Category: Medicine

No, says Andrew Leigh via Mark Thoma:

…not only are our coefficients close to zero,
but our standard errors are small enough that we can reject even modest
detrimental impacts of inequality on health.  As one participant at the NBER
meetings … put it, “it’s not just zero, it’s very
zero”.

Amy N. Finkelstein offers up a juicy abstract and paper:

Abstract: This paper investigates the effects of market-wide changes in health insurance by examining the single largest change in health insurance coverage in American history: the introduction of Medicare in 1965. I estimate that the impact of Medicare on hospital spending is over six times larger than what the evidence from individual-level changes in health insurance would have predicted. This disproportionately larger effect may arise if market-wide changes in demand alter the incentives of hospitals to incur the fixed costs of entering the market or of adopting new practice styles. I present some evidence of these types of effects. A back of the envelope calculation based on the estimated impact of Medicare suggests that the overall spread of health insurance between 1950 and 1990 may be able to explain about half of the increase in real per capita health spending over this time period.

Amy is an assistant professor at MIT; this week’s Business Week has an article claiming she is revolutionizing health care economics.  Perhaps that is an exaggeration, but her home page is worth a look.

Yana and I are now in Vienna, as I will be attending a conference on the social science aspects of pandemics.  If you are a new MR reader, here my paper on the policy implications of avian flu.  Here is an executive summary of the piece.

And what is the latest on avian flu?  The Thais had pretended to solve the problem but they were lying.  The Vietnamese have made real progress.  The Indonesians still refuse to release much of the sequencing information from their samples.  One study suggests that the cases of human-to-human mutation show significant mutation of the virus.  (Here is a more optimistic take.)  For the first time, one of the reported vaccines — from GlaxoSmithKline — seems to have significant potential.  It is unknown how much the virus is spreading in Africa.  Except for Indonesia there is more good news than bad, but of course it is not the average which matters.  The badness of the worst news will determine how the world fares.  It is hard to imagine how a serious pandemic would play itself out in crowded and infrastructure-dysfunctional China or India.

For more information on all these points, see the new version of EffectMeasure blog.

The New York Times runs an excellent article.  It is often forgotten how sick people used to be:

[Robert Fogel and colleagues] discovered that almost everyone of the Civil War generation was
plagued by life-sapping illnesses, suffering for decades. And these
were not some unusual subset of American men – 65 percent of the male
population ages 18 to 25 signed up to serve in the Union Army. “They
presumably thought they were fit enough to serve,” Dr. Fogel said.

Even
teenagers were ill. Eighty percent of the male population ages 16 to 19
tried to sign up for the Union Army in 1861, but one out of six was
rejected because he was deemed disabled.

Heart disease rates and even cancer rates (per age cohort, I believe) were higher in times past.

The big question, of course, is why people are so much healthier (or for that matter smarter, see the Flynn Effect).  It seems to be more than just better nutrition and sanitation.  Scientists are focusing on time in the womb plus the first two years of life.  Children born during the 1918 pandemic, for instance, fare much worse later in life in terms of health.  The hypothesis is that the poor health of their mothers programmed them for later troubles.

The Netherlands is a land of giants.  The people look quite healthy, despite high reported rates of disability.  Average height is 6’1" or 6’2".  And the Dutch are growing taller quickly.  Why?  Is it lots of Gouda cheese for Mommy?  The mayonnaise on the french fries?  Do small families play a role?  The Protestants of the northern Netherlands are taller than the Catholics of the south.  And if it is the cycling, are the teenagers in Davis, CA tall as well?

Prescription drugs
currently account for well under 20 percent of the health-care budget. Within a
generation or two, they will undoubtedly account for most of it–which will be
another good thing.  Pharma’s biochemical cures always
end up far cheaper than the people-centered services they ultimately displace.
Moreover, while much hands-on care only drags things out or soothes, the best
medicines really cure. It is true that, early on in the pharmacological assault
on a grave disease, drugs also stretch things out and can fail to beat the
disease, so we often end up buying more drug and more doctor, too. But
eventually drugs improve to the point where they beat the disease and thus lay off
both doctor and hospital.

