Category: Medicine
The problem
One reason that many Americans believe Medicare does not contribute to the deficit is that the majority thinks Medicare recipients pay or have prepaid the cost of their health care. Medicare beneficiaries on average pay about $1 for every $3 in benefits they receive…However, about two-thirds of the public believe that most Medicare recipients get benefits worth about the same (27%) or less (41%) than what they have paid in payroll taxes during their working lives and in premiums for their current coverage.
Here is more, via Amitabh Chandra.
Sinister Statistics: Do Left Handed People Die Young?
In 1991 Halpern and Coren published a famous study in the New England Journal of Medicine which appears to show that left handed people die at much younger ages than right-handed people. Halpern and Coren had obtained records on 987 deaths in Southern California–we can stipulate that this was a random sample of deaths in that time period–and had then asked family members whether the deceased was right or left-handed. What they found was stunning, left handers in their sample had died at an average age of 66 compared to 75 for right handers. If true, left handedness would be on the same order of deadliness as a lifetime of smoking. Halpern and Coren argued that this was due mostly to unnatural deaths such as industrial and driving accidents caused by left-handers living in a right-handed world. The study was widely reported at the time and continues to be regularly cited in popular accounts of left handedness (e.g. Buzzfeed, Cracked).
What is less well known is that the conclusions of the Halpern-Coren study are almost certainly wrong, left-handedness is not a major cause of death. Rather than dramatically lower life expectancy, a more plausible explanation of the HC findings is a subtle and interesting statistical artifact. The problem was pointed out as early as the letters to the editor in the next issue of the NEJM (see Strang letter) and was also recently pointed out in an article by Hannah Barnes in the BBC News (kudos to the BBC!) but is much less well known.
The statistical issue is that at a given moment in time a random sample of deaths is not necessarily a random sample of people. I will explain.
Over the 20th century, left handers have increased as a fraction of the population. Left handedness may be relatively fixed as a genetic matter but in the earlier decades of the 20th century children were strongly discouraged from exhibiting left-handedness. As a result, many “natural” lefties learned right-handed behavior and identified as right-handed adults. Over time, however, the cultural suppression of left-handedness declined and the proportion of adults exhibiting left-handedness increased, as the figure, at left, illustrates (fyi, I believe British data).
Now suppose you take a random sample of people who died in 1990. In this sample, some people will have died old and some young. Among those those who died old, however, fewer people will be identified as left-handed because the old grew up in a time when left-handedness was suppressed. As a result, the old deaths in your sample will tend to be have more right-handed people and the young deaths will tend to have more left-handed people causing you to incorrectly conclude that left-handed people die younger. Studies show that this statistical artifact can easily explain a 9 year difference in apparent mortality rates.
To make this crystal clear consider the following thought experiment (offered by Chris McManus). Imagine you take a sample of people who died recently and asked their surviving family members, Did the deceased ever read the Harry Potter novels? One would clearly find in such a sample that those who died tragically young (at age 12 let’s say) would have been much more likely to have read Harry Potter than those who died in their 90s. Despite what some might argue, however, we should not conclude that Harry Potter kills.
Hat tip: Tim Harford.
Average Marginal Labor Income Tax Rates under the Affordable Care Act
That is a new paper by Casey Mulligan, here is the abstract:
The Affordable Care Act includes four significant, permanent, implicit unemployment assistance programs, plus various implicit subsidies for underemployment. Every sector of the economy, and about half of nonelderly adults, is directly affected by at least one of those provisions. This paper calculates the ACA’s impact on the average reward to working among nonelderly household heads and spouses. The law increases marginal tax rates by an average of five percentage points (of employee compensation), on top of the marginal tax rates that were already present before the it went into effect. The ACA’s addition to labor tax wedges is roughly equivalent to doubling both employer and employee payroll tax rates for half of the population.
Mulligan summarizes the paper here, with further detail. In another new paper, Mulligan compares ACA with Romneycare.
North Korea Fact of the Day
North Korea is the only country in the world where it is legal to use, sell, transport and cultivate marijuana.
Marketing the asylum
Gentrification and rising real estate prices will lead to many kinds of capital conversion. Here is Mind Hacks:
Regular readers will know of my ongoing fascination with the fate of the old psychiatric asylums and how they’re often turned into luxury apartments with not a whisper of their previous life.
