Medicine

In the major fields of domestic policy responsibility assigned to the new devolved institutions, such as health, education, local government, there have been remarkably few initiatives. A system of local government, reorganised in 1996 on the basis of 32 multi-purpose local authorities and designed by the preceding Conservative UK government, has been largely left untouched. As in England a grossly inadequate system of council tax inherited from the preceding Conservative government and crying out for reform, has been left untouched by the first two Labour/Liberal Democratic administrations and the two successor SNP administrations. And under the latter the system has been shored up by Scottish government funding to facilitate a council tax freeze and containment of local government expenditure.

Or try this:

A 2012 Audit Scotland report has also indicated little change in health inequalities within Scotland in the last decade. Despite avoiding the major structural reorganisations experienced by the NHS in England, and being more generously endowed with public funds, the NHS in Scotland does not seem to have made, under devolution, any fundamental change to the pattern of relatively poor health outcomes. Devolution did not involve much change in the governance of health in Scotland in as much as the ministerial, civil service and medical leadership continued as before but within a new ministerial structure. What was new was the Scottish Parliament and it does not seem to have made much difference.

There is more here, by Norman Bonney, interesting throughout.  The pointer is from www.macrodigest.com.

From Yue Li:

This paper examines the effects of the Affordable Care Act (ACA) by considering a dynamic interaction between extending health insurance coverage and the demand for federal disability insurance. This paper extends the Bewley-Huggett-Aiyagari incomplete markets model by endogenizing health accumulation and disability decisions. The model suggests that the ACA will reduce the fraction of working-age people receiving disability benefits by 1 percentage point. In turn, the changes associated with disability decisions will help fund 47 percent of the ACA’s cost. Last, compared to the ACA, an alternative plan without Medicaid expansion will reduce tax burdens and improve welfare.

The pointer is from the excellent Kevin Lewis.  I have not yet read the piece but thought it of sufficient interest to pass along right away.

There is a new Martin and Pindyck paper on this topic, “Averting Catastrophes: The Strange Economics of Scylla and Charybdis”:

How should we evaluate public policies or projects to avert or reduce the likelihood of a catastrophic event? Examples might include a greenhouse gas abatement policy to avert a climate change catastrophe, investments in vaccine technologies that would help respond to a “mega-virus,” or the construction of levees to avert major flooding. A policy to avert a particular catastrophe considered in isolation might be evaluated in a cost-bene fit framework. But because society faces multiple potential catastrophes, simple cost-bene fit analysis breaks down: Even if the benefi t of averting each one exceeds the cost, we should not avert all of them. We explore the policy interdependence of catastrophic events, and show that considering these events in isolation can lead to policies that are far from optimal. We develop a rule for determining which events should be averted and which should not.

The ungated version is here, I do not at the moment see the link to the gated NBER version I printed out and read.  The main point is simply that the shadow price of all these small anti-catastrophe investments goes up, the more of them we do, and thus we cannot do them all, even if every single investment appears to make sense on its own terms.

I think of this paper as providing a framework for assessing the debates between modern Progressives and pessimistic old school conservatives (not exactly the main debate we are seeing today by the way).  The Progressive states “here is a potential or real catastrophe, let us fix it.”  The pessimistic conservative says in response “there are far greater and less visible catastrophic dangers.  We need to address those instead.”  The pessimistic conservative usually is ignored, and so at the relevant margin it appears the Progressive is correct.  Maybe in a sense the Progressive really is correct.  But in another, more systemic sense the Progressive is walking a dangerous path.  Society is losing the resources it may need to avert the more catastrophic catastrophes.

For the pessimistic conservative of course these often involve foreign policy threats, or they may involve “barbarism” more generally.  I find also that pandemics are popular causes of concern with pessimistic conservatives.

Each time one of these Progressive remedies is adopted, the calculus looks even worse for the pessimistic conservative, as there are fewer resources left to address his causes for concern.  Yet the danger of which the pessimistic conservative warns is greater each time, the longer we ignore it, and the more we devote our resources to other endeavors.

It is an interesting question whether optimistic libertarians or pessimistic conservatives have better (as opposed to more persuasive) arguments against Progressives.  The optimistic libertarian can try “we have a better way of solving this problem!”  The pessimistic conservative is still believing “we must neglect this issue so we can prepare for the even greater doom which may await us.”  The Progressive prefers to argue from general grounds of benevolence, rather than debating which potential catastrophes to confront and neglect, and thus a quest for “free lunch” arguments ensues.