The Commentary article is excellent, the pointer is from Craig Newmark.

Mr. Biggins said funeral homes can do anything that party planners can do.

Not bad for The New York Times.  Here is the very interesting article. 

Asking someone how likely they are to take illegal drugs in the future
can actually increase the likelihood that they will indeed take drugs –
a finding with worrying implications for health research.

Patti Williams and
colleagues recruited 167 undergrads and asked some of them about their
intentions to take drugs, and the others about their intentions to
exercise. Two months later, the students were contacted again, and
those who had been asked about drugs reported taking drugs an average
of 2.8 times in the intervening period, compared with an average of 1.1
times among the students previously asked about exercise.

The
effect was even more dramatic when those students who said they hadn’t
taken any drugs at all were omitted from the analysis. Among the
remaining students, those asked about their drug-taking intentions said
they’d used drugs an average of 10.3 times over the past two months,
compared with an average of 4 times among the students previously asked
about their exercise intentions.

This observation, together with further analysis, suggested it wasn’t
that new drug users had been created, but rather that the questioning
had led to increased use among current users who presumably had a
positive attitude towards drugs in the first place.

Here is the full story.

Inadequate emergency rooms are one of the most neglected policy issues in the United States.  Read this depressing article.  Excerpt:

Emergency medical care in the United States is on the verge of
collapse, with the nation’s declining number of emergency rooms
dangerously overcrowded and often unable to provide the expertise
needed to treat seriously ill people in a safe and efficient manner.

Long waits for treatment are epidemic, the reports said, with
ambulances sometimes idling for hours to unload patients. Once in the
ER, patients sometimes wait up to two days to be admitted to a hospital
bed.

As a system, U.S. emergency care lacks stability and the
capacity to respond to large disasters or epidemics, according to the
25 experts who conducted the study. It provides care of variable and
often unknown quality and depends on the willingness of doctors and
hospitals to lose large amounts of money.

That’s
the grim conclusion of three reports released yesterday by the
Institute of Medicine, the product of an extensive two-year look at
emergency care.

This is one reason why we are less well suited to defend against a pandemic or a major terrorist attack than many people think.  Note that emergency rooms are unpriced resources for many users, so this outcome should not surprise the economist.  Did you know that the number of emergency rooms has decreased since 2001?

Are any of you willing to return to pre-1986 policy, when emergency rooms were not obliged to treat all comers?  Is there evidence on how big a difference this law made?  If we expanded emergency room capacity, but kept current law, would we in effect have national health insurance, paid for by an (implicit) tax on other forms of medical care?

Here is an article on how emergency rooms work.  Here is a claim that most people don’t need to go.  A cross-country comparison of the economics of emergency rooms would make for a fine dissertation, and then some.

A PSA test can reveal the presence of prostate cancer.  But not all such cancers are fatal and treatment involves the risk of impotence.  Do you really want the test?  It’s difficult for patients to evaluate these kinds of risks.  Mahalanobis points us to an article advocating visual tools such as roulette wheels to help patients understand relative risks and chance.  Even better than the diagrams is this impressive video; the video may be of independent interest to the older men in the audience.

Indonesia seems to show a cluster of cases of human-to-human transmission; here is one analysis.  Here is a BBC report.  Sadly Silviu Dochia has had to discontinue writing on our avian flu blog, but if matters get much worse we will resurrect the blog in some form or another.  In the meantime, here are assorted updates.  Here is the home of speculative doom and gloom.

Update: Here is further information, none of it terribly encouraging.

Buried away in a tiny Telegraph column this week was a reference to one of the best academic studies
to emerge in a long time. Doctors in a Scottish hospital have looked at
the hidden costs of charitable parachuting, to the health service in
particular, and published the results in the journal Injury (the link
is to the abstract unless you or your institution subscribe). They
found that the injury rate was 11% and the serious injury rate 7%.
Minor injuries cost the National Health Service £3751 on average and
serious injuries £5781.

As the average parachutist raised all of
£30 (this is just a day out after all) each pound raised for charity
cost the NHS £13.75. Every one of the charitable types who feels
terribly virtuous raising money for charity in this way is actually
preventing the health service treating the sick.