It turns out, a 2003 article in The Psychiatrist looked at exactly this in 71 former asylum care hospitals.
It’s cheekily called ‘The Executives Have Taken Over the Asylum’ and notes how almost all have been turned into luxury developments. Have a look at Table 1 for a summary.
The authors also had a look at the marketing material for these new developments and wrote a cutting commentary on how the glossy brochures deal with the institutions mixed legacies.
The estate agents want to play on the often genuinely beautiful architecture and, more oddly, the security of the sites, while papering over the fact the buildings had anything to do with mental illness.
Here is the article, here is the original 2003 piece (pdf). Here is one summary from Chaplin and Peters:
The only reminders of the former inhabitants found by the authors at any of the 32 redeveloped sites were a memorial garden dedicated to the patients of Cell Barnes and Hill End Hospitals, St Albans, a plaque at Littlemore Hospital, Oxford, and photographs of the former Bethlem Hospital at the Imperial War Museum.
Former mental hospital buildings appear to be undergoing a metamorphosis from containing the most disadvantaged and least-valued members of society to providing homes with character at a high market price. Paradoxically, asylum can now be bought in an ideal self-contained community, with security to keep society out.
A few notes on Singaporean (and other) health care systems
This is oversimplifying of course, but you can think of the Singaporean system as “2/3 private money, 4/5 public provision,” with private hospitals on the side.
You can think of the UK system as “public money, public provision.” Again with some private supply on the side.
The US system is “lots of public money, lots of private money, mostly private provision.”
Many other systems are “public money, private provision.” In all cases there are various complexities piled on top.
Singapore now is making some changes, outlined in brief here. For the most part, Singapore is adding on some public money, but in targeted fashion (one of the changes is for people over 90 years old, another is for people over 60).
Here’s from The Straits Times (gated, I write from the paper copy) from Saturday:
The first [priority] is to keep government subsidies targeted at those who most need them, rather than commit to benefits for all. Universal benefits are “wasteful and inequitable”, and hard to take away once given, he [the Finance Minister] said.
That’s exactly the liberaltarian line and sometimes the conservative line as well. It is a principle I strongly agree with.
I am grateful to have had a lengthy dinner with several of the civil servants who run the Singaporean health care system (I don’t need to tell you about the food). I had the liberty to “ask away” for several hours and I learned a lot.
Yes, the system really is a marvel, and no it is not laissez-faire. The mix of “private money, public provision” has some marvelous properties for economizing on costs, not the least of which is that private hospitals and doctors and medical device salesmen do not become too strong a lobby. And the level of conscientiousness in Singapore is high enough that the public hospitals work fine, though they don’t in general have the luxuries of the private hospitals. Furthermore those public hospitals have to compete against each other for patient loyalty and thus revenue, and so the reliance on private money helps discipline public hospitals.
Whether those public hospitals would work fine everywhere in the world is a debatable proposition. It’s easier to monitor quality in a small, Confucian city-state with high levels of expected discipline. (Oddly, Krugman, who thinks the VA model in the U.S. could be generalized to a national scale, should be especially sympathetic toward a Singapore-like system. An alternative is that the public hospitals are run at city, county, and state levels.)
In any case let’s start by admitting, and keeping on the table, the notion that the current version of the Singapore system is indeed a poster child of some sort. And it is not being modified because somehow it has started spewing out unacceptable health care outcomes. It is being modified because, for better or worse, Singaporean politics is changing.
Now enter Aaron Carroll, who tries to argue Singapore is moving in an ACA-like direction. His post has been cited numerous times, but it is not insightful nor does it show much curiosity about the new changes in Singapore. It is mostly a polemic against Republicans. In any case the new Singaporean emphasis on taking care of the elderly isn’t well understood by a comparison with ACA.
For an additional and important point, here is a good comment by Chris Conover on just how limited Singaporean coverage can be. This ain’t your grandfather’s ACA, though with some luck it may be your grandson’s. Even if the Singapore model is not fully generalizable to larger, more chaotic countries, it shows that government health care coverage and finance, no matter what exact form they take, should and indeed can be quite limited and you still can end up with excellent outcomes, including better cost control.
