Category: Medicine
The thinning out of the medical middle
From Ben Casselman at the WSJ:
The health-care sector, one of the last redoubts of stable and well-paying jobs for less-educated workers, is beginning to look less secure.
A variety of factors, from technological advances to increased attention on both costs and patient outcomes, are driving hospitals and other health-care providers to demand more from both the most- and least-skilled workers, while gradually eroding opportunities for those in the middle.
The result: the gradual disappearance of semiskilled occupations that don’t require a college degree. Positions such as licensed practical nurses and medical-records clerks are being eliminated or pushed out of hospitals into lower-paying corners of the field such as nursing homes. Meanwhile, positions that were once an accessible first rung on the career ladder, such as registered nursing, increasingly require at least a bachelor’s degree.
The trend is worrisome to economists, because health care had been a relative haven from the erosion of middle-skill jobs elsewhere in the economy. Automation, outsourcing and other forces have eliminated many formerly secure jobs in manufacturing, clerical work and other fields. Now health care is following the same path with unforeseen speed.
Here is more.
Cousin Marriage and Democracy
In the United States consanguineous marriage (marriage between close relatives, often cousins) is frowned upon and in many states banned but it is common elsewhere in the world. Approximately 0.2% of all marriages are consanguineous in the United States but in India 26.6% marriages are consanguineous, in Saudi Arabia the figure is 38.4% and in Niger, Pakistan and Sudan a majority of marriages are consanguineous. Cousin marriage used 
to be more common in the West and was particularly common among royal families which gives some hints as to why it may sometimes be useful. Among families with titles or estates, cousin marriage will tend to keep the wealth intact–literally within the family–whereas wealth becomes more dilute more quickly with outside marriage. Cousin marriage may also increase cooperation within the extended family and help to fight off parasites.
A recent paper finds that consangunuity is strongly negatively correlated with democracy:
How might consanguinity affect democracy? Cousin marriages create extended families that
are much more closely related than is the case where such marriages are not practiced. To illustrate,
if a man’s daughter marries his brother’s son, the latter is then not only his nephew but also
his son-in-law, and any children born of that union are more genetically similar to the two grandfathers
than would be the case with non-consanguineous marriages. Following the principles of
kin selection (Hamilton, 1964) and genetic similarity theory (Rushton, 1989, 2005), the high
level of genetic similarity creates extended families with exceptionally close bonds. Kurtz succinctly
illustrates this idea in his description of Middle Eastern educational practices:If, for example, a child shows a special aptitude in school, his siblings might willingly
sacrifice their personal chances for advancement simply to support his education. Yet once
that child becomes a professional, his income will help to support his siblings, while his
prestige will enhance their marriage prospects. (Kurtz, 2002, p. 37).Such kin groupings may be extremely nepotistic and distrusting of non-family members in the
larger society. In this context, non-democratic regimes emerge as a consequence of individuals turning to reliable kinship groupings for support rather than to the state or the free market. It has
been found, for example, that societies having high levels of familism tend to have low levels of
generalized trust and civic engagement (Realo, Allik, & Greenfield, 2008), two important correlates
of democracy. Moreover, to people in closely related kin groups, individualism and the
recognition of individual rights, which are part of the cultural idiom of democracy, are perceived
as strange and counterintuitive ideological abstractions (Sailer, 2004).
By the way, cousin marriage results in an elevated risk of birth defects but on the same order as a 40 year old woman having children as opposed to a 30 year old. In other words, the risks are small relative to other accepted risks. Results do get worse when cousin marriage is prevalent over many generations.
Hat tip to Chris Blattman and Joshua Keating. FYI, Steve Sailer wrote an interesting piece on this issue.
Will Congress exempt itself from ACA exchange provisions?
Congressional leaders in both parties are engaged in high-level, confidential talks about exempting lawmakers and Capitol Hill aides from the insurance exchanges they are mandated to join as part of President Barack Obama’s health care overhaul, sources in both parties said…
There is concern in some quarters that the provision requiring lawmakers and staffers to join the exchanges, if it isn’t revised, could lead to a “brain drain” on Capitol Hill, as several sources close to the talks put it.
The problem stems from whether members and aides set to enter the exchanges would have their health insurance premiums subsidized by their employer — in this case, the federal government. If not, aides and lawmakers in both parties fear that staffers — especially low-paid junior aides — could be hit with thousands of dollars in new health care costs, prompting them to seek jobs elsewhere. Older, more senior staffers could also retire or jump to the private sector rather than face a big financial penalty.
