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Robin Hanson passes along the following
It’s typically the son or daughter who has been physically closest to an elderly parent’s pain who is the most willing to let go. Sometimes an estranged family member is “flying in next week to get all this straightened out.” This is usually the person who knows the least about her struggling parent’s health. … With unrealistic expectations of our ability to prolong life, with death as an unfamiliar and unnatural event, and without a realistic, tactile sense of how much a worn-out elderly patient is suffering, it’s easy for patients and families to keep insisting on more tests, more medications, more procedures. …
There is a lot that I wanted say about the mobility debate but my views are so far out of the mainstream I wasn’t sure where to start. This post by Matt Yglesias lets me at least say something.
Washingtonian, like other regional magazines I’m familiar with, does an annual “best restaurants” issue which is different from their “cheap eats” issue. They also have a “best doctors” issue, but there’s no equivalent of the “cheap eats” concept for health care. My best guess is that this reflects the authentic structure of consumer demand. People sometimes want a great big fancy dinner and sometimes want a great deal on a bowl of pho, but on health care what they want to know is who’s the best.
I was in a doctor’s office with a relation and we noticed a sign on the wall that requested patients not wear perfume or scented lotions of any kind. Then there was another sign that requested that you not make loud noises. The doctor was also fidgety, awkward and significantly “goofy looking.”
We had a conversation that I’ll paraphrase like this:
Relation: Maybe he has Fragile X
Me: Doubt it, Fragile X usually implies mental retardation
Relation: He doesn’t seem very intelligent
Me: An IQ of 80 would make it unlikely that he would finish medical school
Relation: I guess that’s right
Which is to say several things.
First, “best” was not a relevant consideration. Can order blood work was his defining characteristic. This is especially true with a primary care physician. Besides being loose with the prescription pad its not always clear what a “good” primary care physician is.
Second, people grossly underestimate the extent to which society is sorted. This leads to people being thought of as stupid who are in fact well into the right of the distribution. In turn, this leads to people underestimating the extent of the meritocracy. What seem like gross violations are on a larger scale minor discrepancies.
That having been said my baseline is that a well sorted meritocracy increases the case for redistribution. The biggest problem with redistribution is that you may upset the sorting.
If the sorting is really tight then you can redistribute a lot and not worry about messing it up.
Her lips were red, her looks were free,
Her locks were yellow as gold:
Her skin was as white as leprosy,
The Nightmare Life-in-Death was she,
Who thicks man’s blood with cold.
~ Samuel Taylor Coleridge
Sarah Kliff follows up on how doctors die. I quote her quoting Sharron Brownlee
There is good evidence that physicians have thought out end-of-life issues more thoroughly than lay people and are more likely to decline medical intervention. For example, they sign advance directives far more often than the rest of us do. Less than half of severely or terminally ill patients have an advance directive in their medical records.
. . .
Why would doctors be so anxious to avoid the very procedures they deliver to their patients every day? For one thing, they know firsthand that these procedures are most often futile when performed on a frail, elderly, chronically ill person.
This is the kind of explanation that resonates with people, but upon closer examination seems unlikely. Is it really that doctors say “Well the chances are low so forget it.”
What do they have to lose? Why not at least try to live?
Having seen this process up close with family member my bet is that they are not afraid the procedure won’t work. They are afraid that it will.
What are in then is the limbo of being undead. Sometimes literally a zombie, lying on the bed incapacitated, unable to communicate. In almost all cases knowing that you have only bought a temporary reprieve and that very soon everyone is going to go through this process again.
Each time your family will be on edge, unable to say goodbye. Each time you will not know for sure whether this is really the end.
I have heard numerous reports of folks with different insurance being denied at the pharmacy. Which means that a number of people I know are already “off their meds.”
This is not going to be pretty folks. Seriously, someone needs to get on this.
I should like to die of consumption . . Because the ladies will say, “look at that poor [Lord] Byron, look how interesting he looks in dying.”
If there is scientific infighting more significant than that over macro-stabilization, it is that going on inside the Psychiatric community.
What make its particularly hard, however, is in most pursuits we can always lean back on the notion that if we hope to make the best world, then understanding the world as it is – not as we wish it to be – is our best hope. This is not true with mental disease.
In many different ways, not just in the debate over psychotropics, the truth may increase suffering. There are times when you know that forcing someone to acknowledge their insanity, is nothing less than cruel. .
Gary Greenberg gives a admirably even handed take – given what I know his beliefs to be – on the run-up to the DSM-5. Of course, he still lobs the standard grenade:
The fact that diseases can be invented (or, as with homosexuality, uninvented) and their criteria tweaked in response to social conditions is exactly what worries critics like Frances about some of the disorders proposed for the DSM-5—not only attenuated psychotic symptoms syndrome but also binge eating disorder, temper dysregulation disorder, and other “sub-threshold” diagnoses. To harness the power of medicine in service of kids with hallucinations, or compulsive overeaters, or 8-year-olds who throw frequent tantrums, is to command attention and resources for suffering that is undeniable. But it is also to increase psychiatry’s intrusion into everyday life, even as it gives us tidy names for our eternally messy problems.
Its standard to object to the medicalization of everyday disorders. Where does it stop, people ask? Is everything a disorder?
It never stops, I answer. And, it’s a disorder if you dislike it.
The normative element in non-mental health conditions is somewhat hidden because death, disability and pain are almost universally disliked. So, if I say cancer is a disease because it kills, no one is likely to object to this. It doesn’t matter that cancer is, almost as much as anything, a part of life.
As far as we can tell no human has ever been born without the propensity to develop cancer. That people don’t die of cancer is purely a function of the fact that they die of something else before the cancer gets them.
So, why is cancer not just a part of life? Part and parcel with being a multicellular organism? The simple answer is that it causes death, disability and pain. These are widely recognized as bad and so is cancer.
What about feeling sad? To my knowledge no human has ever been born without the propensity to feel sadness. Is sadness simply part and parcel with life? The answer from my corner is, not if you don’t want to be sad.
This is the rub in all mental illness. It is the malady of not wanting to experience the world as we do. And, it raises the deepest questions about what it means to improve wellness.
I stick firmly to the notion that we improve wellness when we alter physiology to produce a preferred state of being. Preference is in the eye of the patient.
However, I do know the question “Am I sick?” has moral meaning to people. Giving a name to a condition can bring comfort or despair, even when it doesn’t change the essential experiences of the person at all.
I missed the opportunity last week to welcome Sarah Kliff to the dark side. No matter, belated is better than never. She writes
What if we’re all wrong? What if prevention doesn’t save money?
. . .
How can this be? The idea that prevention saves money feels intuitive. “When we think of prevention, we tend to think of the individual who benefited,” Russell writes. We conjure up an image of the woman who caught breast cancer early, averting expensive treatments, or the man who brought his weight down and lived a long, healthy life. That, however, discounts all the mammograms that didn’t detect cancer and didn’t prevent anything and all the individuals for whom weight management programs didn’t work. All those costs add up to the point that most preventive interventions cost more than they save.
Your sociopath membership card will be in the mail soon.
Alex Tabarrok, writing at Medical Progress Today
Initially, it was hoped that understanding the genetic code would lead to a slew of blockbusters as we found genes that we could simply switch on or off. Instead of finding master switches, however, genome-wide association studies have tended to find lots of small contributors to disease, with different people having different contributors. As more people are sequenced, it is likely that we will discover even greater heterogeneity of both diseases and persons.
Instead, we must move the FDA away from pre-market gatekeeping and towards post-market surveillance and information provision. By lowering the costs of FDA approval we can increase the profitability of researching and developing drugs for small patient populations. Less pre-market gatekeeping should be combined with universal electronic medical records and extensive post-market surveillance. In an optimal system that trades off risk and benefits, and the better post-market surveillance becomes, the more we should reduce pre-market gatekeeping.
This the type of smart near term based regulatory action I am talking about. We don’t have to be right about the future. Personalized medicine might turn out to be crap in the long run, and indeed I would bet the rejuvenation is going to be a generalized blockbuster treatment that makes most of this stuff unimportant.
Nonetheless, we can see the FDA pinching the market for drugs today. We can see the high costs of R&D today. And, we should do something about it today.
Whatever you think of managed care – and I was a fan – its hard to have lived through the 90s and think there is any serious possibility that the private market will be able to constrain health costs in the face of public backlash.
We make policy with the electorate that we have, not the electorate that we wish we had.