I also should add that quite a few intelligent, non-ideological Singaporean economists and civil servants believe the new changes to be bad ones, driven primarily by the demands of citizens for goodies rather than by the quest for the best technocratic policy. The alternative view is that Singapore is now a wealthy place and it can afford to spend extra on these health care services and indeed should do so to limit inequality and also for reasons of political popularity and stability.
The Singaporean health care system is not done changing.
Why has growth in per capita Medicare spending slowed down?
There is a new CBO study, which I have not read, but which is noteworthy virtually by definition. The abstract is here:
Growth in spending per beneficiary in the fee-for-service portion of Medicare has slowed substantially in recent years. The slowdown has been widespread, extending across all of the major service categories, groups of beneficiaries that receive very different amounts of medical care, and all major regions. We estimate that slower growth in payment rates and changes in observable factors affecting beneficiaries’ demand for services explain little of the slowdown in spending growth for elderly beneficiaries between the 2000–2005 and 2007–2010 periods. Specifically, available evidence does not support a finding that demand for health care by Medicare beneficiaries was measurably diminished by the financial turmoil and recession. Instead, much of the slowdown in spending growth appears to have been caused by other factors affecting beneficiaries’ demand for care and by changes in providers’ behavior. We discuss the contribution that those factors may have made to the slowdown in spending growth and the difficulties in quantifying those influences and predicting their persistence.
The full paper (pdf) is here.
The new Emily Oster book
Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong-and What You Really Need to Know.
It’s out, and if I hadn’t been giving talks in Singapore and eating pepper crab, I would have read and reviewed it by now. I will read it as soon as I can and of course I pre-ordered it once I heard about it, despite my lack of direct connection to the topic…
What explains regional variation in health care spending?
It doesn’t seem to be demand side factors, but rather what doctors believe, including false beliefs. That is scary. There is a new NBER paper by David Cutler, Jonathan Skinner, Ariel Dora Stern, and David Wennberg and the abstract is this:
There is considerable controversy about the causes of regional variations in healthcare expenditures. We use vignettes from patient and physician surveys, linked to Medicare expenditures at the level of the Hospital Referral Region, to test whether patient demand-side factors, or physician supply-side factors, explains regional variations in Medicare spending. We find patient demand is relatively unimportant in explaining variations. Physician organizational factors (such as peer effects) matter, but the single most important factor is physician beliefs about treatment: 36 percent of end-of-life spending, and 17 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence.
There is an earlier ungated version here (pdf).
Beware the beam
Urologists “referred a substantially higher percentage of their prostate cancer patients” to radiation therapy when the doctors owned the equipment — linear accelerators — or had financial ties to those who provided the treatment, the report said.
Here is much more.
Computers which magnify our prejudices
As AI spreads, this will become an increasingly important and controversial issue:
For one British university, what began as a time-saving exercise ended in disgrace when a computer model set up to streamline its admissions process exposed – and then exacerbated – gender and racial discrimination.
As detailed here in the British Medical Journal, staff at St George’s Hospital Medical School decided to write an algorithm that would automate the first round of its admissions process. The formulae used historical patterns in the characteristics of candidates whose applications were traditionally rejected to filter out new candidates whose profiles matched those of the least successful applicants.
By 1979 the list of candidates selected by the algorithms was a 90-95% match for those chosen by the selection panel, and in 1982 it was decided that the whole initial stage of the admissions process would be handled by the model. Candidates were assigned a score without their applications having passed a single human pair of eyes, and this score was used to determine whether or not they would be interviewed.
Quite aside from the obvious concerns that a student would have upon finding out a computer was rejecting their application, a more disturbing discovery was made. The admissions data that was used to define the model’s outputs showed bias against females and people with non-European-looking names.
The truth was discovered by two professors at St George’s, and the university co-operated fully with an inquiry by the Commission for Racial Equality, both taking steps to ensure the same would not happen again and contacting applicants who had been unfairly screened out, in some cases even offering them a place.
There is more here, and I thank the excellent Mark Thorson for the pointer.
The Animals are Also Getting Fat
In a remarkable paper Allison et al. (2011) gather data on the weight at mid-life from 12 animal populations covering 8 different species all living in human environments. Dividing the sample into male and female they find that in all 24 cases animal weight has increased over the past several decades.
