Category: Medicine

The Impact of the Affordable Care Act: Evidence from California’s Hospital Sector

The Affordable Care Act (ACA) authorized the largest expansion of public health insurance in the U.S. since the mid-1960s. We exploit ACA-induced changes in the discontinuity in coverage at age 65 using a regression discontinuity based design to examine effects of the expansion on health insurance coverage, hospital use, and patient health. We then link these changes to effects on hospital finances. We show that a substantial share of the federally-funded Medicaid expansion substituted for existing locally-funded safety net programs. Despite this offset, the expansion produced a substantial increase in hospital revenue and profitability, with larger gains for government hospitals. On the benefits side, we do not detect significant improvements in patient health, although the expansion led to substantially greater hospital and emergency room use, and a reallocation of care from public to private and better-quality hospitals.

That is from a new NBER working paper by Mark Duggan, Atul Gupta, and Emilie Jackson.

Does “putting yourself in the shoes of others” reduce attitude change?

From Rhia Catapano, Zakary L. Tormala, and Derek D. Rucker:

Counterattitudinal-argument generation is a powerful tool for opening people up to alternative views. On the basis of decades of research, it should be especially effective when people adopt the perspective of individuals who hold alternative views. In the current research, however, we found the opposite: In three preregistered experiments (total N = 2,734), we found that taking the perspective of someone who endorses a counterattitudinal view lowers receptiveness to that view and reduces attitude change following a counterattitudinal-argument-generation task. This ironic effect can be understood through value congruence: Individuals who take the opposition’s perspective generate arguments that are incongruent with their own values, which diminishes receptiveness and attitude change. Thus, trying to “put yourself in their shoes” can ultimately undermine self-persuasion. Consistent with a value-congruence account, this backfire effect is attenuated when people take the perspective of someone who holds the counterattitudinal view yet has similar overall values.

Yes, yes the replication crisis.  Still, this may be a useful countertonic against the notion that trying to understand other people always yields high returns.  Perhaps the better approach is simply to drain yourself of values when considering the perspectives of other people.

Philanthropic hospital markets in everything

Nonprofit hospitals across the United States are seeking donations from the people who rely on them most: their patients.

Many hospitals conduct nightly wealth screenings — using software that culls public data such as property records, contributions to political campaigns and other charities — to gauge which patients are most likely to be the source of large donations.

Those who seem promising targets for fund-raising may receive a visit from a hospital executive in their rooms, as well as extra amenities like a bathrobe or a nicer waiting area for their families.

Some hospitals train doctors and nurses to identify patients who have expressed gratitude for their care, and then put the patients in touch with staff fund-raisers.

…it could make patients worry that their care might be affected by whether they made a donation.

Despite such concerns, these practices are becoming commonplace, particularly among the largest nonprofit hospitals. A 2016 survey of 108 hospitals found that 68 had grateful patient programs, according to the Advisory Board, a consulting firm.

Here is more from Phil Galewitz at the NYT.

Those new (old?) service sector jobs

Nobody ever warns the patients at Pennsylvania Hospital about Pete Schiavo, “The Groin Crusher.”

The first time most people meet Schiavo, they’ve just come out of a coronary procedure and he’s explaining that after the catheters are pulled out of their femoral artery, he’s going to apply pressure to their groin for 20 to 40 minutes to aid in clotting.

Awkward!

Or it would be, if it was anyone else but Schiavo, a gregarious, emotional, wisecracking guy who is all South Philly, even if he lives over the bridge in Jersey now.

Schiavo, 52, was so overwhelmed to learn that reader Sandy Kuritzky, whose husband’s groin he crushed earlier this year, nominated him for this series that he wept tears of joy several times during his interview.

“I know he doesn’t remember me or my husband because he has his hands on so many groins,” Kuritzky said. “But Pete’s attitude with his patients and their caregivers is so upbeat and friendly and caring and funny that it makes a stressful time less stressful and difficult.”