Some sophisticated Progressives may think they are in fact the best friends of the pessimistic conservatives.  They may think the choice under consideration is not “which catastrophe to address?” but rather how we can build up our overall willingness to invest in preventing catastrophes.  In this sense the Progressive may be presenting a valuable warm-up exercise, a bit like flexing the muscles for later combat.  Imagine for instance if ACA were to also later help us monitor and confront a pandemic.  Or if it gave us the political will to make other, later sacrifices.  In that case Progressivism could well be right but only as the handmaiden of pessimistic conservatism and the Progressives would become the true Straussians, achieving one view under the guise of another.

There is a new NBER Working paper on that topic, by Mark Pauly, Scott Harrington, and Mark Leive, here is the abstract:

This paper provides estimates of the changes in premiums, average or expected out of pocket payments, and the sum of premiums and out of pocket payments (total expected price) for a sample of consumers who bought individual insurance in 2010 to 2012, comparing total expected prices before the Affordable Care Act with estimates of total expected prices if they were to purchase silver or bronze coverage after reform, before the effects of any premium subsidies. We provide comparisons for purchasers of self only coverage in California and in 23 states with minimal prior state premium regulation before the ACA now using federally managed exchanges. Using data from the Current Population Survey, we find that the average prices increased by 14 to 28 percent, with similar changes in California and the federal exchange states; we attribute the increase primarily to higher premiums in exchanges associated with insurer expectations of a higher risk population being enrolled. The increase in total expected price is similar for age-gender population subgroups except for a larger than average increases for older women. A welfare calculation of the change in risk premium associated with moving from coverage that prevailed before reform to bronze or silver coverage finds small changes.

You will find an ungated version here.  The general point is that you hear enormous amounts of talk, including from economists, about what a success ACA has been.  This talk does not in general consider trade-offs or welfare calculations, as could be illustrated by these results.

Staff members at dozens of Department of Veterans Affairs hospitals across the country have objected for years to falsified patient appointment schedules and other improper practices, only to be rebuffed, disciplined or even fired after speaking up, according to interviews with current and former staff members and internal documents.

An intrinsic problem with government bureaucracy, or just the result of having the wrong people in charge?  I say the former.  The story is here.

Mr. Econotarian wrote:

Actual science is that your brain can be gendered during development in a different fashion than your sex chromosomes. And that gender is not something that hormones alone can “fix”.

For example, the forceps minor (part of the corpus callosum, a mass of fibers that connect the brain’s two hemispheres) – among nontranssexuals, the forceps minor of males contains parallel nerve fibers of higher density than in females. But the density in female-to-male transsexuals is equivalent to that in typical males.

As another example, the hypothalamus, a hormone-producing part of the brain, is activated in nontranssexual men by the scent of estrogen, but in women—and male-to-female transsexuals—by the scent of androgens, male-associated hormones.

I would stress a social point.  If it turns out you are born “different” in these ways (I’m not even sure what are the right words to use to cover all the relevant cases), what is the chance that your social structure will be supportive?  Or will you feel tortured, mocked, and out of place?  Might you even face forced institutionalization, as McCloskey was threatened with?  Most likely things will not go so well for you, even in an America of 2014 which is far more tolerant overall than in times past, including on gay issues.  Current attitudes toward transsexuals and other related groups remain a great shame.  A simple question is how many teenagers have been miserable or even committed suicide or have had parts of their lives ruined because they were born different in these ways and did not find the right support structures early on or perhaps ever.  And if you are mocking individuals for their differences in this regard, as some of you did in the comments thread, I will agree with Barkley Rosser’s response: “Some of you people really need to rethink who you are.  Seriously.”

Some of you people really need to rethink who you are. Seriously. – See more at: http://marginalrevolution.com/marginalrevolution/2014/06/what-do-i-think-of-david-brat.html#comments

It’s not just the libertarian argument that you have — to put it bluntly — the “right to cut off your dick” (though you do).  It’s that there are some very particular circles of humanity, revolving around transsexuality, cross-gender, and related notions, which deserve a culture of respect, above and beyond mere legal tolerance.

India is not the paradise for cross- and multiple-gender individuals that it is sometimes made out to be, but still we could learn a good deal from them on these issues.  If nothing else, the argument from ignorance ought to weigh heavily here: there is plenty about these categories which we as a scientific community do not understand, and which you and I as individuals probably understand even less.  So in the meantime should we not extend maximum tolerance for individuals whose lives are in some manner different?

No, I do not know what are the appropriate set of public policies for when children should receive treatment, if they consistently express a desire to change, and what are the relative limits of family and state in these matters.  But if we start with tolerance and acceptance, and encourage a culture of respect for transsexualism, we are more likely to come up with the right policy answers, and also to minimize the damage if in the meantime we cannot quite figure out when to do what.

