Medicine

“This study finds total marijuana demand to be much larger than previously estimated,” Colorado’s study concluded.

And this, which I think suggests the laws in other states are binding for many consumers:

Colorado concluded that visitors account for 44 percent of recreational marijuana retail sales in the Denver area. In the mountains and other vacation spots, visitors to Colorado account for 90 percent of recreational dispensary traffic.

And this, which sounds tautologous, but is not:

“Heavy users consume marijuana much more often, and more intensely, than other consumers,” the study concluded.

Overall heavy users seem to account for about seventy percent of total demand.  Here is some detail:

Colorado’s market numbers bore out survey estimates that most marijuana is consumed by heavy daily users. For example, survey authors estimated that a third of all Colorado’s pot consumers use the drug less than once a month. But that group accounts for just 0.3 percent of the total market, analysts concluded.

The full story is here, the study itself is here.  For the pointer I thank C., who I believe is not part of that seventy percent of market demand.

Sentences to ponder

by on July 10, 2014 at 10:54 am in Games, Medicine | Permalink

Countless times, I have found that it is only during the physical exam that patients reveal what is truly on their mind. Whether it is the cough that they are reminded of now that I am listening to their lungs, or whether it is the domestic violence, the eating disorder or the genital symptoms that they feel comfortable revealing once we are in a more intimate setting — there is something about touch that changes the dynamic.

That is from Danielle Ofri’s interesting piece on the physical exam in medicine, via Jeffrey Flier.

As wearable health monitors become more sophisticated, some companies, rather than sending their CEO to a public hospital for a check-up twice a year, may choose to monitor them remotely. What is good enough for high-performance teams of athletes could come to be seen as essential for executives looking for an edge over rivals.

Shared data will then become tradeable insider information, as Mr Benioff pointed out. The answer to Mr Dell’s query was that Mr Benioff had had a cold and decided to skip his workout. But imagine if, instead, the interruption to his regime had signalled to his network of high-powered friends and investors that he had suffered a stroke.

That is from Andrew Hill at the FT, there is more here, interesting (but gated?) throughout.

As health data become increasingly digital and the use of electronic health records booms, thieves see patient records in a vulnerable health care system as attractive bait, according to experts interviewed by POLITICO. On the black market, a full identity profile contained in a single record can bring as much as $500.

There is more here, none of it reassuring.

Very good sentences

by on June 30, 2014 at 2:16 pm in Data Source, Economics, Medicine | Permalink

If savings for cross-sectional out-of-pocket nursing home expense risk were held in the form of vehicles, it is large enough to account for the entire stock of transportation equipment in the United States.

That prize goes to Karen A. Kopecky and Tatyana Koreshkova.  That paper was just published in American Economic Journal: Macroeconomics as well.

…my reading of the available evidence convinces me that a social policy that channels benefits through work and thereby encourages paid employment has important advantages over a UBI [universal basic income] in helping the disadvantaged to live full, happy, productive, and rewarding lives.

What evidence? Let’s start with the well-established finding that unemployment has major negative effects on well-being, including both mental and physical health. And the effects are remarkably persistent. A study using German panel data examined changes in reported life satisfaction after marriage, divorce, birth of a child, death of a spouse, layoff, and unemployment. All had predictable effects in the short term, but for five of the six the effect generally wore off with time: the joy of having a new baby subsided, while the pain of a loved one’s death gradually faded. The exception was unemployment: even after five years, the researchers found little evidence of adaptation.

Evidence even more directly on point comes from the experience of welfare reform – specifically, the imposition of work requirements on recipients of public assistance. Interestingly, studies of the economic consequences of reform showed little or no change in recipients’ material well-being. But a pair of studies found a positive impact on single mothers’ happiness as a result of moving off welfare and finding work.

There is more here.  And Ross Douthat offers related remarks on whether it really is possible to encourage work — how well have previous welfare reforms succeeded in this end?

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.