I’ll leave the depth of this argument to my next exchange with Robin Hanson. I’ll try to side step the political landmine by responding to some of my fellow economists. According to CNBC, the National Association of Business Economists:
The majority of economists surveyed by the National Association for Business Economics believe that the federal deficit should be reduced only or primarily through spending cuts.
The survey out Monday found that 56 percent of the NABE members surveyed felt that way, while 37 percent said they favor equal parts spending cuts and tax increases. The remaining 7 percent believe it should be done only or mostly through tax increases.
As for how to reduce the deficit, nearly 40 percent said the best way would be to contain Medicare and Medicaid costs. Nearly a quarter recommended overhauling the tax system and simplifying tax rates and exemptions. About 15 percent said the government should enact tough spending caps and cut discretionary spending.
Which is all well and good and we can have a deep conversation about about radical entitlement reform. Though I am skeptical about large scale real-world change, on the blackboard I am sympathetic to arguments that the entire Industrial Planning system surround medical care should be abandoned.
That means in part getting rid of Medicare, Medicaid, health care tax deductions. But, of course more importantly, it means getting rid of the FDA. It means legalizing the production and distribution of all drugs.
It means undoing medical and pharmaceutical licensing. Undoing any qualifications whatsoever for practicing medicine or surgery. Removing any implied responsibility to provide the highest quality service. Removing any implied responsibility to “first do no harm” and generally allowing the medical industry to become a free market.
If you want to buy it and someone wants to sell it, then Godspeed.
Now somehow I think this plan is unlikely to become law anytime soon. However, the same can be said for a plan that dramatically cuts the actual benefits that retirees receive. And, ultimately thats the issue. The reason medical care in the US is expensive is because people use a lot of medical care. If you want it to be cheaper people have to use less.
Good luck with that.
No one has ever done before. People have however successfully raised taxes. I am betting that tax increases are how this gets done.
As I always I struggle between my desire to push what I think are important points to my overwhelmingly well informed readership and my basic belief that there are some conversations that should not be had in public.
I understand that the conversation is being had whether I approve of it or not. Nonetheless, participating is an issue of personal ethics I haven’t completely worked out.
In the past I’ve chosen obtuseness as the middle path. I’ll stick with that for now.
For those inclined to look Professor Kramer of Brown University has a take in a major daily that mirrors much of my own on the issue. Indeed, the problem of improperly selecting test subjects is likely responsible for the general rise in "relative ineffectiveness” we see across the drug spectrum.
In any case, I think the attention this issue gets in terms of medical funding and research is vastly inadequate relative to issues like cancer and heart disease. The landscape is too dominated by folks with strong opinions and axes to grind. While the issue itself is frankly more important than bodily health.
To update C.S. Lewis, you don’t have a mental state. You are a mental state. You have a body.
A while back my co-blogger Adam took a stand against the anti-salt crusaders. In general the state of knowledge about healthy behaviors is fairly low. Pretty much all of us agree that activity is generally good for the cardiovascular system. Pretty much all of us agree that trans-fatty acids are likely bad for the cardiovascular system. We all agree that you need vitamins as well as fatty acids and essential proteins to survive.
I think the agreement pretty much ends there.
Even on issues like smoking and lung cancer – which the vast majority of people consider a closed case – has smart reasonable people arguing the other side. And, admittedly it is damn hard to find a randomized controlled trial that supports the notion that smoking causes lung cancer.
I say that not to cast doubt on the connection between smoking and lung cancer but just to show how hard it is to get any result in the field behavioral health. No one is going to let you forcibly subject human beings to long term exposure to something you believe to be deadly. Thus, scientific progress requires careful inference and is mind numbingly slow.
All that having been said here is the latest on salt courtesy of Huffpost HT to Mrs. Modeled Behavior
In an analysis that set off a fierce debate over the health effects of salt, researchers said on Wednesday they had found no evidence that small cuts to salt intake reduce the risk of developing heart disease or dying prematurely.
In a systematic review published by The Cochrane Library, British scientists found that while cutting salt consumption did appear to lead to slight reductions in blood pressure, that was not translated into lower death or heart disease risk.
The researchers said they suspected the trials conducted so far were not big enough to show any benefits to heart health, and called for large-scale studies to be carried out soon.
Perhaps larger scale studies will yield results. However, the same argument was made about fat and when the newer, larger scale study was done it came out with ziltch. The response was that a study that large could not possibly have the controls necessary to find an effect.
None of this is to say that there isn’t an effect in either case but we should be clear that the evidence is sorely lacking and that public health authorities have been bordering on dishonest about these issues.
I am always one to be skeptical about conspiracy theories but in this case I think the motivation and method used to promote the conspiracy are clear: people thought they were saving lives. Its hard to get people to band together into some giant united effort at deception but the idea that you are saving the world is one of the few things that can do it.
Unfortunately that type of zeal blinds folks to the data.
The salt case was riddled with issues from the start. Not least of which was that there was no real theory here. It is clear that salt could increase blood volume and thereby temporarily raise blood pressure. However, proponents of the salt theory were suggesting that permanent hypertension would result and from the start it was never exactly clear why this should be the case.
This happens shockingly often in medicine and health.
I have repeatedly questioned the value of screening, particularly cancer screening in extending life. I am, predictably, mildly annoyed by the term “preventing death”, since death is unpreventable.
Regardless, a new Swedish study pushes back on my assertions
The study of 130,000 women in two communities in Sweden showed 30 percent fewer women in the screening group died of breast cancer and that this effect persisted year after year.
Now, 29 years after the study began, the researchers found that the number of women saved from breast cancer goes up with each year of screening.
"We’ve found that the longer we look, the more lives are saved," Professor Stephen Duffy of Queen Mary, University of London, whose study was published in the journal Radiology, said in a statement.
From Matt Yglesias:
…the only thing worse than a greedy pharmaceutical company extracting giant monopoly rents from people who need medicine is people who need medicine going without it since there’s no greedy pharmaceutical company on hand to step up and do the regulatory/educational legwork necessary.
Aaron Carol, at The Incidental Economist, has a post showing that disease prevalence (including obesity) in the United States is a very, very small portion of what is driving health care costs:
Before you start in on me about how obesity is linked to other things and such, you should know that the overall McKinsey & Company analysis showed that the prevalences of disease in the US could account for perhaps an extra $25 billion in health care spending. Let me make a new chart for you:
Yes, obesity is more prevalent in the US, and yes, caring for it costs real money. But even if we get obesity down to the levels in other countries, it’s not going to magically erase the problem. We are spending two to three times per person what they are. There is no simple fix here. There is no one, and no thing, we can easily blame.
Everyone, always will look for a scapegoat. It is in our genes. The good vs. evil story is the oldest trope in existence. Look at the current outcry against “evil speculators” in oil markets (I wonder why Krugman doesn’t make a post about that?). Humans live through stories, humans respond strongly to in-group loyalty, humans have value preferences that lead them to view the world radically differently. I’ve often stated in debate that those who think that a single-payer health care system would somehow reduce our expenditures to a level consistent with other OECD countries are dreaming, at best, or delusional, at worst. And every single data point that passes by in the health care debate does nothing but strengthen the position that Robin Hanson articulated: health care altruism is a permutation of our evolutionary drive to “show we care”; or rather, make infrequent, and very large expenditures to show our loyalty to an alliance. The frequency has gotten greater as our society has gotten richer, but the underlying motive is still linked to our evolutionary roots.
Against this strain of thinking is the hypothesis that Matthew Yglesias articulated in his Bloggingheads diavlog with Karl, that people are stingy in the voting booth, but acquiescent in the doctor’s office. So separating payment and service would act as a brake on health care expenditure. I’m very skeptical of this argument. After all, health care expenditures have risen at a higher rate than GDP/per capita in many countries around the world.
A more interesting question, though, is why is the US different? My crude outline of a hypothesis is that people in the US have only recently come to “share a heritage” that is the United States. It’s only been around 100-ish years that people have really come to view themselves as “Americans”. In the absence of a shared heritage (which provides a built-in in-group), it has been especially important to engage in acts that show inter-tribal loyalty. The US spent a greater amount of money/life/time ending slavery, securing women’s right to vote, and ending segregation than a lot of other countries. We’ve also spent more money/ink/time securing a the minimal welfare state that we have, that is exceedingly expensive (relatively speaking). Not surprisingly, we also spend a ton of money/ink/time on health care that is of extremely dubious effectiveness. A cynic might say that this represents the greater wealth of the United States…but that doesn’t really provide an satisfactory explanation. We have low taxes, so we get away with a lot of inefficiency, but I don’t think that is the underlying driver of our proclivity to expend a lot of resources doing different things.