Plus, lawmakers — especially those with long careers in public service and smaller bank accounts — are also concerned about the hit to their own wallets.
Here is more, via these guys.
Addendum: Here is a response from Ezra Klein to the Politico story, but I don’t see that it counters the basic point, as reflected by this brouhaha, that the exchanges are not necessarily such a wonderful place to be, especially for low wage workers. Megan McArdle also comments.
Why did Cuba become healthier during the economic meltdown of the 1990s?
One should interpret anything about Cuba, or coming out of Cuban data, with extreme caution. Nonetheless I thought this was interesting enough to pass along:
The economic meltdown should logically have been a public health disaster. But a new study conducted jointly by university researchers in Spain, Cuba, and the U.S. and published in the latest issue of BMJ says that the health of Cubans actually improved dramatically during the years of austerity. These surprising findings are based on nationwide statistics from the Cuban Ministry of Public Health, together with surveys conducted with about 6,000 participants in the city of Cienfuegos, on the southern coast of Cuba, between 1991 and 2011. The data showed that, during the period of the economic crisis, deaths from cardiovascular disease and adult-onset type 2 diabetes fell by a third and a half, respectively. Strokes declined more modestly, and overall mortality rates went down.
This “abrupt downward trend” in illness does not appear to be because of Cuba’s barefoot doctors and vaunted public health system, which is rated amongst the best in Latin America. The researchers say that it has more to do with simple weight loss. Cubans, who were walking and bicycling more after their public transportation system collapsed, and eating less (energy intake plunged from about 3,000 calories per day to anywhere between 1,400 and 2,400, and protein consumption dropped by 40 percent). They lost an average of 12 pounds.
It wasn’t only the amount of food that Cubans ate that changed, but also what they ate. They became virtual vegans overnight, as meat and dairy products all but vanished from the marketplace. People were forced to depend on what they could grow, catch, and pick for themselves– including lots of high-fiber fresh produce, and fruits, added to the increasingly hard-to-come-by staples of beans, corn, and rice. Moreover, with petroleum and petroleum-based agro-chemicals unavailable, Cuba “went green,” becoming the first nation to successfully experiment on a large scale with low-input sustainable agriculture techniques. Farmers returned to the machetes and oxen-drawn plows of their ancestors, and hundreds of urban community gardens (the latest rage in America’s cities) flourished.
And this:
During the special period, expensive habits like smoking and most likely also alcohol consumption were reduced, albeit briefly. This enforced fitness regime lasted only until the Cuban economy began to recover in the second half of the 1990s. At that point, physical activity levels began to fall off, and calorie intake surged. Eventually people in Cuba were eating even more than they had before the crash. The researchers report that “by 2011, the Cuban population has regained enough weight to almost triple the obesity rates of 1995.”
That is by Richard Schiffman, the full article is here, and for the pointer I thank Jim Oliver.
Psychic Harm, Repugnant Conclusions and Presumed Consent
Steven Landsburg’s post on psychic harm has created a firestorm of controversy. Many people don’t understand thought experiments and that is part of the problem but it was also a bad idea to combine hypotheticals with a real case involving a real victim. Nevertheless, Landsburg’s post raised important questions about how pure psychic harm (“I don’t like the thought of other people having gay sex.”) differs from a physical transgression without physical harm (rape of someone who is unconscious and which leaves no trace). The point is not about rape but about whether and why (some?) psychic harms should count in the moral calculus. As David Friedman argues, how we answer this question has deep implications.
Moreover, Landsburg’s stark hypothetical is closer to a real policy question than many might imagine. Consider the issue of presumed consent for organ donation, the policy used by many European countries where someone who dies is presumed to have agreed to be an organ donor barring evidence that they opted out. There are good (not necessarily definitive) arguments for presumed consent, namely that it would save some lives at low cost. After all, what harm can be said to occur from taking organs from a dead person? The latter point is obvious to me but it’s only obvious because I think the dead can’t be harmed. Other people, think differently Many religions consider cadaveric organ donation to be a kind of desecration. In fact, some people liken presumed consent to rape of the unconscious. Professor Hugh V McLachlan for example writes:
if someone had sex with an unconscious woman and tried to justify his action by saying that, when she was conscious, she did not indicate that she did not want to have sex, we would not accept this as a reasonable argument. The notion of presumed consent to the use of our organs after our deaths is no more reasonable.
and another commentator on presumed consent in Britain says
The difference between voluntary consent and presumed consent is at least the difference between consensual sex and rape of a drunk person.