Patients and their families don’t forget the way Schiavo touches them — physically and emotionally. He’s won awards, had money donated in his name, and gets stopped all the time by former patients who want to buy him drinks or dinner.

“I’m holding someone’s groin for 20 minutes, they tend to remember me and nobody else,” Schiavo said. “I tell them: ‘I can promise you two things when I’m done: You’ll never forget my name or my face.’ And they never do.”

Here is the full story, via Dean C.

What should I ask Ed Boyden?

I will be doing a Conversations with Tyler with him, no associated public event.  Here is his MIT bio:

Ed Boyden is Y. Eva Tan Professor in Neurotechnology at MIT, associate professor of Biological Engineering and Brain and Cognitive Sciences at MIT’s Media Lab and McGovern Institute for Brain Research, and was recently selected to be an Investigator of the Howard Hughes Medical Institute (2018). He leads the Synthetic Neurobiology Group, which develops tools for analyzing and repairing complex biological systems such as the brain, and applies them systematically to reveal ground truth principles of biological function as well as to repair these systems. These technologies include expansion microscopy, which enables complex biological systems to be imaged with nanoscale precision; optogenetic tools, which enable the activation and silencing of neural activity with light; robotic methods for directed evolution that are yielding new synthetic biology reagents for dynamic imaging of physiological signals; novel methods of noninvasive focal brain stimulation; and new methods of nanofabrication using shrinking of patterned materials to create nanostructures with ordinary lab equipment. He co-directs the MIT Center for Neurobiological Engineering, which aims to develop new tools to accelerate neuroscience progress.

Here are other Ed Boyden links.  So what should I ask him?

Ratio of <= 40 to >= 50 scientists funded by the NIH

The dotted line at the top is the Jones-implied ratio of productivity of <= 40 year olds to >= 50 year-olds, as drawn from Figure 1 in this source.

For the construction of this data source I am indebted to PseudoMontaigne.  Does it not imply that NIH funding is vastly over-allocated according to the criterion of seniority?  Or might this be the rise of the lab system, where the older people are the PIs, and they in turn dole this money out to younger researchers?  More middlemen, so to speak.  Opinions?

My Conversation with Rebecca Kukla

She is a philosopher at Georgetown, here is the audio and transcript, I thought it was excellent and lively throughout.  Here is part of the summary:

In her conversation with Tyler, Kukla speaks about the impossibility of speaking as a woman, curse words, gender representation and “guru culture” in philosophy departments, what she learned while living in Bogota and Johannesburg, what’s interesting in the works of Hegel, Foucault, and Rousseau, why boxing is good for the mind, how she finds good food, whether polyamory can scale, and much more.

Here is one bit:

KUKLA: What’s interesting in Hegel? Okay. You ask hard questions. This is why you’re good at your job, right?

I think Hegel’s fascinating. I think the main idea in Hegel that is fascinating is that any cultural moment, or set of ideas, or set of practices is always internally contradictory in ways it doesn’t notice, that there are tensions built into it. What happens, over time, is that those tensions bubble up to the surface, and in the course of trying to resolve themselves, they create something newer and better and smarter that incorporates both of the original sides.

That was a much more Hegelian way of putting it than I wanted it to come out, basically — the idea that going out and looking for consistency in the world is hopeless. Instead, what we should do is figure out how the contradictions in the world are themselves productive, and push history forward, and push ideas forward, is what I take to be the key interesting Hegelian idea.

COWEN: Michel Foucault. How well has it held up?

KUKLA: Oh, you’re asking me about people I mostly love.

COWEN: But empirically, a lot of doubt has been cast upon it, right?

KUKLA: On the details of his empirical genealogical stories, you mean?

COWEN: Yes.

KUKLA: Yes, but I think that the basic Foucauldian picture, which is — let’s reduce Foucault to just two little bits here. One basic piece of the Foucauldian picture is that power is not a unify-unilateral, top-down thing. Power expresses itself in all of the little micro interactions that go on between people and between people and their environments all the time.