I think that history will show that Robin Hanson is right, and that whatever health care arrangement we devise, it will continue to be significantly more expensive than the world norm. That it has relatively little to do with the structure of the market (though I stand firmly behind a completely free market in primary care/pharmaceuticals [except antibiotics/microbials]), and a lot to do with our evolutionary drive as a “multi-tribal” society.
“I think there’s no question if you take a snapshot, people will run out of money, very quickly [under the GOP Medicare plan if you have cancer]. And if you run out of the government voucher and then you run out of your own money, you’re really left to scrape together charity care, go without care, die sooner. There aren’t really a lot of options.”
Her answer was strong stuff, suggesting that the GOP plan could cause people to “die sooner” if they had cancer and ran out of money. We have been critical of some of the ways Republicans have described the plan, but is this even remotely possible?
I didn’t read it that way. I thought she was saying that dying sooner was the alternative to either getting charity or going without care. This is an essentially correct riposte to an argument I have been making.
For a while, the prevention people tried to make the case that taking action to detect and treat disease early would bring down costs. I, among others, argued this was nonsense. The real way to bring down health costs is to eschew prevention and let disease progress to the point where death comes quickly and without warning.
The earlier you catch a disease the more likely you are to spend a bunch of money treating it. This is only made worse in the rare case that the treatment is successful. At that point you have already dumped a bunch of money into someone who is likely going to come back with another disease later.
In response, folks began arguing that people like me thought the best way to save money is to have people die quickly. And, in my case that is utterly true. I do believe that. Though my point really centered around early detection.
I hoped that this realization would help people get at the problem of affect. Saving money sounds like a good thing. Early detection sounds like a good thing. Its natural to think that they go together. However, they are actually opposites.
This happens all the time. People think that bad things beget other bad things and that good things beget other good things. But, good and bad are properties assigned in the mind. Cause and effect extend from the relationship between real things in space-time.
The two don’t necessarily overlap. We make major reasoning mistakes when we assume that doing good things will have good consequences. Consequences have nothing to do with good or bad. They simply are.
On Blogging Heads with Matt Yglesias and I think I know how to share it now. Nope, the video shows up in my preview but as a link on the actual site.
We do a long ramble moving from Osama to the Fed to Health Care.
I get the feeling that the discussion on health care is not easily absorbed. Either I am mistaken or blogging heads commenters missed the point.
The core case is this:
Look free market medicine might be a great idea, but there is no precedent for it happening. The real choice is between an stingy government run sector that actually spends less money on health care or a less stingy government subsidized sector that spends more money on health care.
Further, in any case there is nothing akin to consumer soverignty in Medicine because first drugs have to be approved by the FDA, or else its illegal to prescribe them. Then you have to convince a licensed physician to prescribe them or else its illegal to buy them.
And, remember the part of medicine that does most of the curing is the actual medicine part, which is the most fiercely regulated.
A true free market in medicine would let people create whatever drugs they wanted, however they wanted and would let consumers buy whatever drugs they wanted however they wanted. If someone chose to get the advice or consul of a physician then fine, but there would be no law making them do so.
Given that this is not likely to happen any time soon our real choice is between bloated medicine and austerity. Since in practice Socialized Medicine is austere medicine, I wonder if this could actually get Bryan Caplan on board for fully socialized health care.
Some time ago I challenged those who don’t believe that paternalistic regulation is characterized by a slippery slope to provide some examples of regulation that would prove them wrong. The problem I saw was that paternalism fans always deny the slippery slope exists by claiming that new regulations are just reasonable policies. But of course this is how the slippery slope works, as today’s new policies will be used to justify future policies and to make them look reasonable. After all, every new step is only a small distance from where we are currently standing, but what are we walking towards? Nobody took the challenge, but pivoting off of San Francisco’s Happy Meal ban I did makee some predictions about future likely paternaism:
Making fast food less attractive may protect parents when they happen to be near a McDonalds with their kids, but it doesn’t protect them from having McDonalds reach out to children in the first place and getting it into their heads that their food and toys are awesome. If you’re going to stop this problem, it must be at the root. One way to do this is to ban advertising of fast food targeted at children. This would probably start with children specific magazines and TV shows, but move to a general ban.
Now regulators are helping to make my predictions come true, as they attempt to place limits on advertising by food companies to children. Here is how Ad Age describes the guidelines:
…the rules would start in 2016 and only allow foods that contain no trans fat and not more than one gram of saturated fat and 13 grams of added sugar per “eating occasion” to be marketed to children. Also, the foods could not contain more than 210 milligrams of sodium per serving. The sodium restrictions would tighten by 2021. In a concession to industry, the rules do not include “naturally occurring” nutrients. Additionally, the foods must provide a “meaningful contribution to a healthful diet,” including from at least one major healthy food group such as fruit, vegetables, whole grain, fish, eggs and beans.
The guidelines are said to be “voluntary”, but as Ad Age points out this is a little murky:
Although not binding, whatever emerges in the final report to Congress will likely be adhered to in some fashion because the rules are put forth by a quartet of agencies that have strong sway over marketers, including the FTC, Food and Drug Administration, Centers for Disease Control and Prevention and Department of Agriculture. “Despite calling these proposals ‘voluntary,’ the government clearly is trying to place major pressure on the food, beverage and restaurant industries on what can and cannot be advertised,” the ANA said in a statement.
I would be interested in reading more about the “strong sway over marketers” that these agencies have, and exactly how the nominally voluntary guidelines would be non-voluntary in practice. This will probably come to light, as Ad Age says that this announcement is only an “opening salvo in what will be a lengthy debate between government and industry on how to solve the growing childhood obesity crisis”.
If paternalists truly were concerned about reducing childhood obesity and not simply trying to make themselves feel good, then they should be willing to include in these regulations a sunset provision that repeals them if they don’t have a demonstratable impact on childhood obesity rates in 5 years. My guess is that paternalists wouldn’t go for this, because deep down they know this isn’t going to make much if any difference in children’s health and are really interested in banning something they find distasteful.
The slippery slope from here is pretty obvious: strictly non-voluntary guidelines that require any food packaging or advertising of must be approved by a regulatory agency and subject to standards similar to those above. But we know that advertising isn’t the only way that companies influence purchasing decisions. Why shouldn’t the color of packaging be regulated? I’m sure behaviorlists can tell us which colors children like most, and I’m sure regulators would be happy to insist on gray boxes for unhealthy foods. Children are also probably more drawn to items low on grocery shelves or in the checkout aisle, so why shouldn’t regulators determine where in a store products can be placed?
I’ll repeat my challenge to paternalists: if this isn’t evidence of the slippery slope of paternalism, then what would be?
Tyler Cowen reposts the question
Have you ever forgone health insurance for yourself to cover your pets?
I don’t know about forgone per se. However, for a few years my dog had health insurance and I did not.
I ultimately got rid of the pet insurance not because I didn’t get vet services but because filing the claims were too complicated.
At heart my consumption of Vet services was a asymmetric information problem. I felt comfortable managing my medical care and refusing much of what doctors would offer. However, I could not talk to my dog. Sometimes she would yelp in pain and I wouldn’t know what was wrong.
Taking her to the Vet was sometimes the only way to find out.
Paul Krugman is upset about Obama’s appeasement of the right
The Post says that Obama is going to more or less endorse Bowles-Simpson in his Wednesday talk.
Matt Yglesias joins
Once the President of the United States accepts the premise that it’s reasonable to ask him to make concessions in exchange for an increase in the debt ceiling that both John Boehner and Eric Cantor have conceded is necessary, he’s giving away the game.
Mike Konczal has general disapproval
At the end of last year I wrote a post about how President Obama is bad at losing. I like that conceptual model because the idea that President Obama is bad at losing – that he loses in a way that conflicts his base, concedes too much to his opponents and doesn’t leave liberalism in a better position to fight next round – is robust to many different ideas about the current state of Democratic Party.
I’ll offer some amateur outside the beltway strategery analysis. Given the behavior of the Obama White House, it looks to me like their primary objective is to secure an expansion in the scope of government funded health care by avoiding conflict on all other issues.
This explains the steady even if bloody push to pass the PPACA. It explains the seeming disinterest in meaningful shifts in policy in other areas. It explains why Obama was for the stimulus when it seemed popular and conceded to austerity when it seemed popular.
This is a classic Fabian approach. Avoid engaging the enemy when time is on your side. This also seems like an accurate description of the progressive movements position. While at the moment Progressivism may lose a head-on confrontation, time is indeed on its side. Its opposition is older and grounded in institutions which are losing power. The intellectual base of the right is eroding. Political opinion is solidifying around the notion that there will be some form of universal health care.