Evidently for some people being dead is similar to being unconscious. Thus in both cases physical harms without physical consequence can be wrong because they generate psychic harm, either in expectation or in the afterlife. Clearly, distinguishing which psychic harms are to be counted and which not quickly becomes a question of metaphysics.
My own view is that as far as possible psychic harms should not be counted at all. Instead I would let ethics dictate the assignment of property rights and economics dictate the allocation. In particular, I would assign body ownership to the individual on strong libertarian and autonomy grounds but I would let individuals sell a kidney (or sex).
One of the virtues of markets is that markets make people pay for their preferences, if only in terms of opportunity cost. My suspicion is that the psychic harm from the thought that after death one’s organs might be used by someone else would quickly dissipate once some cash was on the table. Indeed, it’s often the case that the least cost way to avoid a psychic harm is to change one’s mind and, to paraphrase Upton Sinclair, it’s easier to get a man to change his mind when his salary depends upon him changing his mind.
Australia to Compensate Organ Donors
Australia once again proves that it is a world leader in innovative public policy with an experimental plan to compensate (living) organ donors.
Workers who want to donate a kidney will be offered up to six weeks’ paid leave under a federal government plan to reduce the waiting list for life-saving organs.
Health Minister Tanya Plibersek and parliamentary secretary for health and ageing Shanye Neumann say the government will put up $1.3 million over two year for a trial that will be reviewed in 2015.
Ms Plibersek says living donors will be paid six weeks on minimum wage, totalling up to $3600, to help take the financial pressure off before and after the major surgery.
…the scheme is one step towards bridging the gap between the number of kidney donors and recipients.
The proposed experiment does, however, contains a peculiar restriction which is worth highlighting because it illustrates a tension between economics and ethics, at least ethics as conventionally understood (e,g, Michael Sandel). The compensation “will only be available to donors who have a job.”
The idea, I believe, is to avoid any hint of “exploitation” or “pecuniary coercion.” The problem is that another word for pecuniary coercion is incentive. Thus, the goal is to increase the supply of organs without creating an incentive to supply organs, at least not a strong incentive. To help navigate this invisible line the amount paid is low and the only people who can receive compensation are the ones who don’t need the money. In short, the plan discriminates against the unemployed so that no one can accuse the government of exploiting the unemployed by giving them too much money.
Nevertheless, although the amount is small and restricted, Australia’s willingness to experiment with the idea of compensation in order to save lives is laudable and potentially groundbreaking.
Hat tip: Andrew Leigh.
Addendum: For other innovative approaches to the worldwide shortage of transplant organs see my articles here and here.
Buried treasure in clickthrough agreements
Do you know anyone who stops to read “click-through” agreements on websites in the middle of performing a task? One company, PC Pitstop, deliberately buried a clause in its end-user license agreement in 2004, offering $1,000 to the first person who emailed the company at a certain address. It took five months and 3,000 sales until someone claimed the money. The situation hadn’t improved by 2010 when Gamestation played an April Fools’ Day joke by embedding a clause in their agreement saying that users were selling them their souls.
Here is another good bit:
Ponder the fact that a dermatologist must sign his name to forms almost 30,000 times a year, according to a 2008 article in the Southern Medical Journal.
The article is here and for the pointer I thank Olaf.
The ACA’s four cliffs
…(1) the 50th employee (firms with 49 employees that don’t offer medical insurance will be hit with a $40,000 penalty if they hire just one more worker); (2) the 200 percent threshold (one households cross 200 percent of the poverty line, deductibles might sharply increase); (3) the 400 percent threshold (the dropoff is even bigger once households cross 400 percent of the poverty line); and (4) the early retirement incentive (ACA creates an incentive for many older workers below age 65 to exit the workforce) — reshapes the American labor market, the dominant narrative will be that the $85 billion in sequestration cuts are responsible for sluggish growth.
That is from Reihan, most of the post is on sequestration.
The recent boost to Medicare
This was an under-reported story which I missed at first. Sarah Kliff reports:
…the Obama administration reversed a proposed 2.3 percent pay cut for private Medicare plans, replacing it with a 3.3 percent raise.
For health plans, this was a huge victory. As Citi analyst Carl McDonald put it in a Tuesday note to investors, this was “Armageddon averted.”
“The rate adjustment,” McDonald continues, “sends a pretty clear message that CMS has no interest in seeing major disruption in the Medicare Advantage program right now, quieting concerns about a post election desire to rein in enrollment and margins.”
Medicare Advantage plans will still get a tiny haircut due to other changes the federal government proposed. The 2.3 percent pay cut that became a 3.3 percent raise was one among a few cuts that the Obama administration had proposed for 2014.