Here is the link, and thanks to Matthew Sinclair for the pointer.  Can you think of other comparable examples of negative charity?

Addendum: Jeff Ely directs my attention to this example; buy and drink some water, so that Starbucks will donate money to address the water shortage (in other countries).

1. All but the very rich must buy health insurance.

2. Business that don’t offer health insurance to their employees will have to pay a tax.

3. Individuals can buy insurance with pre-tax dollars, eliminating the favoritism currently shown to employment-linked insurance.

4. Insurance companies will be subsidized to offer barebones policies to the current uninsured.

There is more, here is a Boston Globe summary.  Here is the LA Times.  The Washington Post surveys various reactions.

Arnold Kling is skeptical:

…the politicians’ plan will force insurance companies to offer
no-deductible health insurance to people on modest incomes, at premiums
ranging from $1000 to $2000 per year. My guess is that the insurance
companies will not be willing to pay for more than about $2000 per
person per year in claims, and they will demand that the state provide
reinsurance for the rest. Given average health care spending in
Massachusetts of $6000, "the rest" could be a big number.

Andrew Sullivan approves, mostly for general reasons — "let the states try."

My take: This kind of approach will prove increasingly popular.  You claim to cover everybody.  It doesn’t sound very socialistic and most of the costs are hidden.  It appeals to voters’ sense of justice; there is a general belief that many individuals and businesses are free-riding upon the ready availability of hospital emergency rooms.  It keeps private insurance rather than trying to eliminate it (single-payer plans) or eliminate its tax advantages (HSAs).  This latter feature I find appealing, since I think the private insurance mode, for all its flaws, is or at least should be, the future of the sector.  "Not enough private insurance" is the relevant externality relative to the social welfare function, not "too much private insurance."  Of course various lobbies — most of all the insurance companies — also will like this feature of the program.

In a political debate, this will, for better or worse, probably crush the more ambitious Democratic plans for national health insurance.

The crunch comes, as Kling points out, when you pretend that covering the uninsured will be cheap or can happen under current levels of program budgeting.  Can you imagine California or Texas, both of which have higher levels of uninsured than Massachusetts, trying such a plan?  The long-run future of the idea replaces the insurance company subsidies with health insurance vouchers for the poor.  They would be means-tested, of course, and the expense would require federal involvement.

To me the Massachusetts plan sounds messy and fragmented.  It is a series of concessions rather than a set of solutions.  It relies too heavily on unfunded mandates rather than improving incentives.  I am not sure it will make anyone healthier.  It does nothing to solve the number one problem of the sector, namely bringing competitive forces to bear on improving product quality, accessibility, and affordability.  I just bought a new Toyota Corolla for a lower nominal (much less real) price than I paid nine years ago for the same but inferior make without side air bags.  Why can’t we have more stories like that in health care?  It is the person who figures out how to point health care competition in the right direction who will deserve the brass ring. 

That all being said, the Massachusetts plan is better than I would have expected.  I am not convinced that the plan will work out badly, at least relative to feasible alternatives.

Seth Roberts’ diet book, The Shangri-La Diet has just been published.  Actually, the Shangri-La Diet isn’t really a diet, it’s a method of suppressing appetite.  Roberts argues that the body follows a simple heuristic – when calories are tasty they must be plentiful so turn up the appetite and stock up when the fruit is on the tree.  But if calories taste like cardboard then times must be bad (why else would you be eating cardboard?) so turn the appetite down and use up those fat stores.  If you had to eat cardboard to lose weight the diet wouldn’t be very appealing but Roberts found that a few hundred calories of extra-light olive oil or sugar water are enough to turn the appetite weigh down (pun intended.)

The book is a quick read and in addition to the diet itself there are interesting asides about science, self-experimentation, the obesity epidemic and other topics.

Don’t take my word for it, however.  The great thing about Roberts’ methods is that you will know whether they work within a day or two.  Buy the book, try it out, you have a lot to lose!

Addendum: Long-time readers may recall that I wrote a brief profile of Berkeley psychologist Roberts and his novel self-experiments.  That profile turned out to be one link in a chain that led to the present book (I am kindly mentioned in the acknowledgments.).