As always the Fabian defense is unpopular with hawks, who would prefer that the enemy be engaged and crushed. However, it is successful.
Now as always I think the politics of these big issues is not that important. I suspect that in the end the equilibrium will be determined by fundamentals. However, if you were going to play a pro-progressive political strategy this doesn’t seem like a bad one.
Recently a panel of experts was convened by the FDA to re-examine whether artificial food coloring causes hyperactivity in children. They concluded that evidence did not show a link between the two, stating the following:
Based on our review of the data from published literature, FDA concludes that a causal relationship between exposure to color additives and hyperactivity in children in the general population has not been established
Marion Nestle, a frequently quoted expert on food policy and Professor of Public Health and Sociology at NYU, wrote about the issue on her blog and at The Atlantic. It was unclear to me from what she wrote whether or not Dr. Nestle agreed with the panel’s decision to not ban these products, so I emailed her to see if she would answer a few questions for me, and she kindly complied. I think the exchange is illustrative of two very different ways of thinking about regulation, and what regulators should consider. Below is a lightly edited version of our email exchange:
AO: I’ve been reading what you’ve written on food coloring, it’s not clear to me whether you’d support a ban on food coloring or not. I was hoping you could tell me what your position on the policy is.
MN: Since they are unnecessary and deceptive, I can’t see any reason to do anything to protect their use.
AO: You say that food coloring is “unnecessary and deceptive “. But couldn’t you say the same thing of essentially any garnish or cooking technique designed to make food appear more appealing without physically modifying the flavor?
MN: The issue is artificial. Food garnishes and cooking techniques are usually not.
AO: You say that food additives aren’t “needed” but there are many ingredients and foods which aren’t “needed” given the variety of substitutes and choices we have. If you’re looking at how much a product is worth to consumers, and trying to understand how consumers will be harmed by banning it, isn’t “valued” a more appropriate criteria than “needed”? Shouldn’t that be what regulators consider?
MN: Valued by whom? Industry, certainly. Food is fine as it is. It doesn’t need artificial enhancements. Foods that “need” artificial dyes are not really food. They are “food-like objects.”
AO: You imply in your blog post that if this food coloring is banned, people will eat less of the unhealthy foods that use it. Why would people eat less of these foods when artificial coloring is taken out if they didn’t value that coloring? Doesn’t it have to be the case that they like it less, or that prices go up? And in either case don’t consumers have less of something they value?
MN: Surely, artificial food dyes can be replaced by something better.
AO: If a parent wants to know whether a food contains coloring, can they find out that information today?
MN: To some extent, but the labeling rules leave lots of room for loopholes.
AO: In your blog you also say that parents of hyperactive kids can easily do their own experiments. Are the available labels sufficient for this? Or are clearer labels needed?
MN: My advice to everyone (only slightly facetious) is not to buy foods from the center aisles of supermarkets, and to avoid buying anything with more than five ingredients, anything they can’t pronounce, anything artificial, and anything with a cartoon on the package. That should take care of most problems.
I confess, I did not see this one coming: the Center for Science in the Public Interest has asked the government to ban food coloring. They argue that the coloring worsens hyperactivity in some children. Marion Nestle recently provided a rundown of the science behind food coloring and hyperactivity, and I think you’ll agree with me that the evidence is less than overwhelming. She only discusses two studies in detail. The first had problems, and the second found that 1 out of 23 kids showed a reaction. She links to another, more recent study but doesn’t discuss it. You would think we would need clear and strong evidence of a serious affect before we talked about banning a product.
Nevertheless, whether or not food coloring causes hyperactivity in some children is absolutely besides the point. Surely a cup of black coffee would cause hyperactivity in children, and yet we haven’t banned it. The absolute most this implies is for a clear labeling of products that include food coloring. I say a “clear labeling”, because I was under the impression that product packages already had to list their ingredients, including food coloring. Am I mistaken?
Food paternalists may find this unimaginably barbaric, but some people like a little color on their cakes, and prefer their cheese curls orange. In fact, given the prevalence of orange cheese curls, colored cakes, and a million other uses for food coloring it would appear that lots of people really do like them. But the fact that people prefer them is exactly why food paternalists are targeting them, and the hyperactivity claim is really just an excuse. You can see this in the quote from Marion Nestle:
“These dyes have no purpose whatsoever other than to sell junk food,” Marion Nestle, a professor of nutrition, food studies and public health at New York University.
This issue isn’t really about hyperactivity, it’s about another cudgel with which to try and get people to eat healthier foods. This is an invasive, overreaching, and dishonest attempt at regulating food. I hope that the more extreme the proposals get the more people will hesitate to support the groups like CSPI when they call for bans on stuff they don’t like. Because today they may be coming for a product or ingredient you don’t value, but rest assured, tomorrow they’ll be after something you do.
Many things Modeled Behavior come up in Matt Ridley’s suggestion that we use vouchers to combat obesity.
After all, as Friedrich Hayek pointed out, the true genius of markets is that they discover things. Perhaps the answer to obesity is to spend money not on the producers (of gyms, diets, surgery, vegetables) but on the consumers.
The genius of the market is the way it aggregates masses of information that no single individual could possibly possess and subjects scores of untestable hypothesis to the forces of economic evolution. This allows us to do without knowing what we do and to design without a designer. Great and beautiful things.
However, raw scientific and administrative knowledge are powerful things as well. Indeed this is revealed by the emergence of socialism as a doctrine. It was in large part the ability of technocracy to win wars, purify water and cure diseases that inspired folks to believe that technocracy could do anything.
Drawing a direct analogy with the effect of vouchers in the education system, Messrs. Seeman and Luciani suggest “healthy-living vouchers” that could be redeemed from different (certified) places—gyms, diet classes, vegetable sellers and more. Education vouchers, they point out, are generally disliked by rich whites as being bad for poor blacks—and generally liked by poor blacks. A bottom-up solution empowers people better than top-down government fiat.
This is certainly true, though I am not sure it really gets you anywhere. Lack of empowerment doesn’t seem to be the core problem here. The number of private weight loss attempts that fail every year far exceed those that succeed. People can and do try wacky individualized weight loss programs. Entrepreneurs can and do promote all manner of weight loss products. The overwhelming majority just fail.
After all, the root causes of obesity are multifarious and new ones are being added all the time—such as diet sodas, gut bacteria, genes, sleep apnea, leptin levels, medication, depression, poverty and peer pressure. So the solutions need to be multipronged, too. What works for you may not work for me.
The underlying notion here – that the obesity epidemic is a multipronged problem with lots of individual causes – is likely wrong. There are lots of levers with which one can attack obesity. There are lots of failsafe systems that exist in the regulation of appetite and activity and they can be overridden in different ways. However, the odds that an epidemic with the steady widespread march of obesity is multi-factor are slim. There is probably a single cause and it probably operates directly on the endocrine system. Of course at this point we don’t know what it is, but I suspect that it is a particular molecule or class of molecules.
People in the future will think it as toxic and find it amazing that we were so careless with it. The same way we think it maddening that children used to play with mercury.
In due course, the obesity problem will be solved, I suspect. The ultra-rich have already solved it. Most of them are very thin these days, quite unlike in ancient times. That’s because they can afford the solutions that work for them, from low-carb diets to personal trainers.
In due course I expect it to be solved as well. However, the notion that the ultra-rich have solved it is wrong. First, off there are obviously selection effects that decrease obesity levels among the rich. You are more likely to become rich, by business success and especially by marriage, if you are thin.
Second, we know that susceptibility to obesity is highly heritable. This means that the children of a rich spouse and a thin spouse are more likely to be both rich and thin. A similar effect happens with height. The rich are likely to be tall. Yet, this isn’t because they’ve found a solution to shortness.
Third, as Ridley suggests the rich are spending lots of time and money on combatting what obesity they have. This is not solving the problem. This is managing the symptoms of the problem. Whatever underlying condition is forcing you to expend all of this effort still exists. Its that underlying condition that we want to cure.
For example, managing Tuberculosis by moving to a dryer climate is better than dying in the sewers of Paris, but its not the same as curing TB. Tuberculosis in some ways provides an analog to obesity. It is a disease that has been with us since antiquity yet saw an enormous, at the time inexplicable, spike in the 18th century.
Theories on the cause of tuberculosis ranged from vampirism to masturbation to impure air. It was argued that a variety of maladies could lead one to succumb to Consumption, as it was then known. Consumption was also endemic among the urban poor, a fact sometimes attributed to their low moral character.