Cuts to Medicare Advantage plans mandated in the Affordable Care Act, for example, will still go forward.
Overall though, the cuts are way smaller than what the Obama administration initially proposed. McDonald at Citi estimates that Medicare Advantage plans will see a 2 percent rate reduction, compared to 7 percent to 8 percent that analysts predicted with the initial rates.
Here is more. This is but a single data point, but I take it as further evidence that fiscal consolidation cannot easily be done on a dime. In fact it cannot easily be done at all, especially in the United States. Here is my earlier post “Why are budget issues urgent now?”. You will note that Medicare Advantage is a program considered especially irksome, and especially costly, by many commentators on the left.
Overall health inequality seems to be down
The haves are those who enjoy great health into their 90s. The have-nots are those who suffer from serious health problems and do not live to see adulthood. As we pointed out in a recent study, among those Americans who were born in 1975, the unluckiest 1 percent died in infancy, while the luckiest 1 percent can expect to live to age 105 or longer. Now let’s fast forward to those born in 2012. The bottom percentile of this cohort can expect to survive until age 18. At the other end of the spectrum, the luckiest 1 percent can expect to live to age 108. That’s a much bigger gain in life expectancy among the have-nots than among the haves. Of course, life expectancy is but one measure of health and well-being, but understanding these trends offers a more complete picture than considering income alone.
These findings run counter to headlines noting a widening gap in health outcomes between different demographic groups. For example, a study led by Jay Olshansky of the University of Illinois at Chicago recently demonstrated that the gap in life expectancy between less educated and more educated Americans has widened considerably.
While studies like these are valuable in highlighting disparities between socio-economic groups, they do not tell us much about overall health inequality. That’s because most health inequality occurs within groups. In other words, if we look at a particular demographic group, the best outcomes for people in that group are dramatically different from the worst outcomes for people in the same group. These differences overwhelm any differences in average life expectancy across demographic groups. Thus, while inequality across some demographic groups has increased, it has fallen over the entire population. Overall, therefore, the health have-nots have made progress in catching up to the health haves.
That is from Benjamin Ho and Sita Nataraj Slavov. I am open to counters on the data side, but so far this seems both a) true and b) rooftop-worthy. I am reminded of Arnold Kling’s three axes of ideology; perhaps health care inequality attracts attention only when the victims are a group (the poor) who are part of some other narrative of oppression.
Russian markets in everything
According to this story in Canada’s National Post, cops in Moscow have been ordered to inspect ambulances after learning that VIP commuters are riding around in “ambulance taxis” that cost as much as $200 per hour.
These aren’t just ordinary ambulances, either. They’ve been cleverly fitted with fancy and luxurious interiors so their passengers can eat caviar and sip champagne while they blow through traffic with lights and sirens blazing.
Sarah Constantin replies on MetaMed
Not long ago I linked to this Robin Hanson blog post on MetaMed. I was sent this reply, which I will put under the fold:
I noticed you linked Robin Hanson’s article on MetaMed on Marginal Revolution. I’m the VP of research at MetaMed, and I just wanted to tell you a little bit more about us, because if all you know about us is the Overcoming Bias article you might get some misleading impressions.
Medical practice is basically a mass-produced product. Professional and regulatory bodies (like the AMA) put out guidelines for treatment. At their best, these guidelines follow the standards of evidence-based medicine, which means that on average they will produce the best health outcomes in the general population. (Of course, in practice they often fall short of that standard. For example, checklists are overwhelmingly beneficial by an evidence-based medicine standard, and yet are not universally used.)
But even at their best, the guidelines that are best from a population-health standpoint need not be optimal for an individual patient. If you have the interest and the willingness to pay, investigating your condition in depth, in the context of your entire medical history, genetic data, and personal priorities, may well turn up opportunities to do better than the standardized medical guidelines which at best maximize average health outcomes.
That’s basically MetaMed’s raison d’etre. And it’s a pretty conservative hypothesis, in fact. We may harbor a few grander ambitions (for example, I come from a mathematical background and I’m working on some longer-term projects related to algorithmically automating parts of the diagnostic process, and using machine learning principles on biochemical networks in novel ways) but fundamentally the thing we claim to be able to do is give you finer-grained information than your doctor will. We’re, of course, as yet unproven in the sense that we haven’t had enough clients to provide empirical evidence of how we improve health outcomes, but we’re not making extraordinary claims.