It seems maybe so, from a new paper by Judith Aldridge and David Décary-Hétu, the abstract is this:

The online cryptomarket Silk Road has been oft-characterised as an ‘eBay for drugs’ with customers drug consumers making personal use-sized purchases. Our research demonstrates that this was not the case. Using a bespoke web crawler, we downloaded all drugs listings on Silk Road in September 2013. We found that a substantial proportion of transactions on Silk Road are best characterised as ‘business-to-business’, with sales in quantities and at prices typical of purchases made by drug dealers sourcing stock. High price-quantity sales generated between 31-45% of revenue, making sales to drug dealers the key Silk Road drugs business. As such, Silk Road was what we refer to as a transformative, as opposed to incremental, criminal innovation. With the key Silk Road customers actually drug dealers sourcing stock for local street operations, we were witnessing a new breed of retail drug dealer, equipped with a technological subcultural capital skill set for sourcing stock. Sales on Silk Road increased from an estimate of $14.4 million in mid 2012 to $89.7 million by our calculations. This is a more than 600% increase in just over a year, demonstrating the demand for this kind of illicit online marketplace. With Silk Road functioning to considerable degree at the wholesale/broker market level, its virtual location should reduce violence, intimidation and territorialism. Results are discussed in terms of the opportunities cryptomarkets provide for criminologists, who have thus far been reluctant to step outside of social surveys and administrative data to access the world of ‘webometric’ and ‘big data’.

Here is a write-up in Wired.  For the pointer I thank Andrea Castillo.

Currently health care is very expensive in the United States, especially if you have to buy hospital care without formal insurance.  Under ideal institutions, it would be much cheaper, maybe a third of the current price or lower yet (not for everything, though).  For instance in Singapore health care expenditures are about four percent of gdp.  A libertarian may think that laissez-faire or near laissez-faire is the way to go, while others might favor single payer with price controls, and so on.  In any case, in the meantime we are stuck with expensive health care, and for reasons related to bad and coercive government policy.

Now, would a libertarian think that we should cut health care services in prisons, simply because tax dollars are in play?  No, the prisoners — many of whom are morally innocent — have nowhere else to go for treatment.  When it comes to health care, many potential Medicaid recipients are in essence prisoners, locked into a policy-deficient environment and so they cannot buy quality care at affordable prices.  So if we favor health care expenditures for prisoners we might also favor Medicaid expansions.

That said, expanding the current version of Medicaid is unlikely to be a first-best solution, no matter what your broader political stance.

Addendum: Jacob Levy offers comment.

In response [to the rise of diagnostic algorithms], NNU [National Nurses United] has launched a major campaign featuring radio ads from coast to coast, video, social media, legislation, rallies, and a call to the public to act, with a simple theme – “when it matters most, insist on a registered nurse.”  The ads were created by North Woods Advertising and produced by Fortaleza Films/Los Angeles.  Additional background can be found at http://www.insistonanrn.org.

Here is the link.  Here is an MP3 of the ad.  Remarkable, do give it a listen.  It has numerous excellent lines such as “Algorithms are simple mathematical formulas that nobody understands.”

For the pointer I thank Eric Jonas.

Yaoming

Former NBA star Yao Ming is being sued by Beijing resident Feng Changshun for endorsing a health food product that Feng said misleads consumers, in one of the first consumer rights cases involving a celebrity since a new protection law was enacted in March.

Feng is suing Baxsun Pharmacy, a retail chain in Beijing, for exaggerating the benefits of its fish oil capsules.

Yao, a spokesman for the product, is also being sued. Beijing’s Xicheng district court has confirmed that it will hear the case.

Feng said he is seeking 500 yuan ($80.10) in compensation from the retail chain and 0.01 yuan from Yao Ming.

“(The lawsuit) is symbolic. I want (Yao Ming) to admit to infringements of my rights,” he said.

You can read more here.

Black males, overall.  Abigail K. Wozniak has a new NBER paper on this topic:

Nearly half of U.S. employers test job applicants and workers for drugs. A common assumption is that the rise of drug testing must have had negative consequences for black employment. However, the rise of employer drug testing may have benefited African-Americans by enabling non-using blacks to prove their status to employers. I use variation in the timing and nature of drug testing regulation to identify the impacts of testing on black hiring. Black employment in the testing sector is suppressed in the absence of testing, a finding which is consistent with ex ante discrimination on the basis of drug use perceptions. Adoption of pro-testing legislation increases black employment in the testing sector by 7-30% and relative wages by 1.4-13.0%, with the largest shifts among low skilled black men. Results further suggest that employers substitute white women for blacks in the absence of testing.