Yet, in the end it was a single disease with a single cause and streptomycin was the cure.
We had the debate over the efficacy of health insurance in light of the poor efficacy of modern medicine. The common reconciliation is that uninsured get such bad treatment they end up worse off. In many cases worse of than Christian Scientists, who receive no treatment at all.
Another hypothesis I was kicking around was this: perhaps its not the medicine at all. Perhaps it’s the insurance. We know that stress is harmful and dealing with health care bills can be among the worst stressors at the worst time.
Could the effect be that large?
The psychological effects were the biggest health effects of all — by far,” said Fred Mettler, a University of New Mexico professor emeritus and one of the world’s leading authorities on radiation, who studied Chernobyl for the World Health Organization. “In the end, that’s really what affected the most people.”
Fears of contamination and anxiety about the health of those exposed and their children led to significantly elevated rates of suicidal thinking and anxiety disorders, and rates of post-traumatic stress disorder and depression about doubled, Mettler and others said.
“The effect on mental health was hugely important,” said Evelyn Bromet, a professor of psychiatry at Stony Brook University who studied the aftermath of Three Mile Island and Chernobyl. “People’s fears about getting cancer, or their children getting cancer, and family and friends dying from radiation exposure were very intense.”
Now granted this is because people are overaffraid of nuclear radiation and that affects both ends. The direct danger is usually pretty low and the stress is extremely high.
Still it notches up the insurance alone does a body good, hypothesis.
Onen thing that seems to pop up over and over is that chronic extreme stress is really not good for you. Not, in a you should eat more leafy greens kind of way. But, in a you shouldn’t smoke three packs a day or have more than 5 alcoholic drinks a day, everyday kind of way.
Since I can remember I’ve loved reminding my audiences that economics is not morality play. It wasn’t until Paul Krugman started blogging that I realized that I must have picked it up from one of his early writings.
That virtue can sometimes be vice is one of the most fun lessons of economics. There is a perverse delight in explaining how foreign aid may impoverish the Third World but sweatshops would make it grow rich.
I can understand why many of my fellow economists were so eager to transport this insight to the political realm. Politics they argued was a fight between interest groups – a battle over the fiscal commons. There weren’t good guys and bad guys. There were just naturally self-interested people.
Tyler Cowen pays homage to this legacy in a recent NYT piece
James M. Buchanan, a Nobel laureate in economics — and my former colleague and now professor emeritus at George Mason University — argued that deficit spending would evolve into a permanent disconnect between spending and revenue, precisely because it brings short-term gains. We end up institutionalizing irresponsibility in the federal government, the largest and most central institution in our society. As we fail to make progress on entitlement reform with each passing year, Professor Buchanan’s essentially moral critique of deficit spending looks more prophetic.
Curiously Tyler refers to a rational actor model as a moral critique but then again he certainly knew Buchanan better than I.
Still, to borrow a phrase from another of my favorite economists, the only problem with this analysis is that it is at odds with the facts.
If we want to build a model of what the government spends money on we would be best to start this way: ask people what social obligations do they believe “society” has. Look around for the cheapest – though not necessarily most efficient – programs that could credibly – though not necessarily effectively– address those obligations. Sum the cost of those programs. That will be government spending.
Contrary to Jonah Goldberg and others who see Canada and the United States as examples of two clashing ideologies, they are actually examples of two different ethnic distributions. The United States is not Canada because there is ethnic strife between Southern Blacks and Southern Whites. That strife reduces the sense of moral obligation on the part of the white majority and so reduces government spending.
I want to be very clear that I don’t say this to paint those against social spending as racists. From where I sit I am betting that most of the intellectuals lined up against expanding the welfare state are naively unaware that their support rests upon racial strife. Otherwise they would realize that as America integrates they are doomed. They are fighting as if they believe they have a chance of winning. Given the strong secular trend in racial harmony, they do not.
I point this out also to show why the major Republican strategy for limiting government was doomed from the start and why I am also not particularly worried about Americas fiscal future per se.
In the 1980s some conservatives believed that they might not be able to cut government but they could cut taxes and thereby starve the beast. Rising deficits would force the hand of future governments. Spending would have to be cut in order to bring the budget into balance.
Much of the current handwringing about fiscal irresponsibility is a sense of alarm not only on the right, but throughout much of the political center, that these spending cuts are not actually materializing.
But, by what theory of government did you ever believe they would? Governments don’t look at how much money they have and then decide what they want to buy. They decide what they want to buy and then they look for ways to fund those purchases.
Divorcing the two – through sustained deficits – was only going to lead to ever increasing levels of debt. This is what we got. At no point was the beast ever starved. The peace dividend lowered government spending growth somewhat, but that was undone by the war on terror. Otherwise spending hummed along, as it always will, with the government buying things the public thinks it ought to buy.
Yet, if this is causing upset stomachs among many of my fellow bloggers it calms mine. Its quite clear how this will end. Racial strife will continue to abate. The public will coalesce around the welfare state and taxes will be raised to meet the cost.
The fundamentals do not predict rising debt forevermore. The fundamentals predict a VAT.
This is not to say I am unconcerned about our economic future. Health care costs will continue to eat up more and more of our economy unless something is done. However, trying to convince people that health care is not a social obligation a fool’s errand. The best you could do is convince them we have no obligation to the other. As the other integrates this will likewise prove impossible.
No, people will ultimately believe that health care for all is a social obligation and therefore government will pay for it. There is no more analysis to be done on that part of the question.
The only part left is looking around for the cheapest program. This is where our attention should be focused. Can we lower the cost of those obligations? Can we make medicine more efficient?
If we can there will be economic room for other things. If we can’t, well just hang in there until the artificial intelligence revolution.
Ezra Klein pinch hits for the med skeptics
File this one under "health care doesn’t work nearly as well as we’d like to believe." A group of researchers followed almost 15,000 initially healthy Canadians for more than 10 years to see whether universal access to health care meant that the rich and the poor were equally likely to stay healthy. The answer? Not even close.
. . .
The problem, the researchers say, is that the medical system just isn’t that good at keeping people from dying. "Health care services use by itself had little explanatory effect on the income-mortality association (4.3 percent) and no explanatory effect on the education-mortality association," they conclude.
Ezra seemed to backtrack a little in a later post but I can see he really wants to come over to the skeptical side. Don’t let Tim Carney’s abrasiveness scare you away. The skeptics really are a nice, internally consistent bunch.
I, for example, have never paid a dime of my own money for my own health insurance. I have always chosen the lowest quality health plan when rolled into my employment package and no health plan when not.
Really quickly I’d also just like to plant another seed. There are clear cases when medical care saves people’s lives. However, if access to more medical services isn’t associated with a longer life, then we have to take seriously the proposition that medical care is also causing a significant number of deaths. I’ll get into the life expectancy of Christian Scientists in another post.
All that having been said, what I really wanted to talk about the possibility of education improving health outcomes.
Ezra goes on
Rather, the best way to make people healthier would be to get health-care costs under control so there’s more money in the budget for things like early-childhood education and efforts to strip lead out of walls, both of which seem to have very large impacts on health even though we don’t think of them as health-care expenditures.
Arnold Kling cosigns on the general concept education for health
My guess is that if you want to improve health outcomes in the United States, ignore health insurance and focus on literacy. Even if it has nothing to do with whether or not they can follow a doctor’s written instructions, my guess is that better literacy has a positive impact on health outcomes.
I am skeptical about a fundamental link here. I suspect we have two things going on.
First, education confers status and status is related to health outcomes. For example Oscar winners live longer than those simply nominated. How this link occurs is not totally clear. It seems that the hormones associated with stress and disappointment – cortisol for example – reduce long run health. However, this may not be the mechanism. No one really knows at this point.
Second, for a long list of reasons there is correlation between education and physical attractiveness. Physical attractiveness is by evolutionary design a proxy for health. Which to say, healthier folks are more likely to become well educated.
This makes me doubt that power of health improvements from increasing education.
In general it is just damn hard to improve health outcomes. Our bodies are the product of about 4 billion years of evolution. Just making sense of how they work is hard enough. Making them work better is a herculean task.
In the debate over public sector unions a lot of liberals have been arguing that they are a positive political counterweight to corporate interests and a defender of the working man, and without them democracy will fail, the American Dream will die, and the earth will drift into the sun… or something like that. I recently provided an example via twitter that I thought demonstrated this isn’t always the case: teacher union opposition to charter school caps, which you’d hardly call good for working class people.