Power isn’t about a big set of rules that’s imposed on people. Power is about all of the little things that we do with one another as we move through the world. All of those add up to structures of power, rather than being imposed top-down. I think that has been, at least for me and for many other people, an incredibly fertile, productive way of starting to think about social phenomenon.

The other bit of the Foucauldian picture that I think is incredibly important is the idea that a lot of this happens at the level of concrete, fleshy bodies and material spaces. Power isn’t sets of abstract rules. Power is the way that we are trained up when we are little kids — to hold our legs in a certain way, or to hold our face in a certain way, or to wear certain kinds of clothing. Power is the way that schools are built with desks in rows that enforces a certain direction of the gaze, and so on.

I could go on and on, but the way that the materiality of our bodies and our habits and our environments is where power gets a hold, and where our social patterns and norms are grounded, rather than in some kinds of high-level principles or laws, is also, I think, very fertile.

That’s independent of the details of his genealogical stories. Because, yeah, he does seem to have played fairly fast and loose with actual historical details in a lot of cases.

Here is another segment:

COWEN: Let me start with a very simple question about feminism. What would be a rhetorical disadvantage that many women are at that even, say, educated or so-called progressive men would be unlikely to see?

KUKLA: A rhetorical disadvantage that we’re at — that’s a fascinating question. I think that there is almost no correct way for a woman to use her voice and hold her body to project the proper kind of expertise and authority in a conversation.

I think that there’s massive — I don’t even want to call it a double bind because it’s a multidimensional bind — where if we sound too feminine, sounding feminine in this culture is coded as frivolous and unserious. If we sound too unfeminine, then we sound like we are violating gender norms or like we are unpleasant or trying to be like a man.

I think that almost any way in which we position ourselves — if we try to be polite and make nice, then we come off as weak. If we don’t make nice, then we’re held to a higher standard for our appropriate behavior than men are. I think there’s almost no way we can position ourselves so that we sound as experts. So oftentimes, the content of our words matters less than our embodied presentation as a woman.

Definitely recommended.

Department of Unintended Consequences, American health care edition

In 2010, the federal agency that oversees Medicare, the Centers for Medicare and Medicaid Services, established the Hospital Readmissions Reduction Program under the Affordable Care Act. Two years later, the program began imposing financial penalties on hospitals with high rates of readmission within 30 days of a hospitalization for pneumonia, heart attack or heart failure, a chronic condition in which the heart has difficulty pumping blood to the body.

At first, the reduction program seemed like the win-win that policymakers had hoped for. Readmission rates declined nationwide for target conditions. Medicare saved an estimated $10 billion because of the reduction in hospital admissions. Based on those results, many policymakers have called for expanding the program.

But a deeper look at the Hospital Readmissions Reduction Program reveals a few troubling trends. First, since the policy has been in place, patients returning to a hospital are more likely to be cared for in emergency rooms and observation units. This has raised concern that some hospitals may be avoiding readmissions, even for patients who would benefit most from inpatient care.

Second, safety-net hospitals with limited resources have been disproportionately punished by the program because they tend to care for more low-income patients who are at much higher risk of readmission. Financially penalizing these resource-poor hospitals may impede their ability to deliver good care.

Finally, and most concerning, there is growing evidence that while readmission rates are falling, death rates may be rising.

In a new study of approximately eight million Medicare patients hospitalized between 2005 and 2015 that we conducted with other colleagues, we found that the Hospital Readmissions Reduction Program was associated with an increase in deaths within 30 days of discharge among patients hospitalized for heart failure or pneumonia, though not for a heart attack.

That is by Rishi K. WadheraKaren E. Joynt Maddox and Robert W. Yeh in The New York Times.