Cats and dogs, for example, both increased in weight. Female cats increased in body weight at a rate of 13.6% per decade and males at 5.7% per decade. Female dogs increased in body weight at a rate of 3% per decade and males at a rate of 2.2% per decade.
One ready, although not necessarily correct explanation, is that fat people feed their cats and dogs more and exercise them less. Thus, the authors also looked at animals not directly under human control such as rats.
…For the 1948–2006 time period, male rats trapped in urban
Baltimore experienced a 5.7 per cent increase in body
weight per decade from 1948 to 2006 and a nearly
20 per cent increase in the odds of obesity. Similarly,
female rats trapped in urban Baltimore experienced a
7.22 per cent per decade increase in body weight, along
with a 26 per cent increase in the odds of obesity.
that too has a ready, although not necessarily correct, explanation:
… just as human real wealth and food
consumption have increased in the United States, rats
which presumably largely feed on our refuse, may also
be essentially richer.
To counter both of these objections the authors do something very clever, they gather data on the weight of control mice used in many different experiments over decades.
Among mice in control groups in the National Toxicology
Programme (NTP), there was a 11.8 per cent
increase in body weight per decade from 1982 to 2003
in females coupled with a nearly twofold increase in the
odds of obesity. In males there was a 10.5 per cent
increase per decade.
Control mice are typically allowed to feed at will from a controlled diet that has not varied much over the decades, making obvious explanations less plausible. Could mice have gained weight due to better care? Possibly although that is speculative.
More generally, there are specific explanations for the weight gain in each of the animal populations, just as there are for humans. Each explanation looks plausible taken on its own but is it plausible that each population is gaining weight for independent reasons? Could there instead be a unifying explanation for the weight gain in all populations? No one knows what that explanation is: toxins? viruses? epigenetic factors? I am not ready to jump on any of these bandwagons and in some cases the author’s samples are small so I am not yet fully convinced of the underlying facts, nevertheless this is intriguing and important research.
Hat tip: David Berreby writing in Aeon about The Obesity Era.
Online Therapy as Good as Face to Face
A small study suggests that online therapy is as effective as face to face.
Online psychotherapy is just as efficient as conventional therapy. Three months after the end of the therapy, patients given online treatment even displayed fewer symptoms.
Six therapists treated 62 patients, the majority of whom were suffering from moderate depression. The patients were divided into two equal groups and randomly assigned to one of the therapeutic forms. The treatment consisted of eight sessions with different established techniques that stem from cognitive behavior therapy and could be carried out both orally and in writing. Patients treated online had to perform one predetermined written task per therapy unit – such as querying their own negative self-image. They were known to the therapist by name.
“In both groups, the depression values fell significantly,” says Professor Andreas Maercker, summing up the results of the study. At the end of the treatment, no more depression could be diagnosed in 53 percent of the patients who underwent online therapy – compared to 50 percent for face-to-face therapy. Three months after completing the treatment, the depression in patients treated online even decreased whereas those treated conventionally only displayed a minimal decline: no more depression could be detected in 57 percent of patients from online therapy compared to 42 percent with conventional therapy.
If therapy works well online imagine what else might work online?
Will Uruguay legalize marijuana?
Members of Uruguay’s House of Representatives have passed a bill to legalise marijuana.
If it goes on to be approved by the Senate, Uruguay will become the first country to regulate the production, distribution and sale of marijuana.
The measure is backed by the government of President Jose Mujica, who says it will remove profits from drug dealers and divert users from harder drugs.
Under the bill, only the government would be allowed to sell marijuana.
There is more here, and reports indicate that approval for the bill is expected.
*The Great Escape*
The author is Angus Deaton and the subtitle is Health, Wealth, and the Origins of Inequality. It is a very good book, as you might expect. Here are two bits I found especially interesting:
In Sweden in 1751 — well before the modern mortality decline — it was riskier to be a newborn than to be an 80-year old.
And, somewhat more recently:
…until around 1900, adult life expectancy in Britain was actually higher than life expectancy at birth. In spite of having lived for 15 years, those teenagers could expect a longer future than when they were born.
The book’s home page is here.