Kevin Drum responded that a single incidence of union political malfeasance doesn’t make them bad overall. Well that would indeed be a silly argument to make, and were this the only example of unions being on the wrong side of educational reform then that clearly would be the argument I was making. But do I really have to run down the litany of bad policies unions have fought to keep, and good policies they’ve fought against in education reform? A clear indicator of how bad they’ve been is that the most anyone will say in their defense on education reform is that “well, some unions are embracing reform now in some places!”. That’s some defense. As Megan McArdle sarcastically pointed out on twitter “to be fair, it DID only take thirty years”.
But is education reform the only place the public sector unions have been a very important obstacle to good policy? Here’s another important example from Ezra Klein from way back in the health care debate:
I have bad dreams. Nightmares, really. They used to be pretty rare. Every fortnight, maybe. But ever since the public employee unionAmerican Federation of State, County and Municipal Employeestook a knife to Sen. Ron Wyden (D-Ore.), they’ve been coming more frequently.
Wyden, after all, is a liberal Democrat. AFSCME is a left-leaning union. Both are desperate for health reform. But AFSCME is spending its time attacking Wyden. Why? Because Wyden wants to replace the employer tax exclusion (I told you that thing was important!) with a progressive tax deduction that all Americans, not just those with good employer benefits, would get. That means the poorest among us would get slightly more and AFSCME’s members might get slightly less….
They’re hitting Wyden to demonstrate their willingness to attack anyone who touches their tax benefit. This is less an assault on Wyden than a warning to Wyden’s colleagues.
And AFSCME isn’t necessarily alone. The Health Care for America Now coalition, which includes AFSCME and other unions, has come out against touching the employer tax exclusion…
And all this elides a simple fact: Capping the employer health care exclusion is good policy. Eliminating it entirely would be better policy.
Of course, critics will say “Ok, you’ve got two policies charter school caps and the employer tax exclusion for health care.” But education reform is a big one, and obviously about more than charter schools caps, and as I’m sure Ezra would agree, getting rid of the employer deduction would be a really big step in reforming health care. But really, my opposition to unions can stand on economics alone: they’re an anti-competitive cartel, and like other cartels are economically undesirable. It’s union defenders who need to appeal to the political power of unions to explain their desirability. I’m just pointing out some pretty terrible examples where this isn’t the case. See Megan for more.
A problem I have tried to highlight is that healthism (medical care, “healthy lifestyles”, prevention, etc) does not always lead to better average outcomes.
A study I just ran across offered people a choice between enhanced probability of survival, a pretty major health outcome, and raw healthism. The people chose healthism.
Cure me even if it kills me: preferences for invasive cancer treatment.
PURPOSE: When making medical decisions, people often care not only about what happens but also about whether the outcome was a result of actions voluntarily taken or a result of inaction. This study assessed the proportion of people choosing nonoptimal treatments (treatments which reduced survival chances) when presented with hypothetical cancer scenarios which varied by outcome cause.
METHODS: A randomized survey experiment tested preferences for curing an existent cancer with 2 possible treatments (medication or surgery) and 2 effects of treatment (beneficial or harmful). Participants were 112 prospective jurors in the Philadelphia County Courthouse and 218 visitors to the Detroit-Wayne County Metropolitan Airport.
RESULTS: When treatment was beneficial, 27% of participants rejected medication, whereas only 10% rejected surgery with identical outcomes ( 2 = 5.87, P < 0.02). When treatment was harmful, participants offered surgery were significantly more inclined to take action (65% v. 38%, chi(2) = 11.40, P = 0.001), even though doing so reduced overall survival chances.
CONCLUSIONS: Faced with hypothetical cancer diagnoses, many people say they would pursue treatment even if doing so would increase their chance of death. This tendency toward active treatment is notably stronger when the treatment offered is surgery instead of medication. Our study suggests that few people can imagine standing by and doing nothing after being diagnosed with cancer, and it should serve to remind clinicians that, for many patients, the best treatment alternative may not only depend on the medical outcomes they can expect to experience but also on whether those outcomes are achieved actively or passively.
Now, there are lots of reasons why this might make sense. People want to go down swinging. They want to feel like they did something.
It may be that on a deep level we are not programmed to avoid death so much as we are programmed to fight for life. This makes perfect sense as an evolutionary design. Attack-threats-to-life is an easier problem to solve than maximize-life-expectancy and in the natural environment the two are likely to yield roughly the same answer.
However, in the modern environment this is not always the case. Sometimes taking a wait-and-see approach is the optimal survival strategy, even if it doesn’t feel right.
The policy question within all of this is whether or not the government should subsidize, fully in some cases, people making choices which are likely to lead to worse health outcomes. I am of course not suggesting that people, not be allowed to pursue worse health outcomes if that’s what they want.
However, should the state be picking up the tab?
Don’t do it, Ezra. You just calmly finish drinking that diet soda and don’t concern yourself for one second. I know you’re worried, because you fearfully tweeted earlier today about this Tom Philpott story at Grist about how diet soda causes cancer. But the best thing you can do for your health is not listen to Tom Philpott, because the unnecessary stress caused by worrying about the aspartame in your diet soda is far more dangerous for you than the aspartame in your soda. Philpott brings two pieces of evidence to bear in his argument that diet soda is bad, neither of them will be unfamiliar to you if you’ve followed the debate (I use the term “debate” loosely, in the same sense that we’re “debating” whether 9/11 was an inside job). The first is the old story hippies tell each other around the campfire about how Donald Rumsfeld and Reagan-fueled ’80s snuck aspartame past the FDA with all sort of hijinks. Not only is this story old, so too is it’s debunking. The GAO was asked in 1987 to do a full retrospective study of the approval of aspartame by the FDA and here is what they reported:
FDA adequately followed its food additive approval process in approving aspartame for marketing by reviewing all of Searle’s aspartame studies, holding a public board of inquiry to discuss safety issues surrounding aspartame’s approval, and forming a panel to advise the Commissioner on those issues. Furthermore, when questions were raised about the Searle studies, FDA had an outside group of pathologists review crucial aspartame studies.
The second piece of evidence is a study by the Ramazzini Foundation, whose name also familiar to anyone following the aspartame “debate”. Here is what the FDA had to say about this study in September of 2010:
FDA could not conduct a complete and definitive review of the study because ERF did not provide the full study data. Based on the available data, however, we have identified significant shortcomings in the design, conduct, reporting, and interpretation of this study. FDA finds that the reliability and interpretation of the study outcome is compromised by these shortcomings and uncontrolled variables, such as the presence of infection in the test animals.
Additionally, the data that were provided to FDA do not appear to support the aspartame-related findings reported by ERF. Based on our review, pathological changes were incidental and appeared spontaneously in the study animals, and none of the histopathological changes reported appear to be related to treatment with aspartame.
The FDA aren’t alone in believing aspartame doesn’t cause cancer. They’re joined in this conclusion by The American Cancer Society, National Cancer Institute, National Institutes of Health, and the Mayo Clinic. So you can trust Tom Philpott and the Ramazzini Foundation or you can trust the most highly esteemed medical institutions in the United States. Like I said Ezra, drink up.
If you want even more details about this tall tale (let’s face it, you don’t), here is an older post where I dig in much more.
What is it about smallness that turns erstwhile progressives into the next pro-business lobbyist? I think the fetishization of small, whether it’s small businesses or small farmers, does a huge disservice to welfare generally, but in particular it can easily get in the way of policies and outcomes that progressives care about.
Case in point is Marion Nestle discussing Walmart’s new healthy foods initiative. Now sketpicism is of course merited anytime a business appears to be doing something that is less than profit maximizing, but skepticism about efficacy is not what bothers me about Nestle’s take. No, it’s worrying about how the policy will affect our cherished smallness:
Walmart says it will price better-for-you processed foods lower than the regular versions and will develop its own supply chain as a means to reduce the price of fruits and vegetables. This sounds good, but what about the downside? Will this hurt small farmers?…
And then there is the one about putting smaller Walmart stores into inner cities in order to solve the problem of “food deserts.” This also sounds good—and it’s about time groceries moved into inner cities—but is this just a ploy to get Walmart stores into places where they haven’t been wanted? Will the new stores drive mom-and-pop stores out of business?
Now we should consider all costs and benefits when examining policies, but the displacement of inefficient businesses by more efficient ones while making poor people healthier and providing consumers more choices doesn’t strike me as a particularly important cost economically. As to whether a coherent set of progressive values should lead you to consider the interests of upper and middle class capital owners when evaluating policies designed to help poor people, I’ll leave it to those in possession of such values to debate.