Rational self-medication

We develop a theory of rational self-medication. The idea is that forward-looking individuals, lacking access to better treatment options, attempt to manage the symptoms of mental and physical pain outside of formal medical care. They use substances that relieve symptoms in the short run but that may be harmful in the long run. For example, heavy drinking could alleviate current symptoms of depression but could also exacerbate future depression or lead to alcoholism. Rational self-medication suggests that, when presented with a safer, more effective treatment, individuals will substitute towards it. To investigate, we use forty years of longitudinal data from the Framingham Heart Study and leverage the exogenous introduction of selective serotonin reuptake inhibitors (SSRIs). We demonstrate an economically meaningful reduction in heavy alcohol consumption for men when SSRIs became available. Additionally, we show that addiction to alcohol inhibits substitution. Our results suggest a role for rational self-medication in understanding the origin of substance abuse. Furthermore, our work suggests that punitive policies targeting substance abuse may backfire, leading to substitution towards even more harmful substances to self-medicate. In contrast, policies promoting medical innovation that provide safer treatment options could obviate the need to self-medicate with dangerous or addictive substances.

That is a new NBER working paper by Michael E. Darden and Nicholas W. Papageorgge.

A social credit system for scientists?

Researchers in China who commit scientific misconduct could soon be prevented from getting a bank loan, running a company or applying for a public-service job. The government has announced an extensive punishment system that could have significant consequences for offenders — far beyond their academic careers.

Under the new policy, dozens of government agencies will have the power to hand out penalties to those caught committing major scientific misconduct, a role previously performed by the science ministry or universities. Errant researchers could also face punishments that have nothing to do with research, such as restrictions on jobs outside academia, as well as existing misconduct penalties, such as losing grants and awards.

“Almost all aspects of daily life for the guilty scientists could be affected,” says Chen Bikun, who studies scientific evaluation systems at Nanjing University of Science and Technology.

The policy, announced last month, is an extension of the country’s controversial ‘social credit system’, where failure to comply with the rules of one government agency can mean facing restrictions or penalties from other agencies.

The punishment overhaul is the government’s latest measure to crack down on misconduct. But the nature and extent of the policy has surprised many researchers. “I have never seen such a comprehensive list of penalties for research misconduct elsewhere in the world,” says Chien Chou, a scientific integrity education researcher at Chiao Tung University in Taiwan.

By David Cyranoski in Nature, via Michelle Dawson.

The second cohort of Emergent Ventures winners

Here is the list of the second set of winners, in the order the grants were made, noting that the descriptions are mine not theirs:

Kelly Smith has a for-profit project to further extend a parent-run charter school system in Arizona, using Uber-like coordinating apps and “minimalist” OER methods.

Andrew L. Roberts, Northwestern University, a small grant to further his work on how sports relates to politics.

Stefan de Villiers, high school student, to create podcasts on the decisions of other high school students and how/why they become successful.

Brian Burns is working (with Samo Burja) on the history of mathematics and career networks, with special attention to the blossoming of innovation in 18th century Göttingen: “The secret to producing flourishing mathematical and scientific traditions may lie in a careful study of institutions. I will undertake this investigation and in the process uncover lost mathematical knowledge.”  Gauss, Riemann, and Hilbert!

Can Olcer is one of the two entrepreneurs behind Kosmos School, a K-12 school that exists only in virtual reality, a for-profit enterprise with an emphasis on science education.

Anonymous, working on a board game for ten years, aimed at teaching basic economics, including supply and demand and the core ideas of Ronald Coase.  The grant is for marketing the game.

Sophie Sandor is a 23-year-old Scottish film-maker making films with “noticeable themes [of] rational optimism, ambition and a rejection of the victimhood notion that millennials are prone to.”  She is also interested in making documentaries in the education space.

Nicholas Dunk has a for-profit to bring voice recognition/machine transcription to the daily tasks of doctors.  The goal is to solve paperwork problems, free up doctor time, encourage better record-keeping, and improve accuracy, all toward the end of higher quality and less expensive health care.

Lama Al Rajih, a young Saudi CS student, building Therma, among other projects, she received a travel grant to visit potential mentors.

I am very excited by this new cohort.  Here is a list of the first round of winners, and here is the underlying rationale for Emergent Ventures.  You can apply here.

