limited a role as possible in providing health services to your state population, then it doesn’t matter what you say. . . . They don’t care about evidence because they don’t believe that government should have a role in providing health care.”

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.