One of the obvious areas where Tyler’s thesis will run into controversy is in Medicine. Medicine is the most obvious place to look for innovation outside of the information sector.
Its also where a big chunk of the middle America’s paycheck has gone. Its not much of a stretch to say that if you think medicine has done a lot of good then you think the last 30 years have been good for the average American. If not then not.
Here I tend to side with Tyler. I don’t think most medicine has done that much good and I am not optimistic about the usefulness of most future medical spending.
This is not to say I don’t think there will be important breakthroughs. I think there will and the next fifty years will be exciting on that front. Its just that along the way we will dump a bunch of GDP down the drain, paying for medicine that is not so good.
The question is why are we doing this?
I have struggled with this. Is it because medical breakthroughs are reaching diminishing marginal returns. That doesn’t seem right because quite frankly there weren’t that many breakthroughs in the past.
We have vaccines, antibiotics, sterilization and anesthesia. That’s about it for really big time breakthroughs.
The view I subscribe to currently is that most people don’t care that much about increasing their life expectancy, they care about being cared for and being cared about. They care about reassurance and they care about feeling like they are not alone.
We can see that people don’t care that much about maximizing their life expectancy because they place an enormous premium on their doctor’s bedside manner and a much smaller premium on his error rate. We can see that when objectively bad doctors who are nice rarely get sued for malpractice, while much better doctors ,who are assholes get sued all the time.
We can see that when we offer potential surgical patients stats on the number of fatalities at prospective hospitals and they refuse them. We can see that when message boards about doctors are filled with comments like “He really understood me.” “She took the time to stop and listen. “ “I knew they cared about whether I got better” “I was more than just a number.”
These are not comments about the skill of the medical provider but about the caring of the medical provider.
Now, when I present this stuff to my students they often say: but a doctor who cares will do a better job and so you are more likely to live longer.
Lets ignore the fact that if this were true it should be captured in the doctors’ stats. Suppose that it is true. Then why in the world are we investing all of this time an energy selecting really smart students and then putting them through years and years of training if the main thing that matters is how much the doc cares?
Dealing with this is a real puzzle. Though I am a free market person, I see the price system’s big advantage is that it conveys information. In medicine virtually no information is conveyed through price. People at all levels are confused about what they really want or what we should do.
For example, when I speak with doctors the issue of non-compliance often comes up. This is typically to explain why treatments that look good in clinical trials don’t work out as well in real life.
Non-compliance is the issue of getting patents to go along with some aspect of the treatment they don’t want to go along with. I argue that if the treatment only works if the patient does something that he or she isn’t going to do, then the treatment doesn’t work. Doesn’t matter what JAMA says. To the docs I say, you go to war with the patients you have, not the patients you wish you had.
To society at large, however, I say, we have to rethink what we are doing here. Ultimately, we want to make sure that we are spending money to make someone better off. If the doctor is complaining, the patient is complaining, and either the insurer or the government is getting a huge bill, then exactly who are we serving here?
It’s my inclination to be drawn to studies showing that we waste money on medical care. This is probably because the fact that so much medical care has no impact, or worse, on actual health outcomes is a underappreciated and counterintuitive truth than the fact that some medical care has benefits that exceed costs. Even after reading many of them, marginal studies showing the former are still always more interesting to me than the latter. But it’s important to focus as well on studies that demonstrate places where medical care has real value.
In this vein, an abstract from a new paper in The Quarterly Journal of Economics has really stuck with me all week for it’s empirical ingenuity and it’s results:
A key policy question is whether the benefits of additional medical expenditures exceed their costs. We propose a new approach for estimating marginal returns to medical spending based on variation in medical inputs generated by diagnostic thresholds. Specifically, we combine regression discontinuity estimates that compare health outcomes and medical treatment provision for newborns on either side of the very low birth weight threshold at 1,500 grams… Under an assumption that observed medical spending fully captures the impact of the “very low birth weight” designation on mortality, our estimates suggest that the cost of saving a statistical life of a newborn with birth weight near 1,500 grams is on the order of $550,000 in 2006 dollars.
ADDENDUM: See Mark Thoma in the comments. The paper’s results may actually be spurious. So much for some good news.
I’ve recently challenged paternalism supporters to tell me, if the most recent headline paternalism that bans Happy Meals in San Francisco does not constitute taking us down the slippery slope, then what would? Matt Steinglass at the Economist has responded to this challenge by accepting it’s legitimacy, and reversing it, but not answering it. Granted, speculating what people will decide the government should crack down on next is a tricky game. I mean who would have guessed that Happy Meals were on the chopping block? But from the logic of this ban, we can see a wide range of policies the future might hold.
First, lets look at the logic of this policy. Here is how Steinglass makes the case:
Now, not every parent objects to their children eating unhealthy fast food. But I do, and there are a lot of other parents like me, especially in places like San Francisco. For such parents, the Happy Meal represents an effort by some adults to profitably exploit and exacerbate the tensions in other adults’ parent-child relations over food.
So what are other policies by which some adults profitably exploit and exacerbate the tensions in other adults’ parent-child relations over food?
First note that we don’t need a one-to-one relationship between that which is attracting the children in the first place -in this case a toy- and something that is unhealthy -in this case unhealthy food. Matt can actually get a Happy Meal with chicken McNuggets, 1% milk, and slices of apple with low-far caramel dip. In fact, at 390 calories, 32% of which come from fat, McDonalds will be able to sell this food with the toy after the ban, which only prevents Happy Meals with more than 600 calories and 35% of the calories from fat. So it’s not like the only way for Matt to get this toy for his kids is to buy them the “cheap Jumbo McFattyburger”. McDonald’s has given them a relatively healthy option that allows parents to cave into their children on the toy but not on lunch. What more do you want parents? Must we hold your hand the whole way through raising your children, cordoning off everything you don’t have the will to tell them they can’t have?
Given the nature of the justifications for this policy -protecting parents from having to tell their kids no- what would be logical extensions of it?
Well without leaving McDonalds there’s some obvious ones. For one thing, the playland probably draws kids as often as the toys do. So new McDonalds could be banned from being built with playlands. Along the same lines, fast food restaurants could be banned from being near places where children play in the first place, like parks and schools. I know this one has been called for before, and I’m not sure, but it may even be in affect in some places.
Making fast food less attractive may protect parents when they happen to be near a McDonalds with their kids, but it doesn’t protect them from having McDonalds reach out to children in the first place and getting it into their heads that their food and toys are awesome. If you’re going to stop this problem, it must be at the root. One way to do this is to ban advertising of fast food targeted at children. This would probably start with children specific magazines and TV shows, but move to a general ban.
However, these policies only target fast food, and we know that kids beg for unhealthy food all over the place, not just there. So let’s look at the grocery store.
One obvious example is banning candy from checkout lines. Sure many stores have aisles that are candy free for just this purpose, but McDonalds has a healthy lunch option as well.
Another thing that could be done is to counteract the behavioral economics and marketing used by grocery stores and food companies to target children. Unhealthy food that children like, for instance sugary cereals, could be required to be placed on top shelves where it’s harder for children to see and reach for them. More extreme than this would be to ban any cartoon characters from unhealthy food containers. I’m pretty sure many people would take a bullet for Cap’n Crunch and those elves from Rice Crispies, so the bar for unhealthy would be set pretty high… at first.
Eventually there could be a regulatory agency that has to approve all foods to ensure that no behavioral economics or marketing wizardry draws children to it whatsoever.
In addition to how stuff is sold, anything that is enumerated on a nutrition label could be regulated. We know that portion size is a problem, so maximum portion sizes could be set. Also you might also see maximum calories for single serving foods like hot pockets and candy bars.
In order to prevent an outcry from adults there may be a two-track regulation where food is categorized either as “mostly for adults” or “mostly for children”. Foods that are “mostly for children” will be regulated more strictly and on many dimensions, while “mostly for adults” remain freer … at first. Eventually all foods could fall to the more draconian regulations as two-track regulation fails because parents will just buy unhealthy “mostly for adults” food for their children.
If you think setting the maximum number of calories and other nutritional measures for every kind of food seems absurd then you should read the Institute of Medicine report on salt regulations, which pretty much suggests doing this this for sodium content.
Many of these suggestions probably seem so extreme as to be unbelievable. But they seem extreme from the vantage point of where we are on the slippery slope. The farther down we go and the more accustomed we become to these sorts of things then the less and less radical the currently extreme examples will seem. I’m not predicting all of these will happen everywhere, but some of these, or things like these, will be pushed for, and some of them will be put into place.