There is an earlier ungated version here.

*A Nation in Pain*

by on May 12, 2014 at 3:40 am in Medicine, Philosophy, Uncategorized | Permalink

The author is Judy Foreman and the subtitle of this excellent book is Healing our Biggest Health Problem.  Here is one excerpt:

In those not-so-old days when Jeffrey was born, as a preemie, many doctors mistakenly believed that babies’ nervous systems were too immature to process pain and that, therefore, babies didn’t feel pain at all.  Or, doctors rationalized, if babies did somehow feel pain, it was no big deal because they probably wouldn’t remember it.  Besides, since nobody knew for sure how dangerous anesthesia drugs might be in tiny babies, doctors figured that if surgery was necessary to save a child’s life, they’d better operate anyway — and comfort themselves with the hope that the child wouldn’t feel pain.  As one scientific paper from those days intoned, “Pediatric patients seldom need medication for relief of pain.  They tolerate discomfort well,”

That’s preposterous, obviously.  But doctors had to have these self-protective beliefs for their own emotional survival, says Neil Schechter, a pediatric pain physician at Children’s Hospital in Boston. “Doctors were not sure how to do anesthesia in babies.  In response, they had to believe  that the babies couldn’t feel pain.  They were too scared of the anesthetics.”

Here is part of the Amazon summary:

Out of 238 million American adults, 100 million live in chronic pain. And yet the press has paid more attention to the abuses of pain medications than the astoundingly widespread condition they are intended to treat. Ethically, the failure to manage pain better is tantamount to torture. When chronic pain is inadequately treated, it undermines the body and mind. Indeed, the risk of suicide for people in chronic pain is twice that of other people. Far more than just a symptom, writes author Judy Foreman, chronic pain can be a disease in its own right — the biggest health problem facing America today.

This book will make my best of the year list.

In the middle of nowhere on the outskirts of Hongcheon, 58 miles northeast of Seoul, Kwon Yong-seok runs “Prison Inside Me,” a stress-reduction center with a penal theme. A meditation building, auditorium and management center sit on a 2-acre piece of land.

It is like this:

In June last year, the construction of the prison-like spiritual house was completed. It took a year and cost Mr. Kwon and his wife Roh Ji-hyang, head of a theater company, 2 billion won, or $19 million. Parts of the cost were covered by donations and loans from friends and relatives. Mr. Kwon says the goal of the facility, which has 28 solitary confinement cells, isn’t to make a profit.

On top of private meditation sessions, paying guests are helped to reflect on their lives and learn how to free themselves from what Mr. Kwon calls the “inner prison,” through meditation, spiritual classes and “healing” plays in a group session in the auditorium. A two-night stay costs 150,000 won or about $146.

But it may not succeed:

So far, it hasn’t been as easy for the couple to run the place as they had envisioned. They had to cut the length of stays to as little as two days because people aren’t willing to, or simply can’t, take time off. Also the facility had to make another big concession to modernity—allowing guests to check their smartphones at least once a day.

The full story is here, and for the pointer I thank Ben Smeal.

1. Here is Timothy Lee on the Comcast merger.

2. Will Obamacare help you live longer?  This result seems too rapid and too large to be attributable to improved access to health care, and out of line with other more general (non-policy) estimates.

Still, many people are touting this result.  In any case we are committed to providing you with a broad range of perspectives, including those contrary to our own, so do read these.  I am in the midst of travel and will not have a chance to read the health care study for a while.

Why Vampires Live So Long

by on May 5, 2014 at 1:18 pm in Law, Medicine, Science | Permalink

NYTimes: Two teams of scientists published studies on Sunday showing that blood from young mice reverses aging in old mice, rejuvenating their muscles and brains. As ghoulish as the research may sound, experts said that it could lead to treatments for disorders like Alzheimer’s disease and heart disease.

wallpaper-true-blood-bottle-1600The key papers are here and here and here. Some of the papers are pointing to a specific protein but the last paper suggests that simple transfusions also work and that raises a number of issues of public policy. As Derek Lowe notes:

Since blood plasma is given uncounted thousands of times a day in every medical center in the country, this route should have a pretty easy time of it from the FDA. But I’d guess that Alkahest is still going to have to identify specific aging-related disease states for its trials, because aging, just by itself, has no regulatory framework for treatment, since it’s not considered a disease per se.

…You also have to wonder what something like this would do to the current model of blood donation and banking, if it turns out that plasma from an 18-year-old is worth a great deal more than plasma from a fifty-year-old. I hope that the folks at the Red Cross are keeping up with the literature.