Robin Hanson seems to be implying that MetaMed is claiming to be useful only because we’re members of the “rationalist community.” This isn’t true. We think we’re useful because we give our clients personalized attention, because we’re more statistically literate than most doctors, because we don’t have some of the misaligned incentives that the medical profession does (e.g. we don’t have an incentive to talk up the benefits of procedures/drugs that are reimbursable by insurance), because we have a variety of experts and specialists on our team, etc.
The “rationalist” sensibility is important, to some degree, because, for instance, we’re willing to tell clients that incomplete evidence is evidence in the Bayesian sense, whereas the evidence-based medicine paradigm says that anything that yet hasn’t been tested in clinical trials and found a 5% p-value is completely unknown. For instance, we’re willing to count reasoning from chemical mechanisms as (weak) evidence. There’s a difference in philosophy between “minimize risk of saying a falsehood” and “be as close to accurate as possible”; we strive to do the latter. So there’s a sense in which our epistemic culture allows us to be more flexible and pragmatic. But we certainly aren’t basing our business model on a blanket claim of being better than the establishment just because we come from the rationalist community.
Update on the bending of the health care cost curve
So is it possible to keep the trend going? On this, we have somewhat conflicting news. A recent report from the Altarum Institute found that slow growth is continuing at the national level, with total health-care spending rising slightly more than 4 percent in nominal terms from January 2012 to January 2013. On the other hand, incoming Medicare data suggest spending is speeding up a bit.
The Medicare data this year are complicated because the 2012 figures were artificially depressed by the calendar (the start of the 2012 fiscal year, on Oct. 1, 2011, fell on a weekend, so some payments were shifted back to fiscal year 2011.) Adjusting for these timing details, spending per beneficiary fell slightly in 2012. In the first five months of fiscal year 2013, by contrast, the adjusted spending per beneficiary figures show an increase of more than 2.5 percent. That is still very low by historical standards, but noticeably higher than in 2012. At this point, it is unclear what is driving the acceleration.
It seems, by the way, that if the last three years remain typical that about one-third of our long-term budget problem goes away.
Why a coach should be ambiguous
Remember how Mr. Miyagi taught The Karate Kid how to fight? Wax on/Wax off. Paint the fence. Don’t forget to breathe. A coach is the coach because he knows what the student needs to do to advance. A big problem for coaches is that the most precocious students also (naturally) think they know what they need to learn.
If Mr. Miyagi told Daniel that he needed endless repetition of certain specific hand movements to learn karate, Daniel would have rebelled and demanded to learn more and advance more quickly. Mr. Miyagi used ambiguity to evade conflict.
An artist with natural gift for expression needs to learn convention. But she may disagree with the teacher about how much time should be spent learning convention. If the teacher simply gives her exercises to do without explanation her decision to comply will be on the basis of an overall judgment of whether this teacher, on average, knows best. To instead say “You must learn conventions, here are some exercises for that” runs the risk that the student moderates the exercises in line with her own judgment about the importance of convention.
Thwarted body part markets in everything
The Chicago-based nonprofit faces “the same challenge any business would have, whether I’m selling Hostess Twinkies or cadavers,” says Stephen Burnett, a professor of management and strategy at Northwestern University’s Kellogg School of Management.
To stay ahead, the association wants to supply body parts to the FBI and launch new products, including its own plastinated bodies, says Mr. Dudek, 62, executive vice president since 2005. He draws on his entrepreneurial experience as a co-owner of an MRI center in the south suburbs, which he sold to join the association.
Originally known as the Demonstrator’s Society, the association has not changed its business plan since its founding in 1918. Bodies are donated, embalmed and transferred to institutions such as med schools, where dissection remains a rite of passage.
Reasons for donations vary. Some gifts are part of estate planning, while others are made by relatives who cannot afford funerals.
By law, bodies cannot be sold, although groups like the association can be paid for processing. Member med schools pay about $1,300 per cadaver; nonmembers pay $2,300.
Nationwide, there’s a shortage of cadavers, in part because of the rise in organ donation. Cadavers without their organs are not suitable for medical education, Mr. Dudek notes. The association needs about 425 bodies a year for its members but missed that mark in 2009 and has barely met it in three of the last six years.
And yet globalization and government may come to the rescue:
The Middle East, where the culture discourages body donations, could be a new market. Schools in Lebanon and Saudi Arabia have recently expressed interest, he says. Law enforcement agencies also are prospects. Anatomical Gift is close to signing a contract to supply the FBI’s K-9 unit, which uses body parts to train dogs to find crime victims, he says. Limbs cost $570, plus $335 for HIV and hepatitis testing, since they are not embalmed, Mr. Dudek says. An FBI spokeswoman declines to comment.
There is more here, and for the pointer I thank G. Patrick Lynch.