Cohort effects and life expectancy and many other facts about the history of American medicine

The cohort reaching age 55 around 1982 (born around 1927) has significantly higher mortality than the cohort 10 years younger. That higher mortality continues through the cohort passing through that age range in the mid-1990s, roughly, when the cohort born in 1933 reaches age 65. That same cohort also has higher mortality when they are 65-74 and 75-84. The story is not one of selection – a handful of less healthy people who die and leave behind healthier stock. Rather, it seems that an entire generation was rendered vulnerable by being born during and just before the Great Depression (Lleras-Muney and Moreau, 2018).

That is from a new NBER history of health care paper by Maryaline Catillon, David Cutler, and Thomas Getzen.  This piece is interesting on virtually every page.  For instance, on the rise of American science:

Of the 18 Nobel Prizes in Physiology or Medicine awarded 1901-1920, none went to US researchers. Over the next two decades, four out of twenty-four did, then for the rest of the century, more than half.

Then:

…our analysis of Massachusetts data does not support a large impact of medical care supply on mortality in the pre-antibiotic era.

Using the best data I’ve seen to date, apart from RCTs, the authors conclude from their statistical work:

…there is little evidence that access to medical care plays a role in mortality over the entire 1965-2015 period, but it appears to have had an effect during recent years.

That is from p.33

Death rates from influenza/pneumonia and cancer seem most responsive to access to medical care.  And I had not known this:

The period from 1935 to 1950 saw the most…decline in infant and child mortality of any time period since 1900.  It is unclear how much of this change would have happened without antibiotics, but blood banking and advances in surgical techniques were among the host of distinct and incremental improvements that added to life expectancy while the health share of GDP increased only slightly.

Recommended.

What should I ask Larissa MacFarquhar?

I will be doing a Conversations with Tyler with her, no associated public event.  Here is her New Yorker bio:

Larissa MacFarquhar has been a staff writer at The New Yorker since 1998. Her Profile subjects have included John Ashbery, Barack Obama, Noam Chomsky, Hilary Mantel, Derek Parfit, David Chang, and Aaron Swartz, among many others. She is the author of “Strangers Drowning: Impossible Idealism, Drastic Choices, and the Urge to Help” (Penguin Press, 2015). Before joining the magazine, she was a senior editor at Lingua Franca and an advisory editor at The Paris Review, and wrote for ArtforumThe NationThe New Republic, the New York Times Book ReviewSlate, and other publications. She has received two Front Page Awards from the Newswomen’s Club of New York and the Academy Johnson & Johnson Excellence in Media Award. Her writing has appeared in “The Best American Political Writing” (2007 and 2009) and “The Best Food Writing” (2008). She is an Emerson Fellow at New America.

She also wrote famous profiles of Richard Posner and Paul Krugman.

So what should I ask her?

The Political Economy of Lobotomies in the United States

The actual title starts with: “Gordon Tullock Meets Phineas Gage:”, and here is the abstract:

In the late 1940s, the United States experienced a “lobotomy boom” where the use of the lobotomy expanded exponentially. We engage in a comparative institutional analysis, following the framework developed by Tullock (2005), to explain why the lobotomy gained popularity and widespread use despite widespread scientific consensus it was ineffective. We argue that government provision and funding for public mental hospitals and asylums expanded and prolonged the use of the lobotomy. We support this claim by noting the lobotomy had virtually disappeared from private mental hospitals and asylums before the boom and was less used beforehand. This paper provides a more robust explanation for the lobotomy boom in the US and expands on the literate examining the relationship between state funding and scientific inquiry.

That is from Raymond March and Vincent Geloso, via the excellent Kevin Lewis.

China possible fact of the day

A Chinese researcher claims that he helped make the world’s first genetically edited babies — twin girls born this month whose DNA he said he altered with a powerful new tool capable of rewriting the very blueprint of life.

If true, it would be a profound leap of science and ethics.

A U.S. scientist said he took part in the work in China, but this kind of gene editing is banned in the United States because the DNA changes can pass to future generations and it risks harming other genes.

Here is the full story.  Here is further background.