My question to paternalism supporters is which of these things would be ok with you? And by what basis do you reject them but approve the Happy Meal regulations? To those on the fence about paternalism, or ok with the happy meal ban but wary of more strict regulations, pay attention to the answer your paternalism allies give to these questions; as you may someday find yourself on the other end of this argument.
Urged on by government warnings about saturated fat, Americans have been moving toward low-fat milk for decades, leaving a surplus of whole milk and milk fat. Yet the government, through Dairy Management, is engaged in an effort to find ways to get dairy back into Americans’ diets, primarily through cheese….
…Dairy Management, whose annual budget approaches $140 million, is largely financed by a government-mandated fee on the dairy industry. But it also receives several million dollars a year from the Agriculture Department, which appoints some of its board members, approves its marketing campaigns and major contracts and periodically reports to Congress on its work.
The organization’s activities, revealed through interviews and records, provide a stark example of inherent conflicts in the Agriculture Department’s historical roles as both marketer of agriculture products and America’s nutrition police.
Read the whole article, it’s in turn depressing and hilarious. The fact that government in this day in age still considers it important to “bolster farmers” is exactly the kind of thing I’m talking about when I worry about industrial policy’s inability to cease once it’s outlived it’s usefulness. Bad subsidies really seem to have a hard time going away.
There is a very interesting article at the Atlantic from David Just and Brian Wansink from the Cornell Center for Behavioral Economics in Child Nutrition Programs. They discuss their work on improving healthy eating in school cafeterias using the subtle wizardry of behavioral economics. There have been some impressive results:
One school in upstate New York was able to increase consumption of salads by close to 300 percent by simply moving their salad bar six feet from the wall and placing it near a natural bottleneck in the check-out line. Another school increased fruit sales by 105 percent by moving the apples and oranges from stainless steel bins into a well-lit and attractive basket.
It is encouraging to see behavioral economics being put into creative use like this. The authors argue that “It is difficult to teach a high school student how to make healthy choices in the real world if only escarole and tofu on are on the school lunch menu”. But is this teaching them to choose better or tricking them into choosing better? After all, if behavior is so amenable to subtle tricks like this then what hope can there be that any behavioral changes will actually last? I can’t tell if articles like this should make us more or less hopeful. Yes, the good scientists here are making a difference, but are we really so impressionable?
Kevin Drum asks
Now, there are a bunch of things you might say about this right from the start. Maybe governments shouldn’t be in the business of running nanny state ads about personal nutrition. Maybe this particular ad was disgusting and shouldn’t have been released. Maybe obesity isn’t really that big a deal in the first place. But those weren’t the issues at stake. Rather, it was this single sentence in the ad:
Drinking 1 can of soda a day can make you 10 pounds fatter a year.
What, I thought, could be wrong with that? A can of sugared soda contains about 150 calories, and adding 150 calories a day to your diet would almost certainly produce a ten-pound weight gain over the course of a year or so. There are some caveats, of course:
So I’m curious: what do you all think of this? I’m open to argument here, but it seems crazy to me, less a politicization of science from the health commissioner than a case of geekdom run amok among the scientists. I mean, if you can’t tell people that adding a bunch of calories to your diet will make you gain weight, what can you tell them?
The problem is that the calorie balance interpertation implies a completely false understanding of what is going on. There is an extent to which geekdom can tolerate this level of nonsense and there is a point at which it must be combated.
I will compare to something I know Kevin gets. The calorie balance logic is equivalent to saying.
Government deficits drain savings. Savings are the engine of growth. Therefore, cutting the deficit immediately is our best shot at growth.
In both cases you are taking an accounting identity
- Private Savings – Public Borrowing = Net National Investment
- Calories-In – Calories-Out = Calories Contained in the Body
And, treating it as if it were a model of the world.
You have to be aware that public borrowing might effect private savings. In particular if public borrowing stimulates the economy it will increase private income which in turn will increase private savings.
You also need to be aware that Calories-In affects energy and hunger levels which not only feeds back to Calories-Out but also to other Calories-In.
I used to post this thing a lot, but since the blog has new readers it might be worth our while to look at how a properly functioning metabolism responds to a rapid increase in Calories-In
The big question we have is why does this stop working in some people? Just to note, there are many, many other feedback loops that are important as well. I point out this one because it so obvious both that it works in the healthy metabolism and that it fails in the unhealthy one.
You are probably aware of the relationship between diabetes and obesity. It is commonly assumed that obesity causes diabetes. This is in part because even some scientists are fixated on the accounting identity. However, there is a reasonable case that diabetes may cause obesity.
That is, the resistance of the muscles to insulin causes the breakdown in the “sugar rush” response (and other loops) which then breaks down the feedback from calories-in to calories-out.
Now, if it is in fact the case that sugary drinks induce insulin resistance this connection may still hold. However, it is almost certain that the simple minded thinking that in general dropping a 150 calorie item from your diet will not feedback on other metabolic components promotes a fundamental misunderstanding of what’s going on.
For the geeks. Yes, in truth even what I have written here is a gross oversimplification and ignores central facts such that an increase in obesity from sugar consumption must be proximately caused by an increase lipogenesis or a decrease in lypolysis both of which are hormonly regulated processess. That is, just as there is no such thing as immaculate transfer there is no such thing as immaculate obesity.
You can’t just throw organic matter at a metabolism and get fat. You actually have to create fatty acids and bind them up into triglycerides. Any model that assumes that you can is going to wind up disappointing you and of course there are a fair bit of disappointed dieters. We need to do better as intellectuals.
When the Institute of Medicine recommended broad, draconian regulation of salt last year, I pushed back against the idea, one might say, obsessively. Now, via Marion Nestle, comes a new paper in The American Journal of Clinical Nutrition arguing that the current level of sodium intake is not a problem for the population. The article comes with an accompanying editorial titled “Science trumps politics: urinary sodium data challenge US dietary sodium guideline” that closes with this appeal:
The analyses of extensive measurements of 24-h UNaV, which these 2 reports have collected from the medical literature over the past 5 decades, are compelling. They provide plausible, scientific evidence of a “normal” range of dietary sodium intake in humans that is consistent with our understanding of the established physiology of sodium regulation in humans. This scientific evidence, not political expediency, should be the foundation of future government policies, thus respecting the known and unknown scientific complexities surrounding sodium’s role in health and disease. Guidance for sodium intake should target specific populations for whom a lower sodium intake is possibly beneficial. Such an approach would avoid broad proscriptive guidelines for the general population for whom the safety and efficacy are not yet defined. An appropriate next step is not to lower the sodium guideline further.
So there has long been a casual argument that cancer is a disease of civilization. That is, that cancer was rare up until at least the development of large cities and perhaps industrialization. This might suggest pollution of some sort is a vital precursor to cancer.
Robin Hanson posts on some evidence to back up this claim
In modern populations, tumours arising in bone primarily affect the young, so a similar pattern would be expected in ancient populations. … Another explanation for the rarity of tumours in ancient remains is that tumours might not be well preserved; however, experimental studies show that mummification preserves the features of malignancy. ..
We propose that the minimal diagnostic evidence for cancer in ancient remains indicates the rarity of the disease in antiquity.
Though if this is the case then it seems we may be dealing with a ubiquitous set of pollutants as wild animal deaths from cancer seem to be on par with human rates.
TV chef Anthony Bourdain has had some choice words, and also words of praise, for slow food maven Alice Waters, who I’ve also criticized, and praised, here and here. Here he is agreeing with the substance of my criticism of the slow food movement and it’s impracticality for low income people:
I am suspicious of wealthy suburbanites who preach “back to the soil” philosophies—as if most—or even many—could start digging subsistence gardens in their back yards or afford expensive organic or locavore lifestyles.
This summary of part of Bourdain and Water’s interaction at a recent food panel sums up their disagreements well:
According to Alice, we should “provide breakfast, lunch and a snack FOR FREE to every child in America,” even if it cost billions. “How could it not be worth it?” she defended, “these children are our future.” Then she mentioned a bumper sticker she saw that said, “If you are what you eat, I’m fast, cheap and easy” — and the shame in it. After that she went on and on till Bourdain said – “I put literacy above that as a priority” and everyone clapped.
It’s not just Anthony Bourdain that’s backing me up either; here’s is Alice Waters in an interview with Leslis Stahl on slow food as a luxury:
Waters told Stahl she rarely goes into a regular supermarket. “I’m looking for food that’s just been picked. And so, I know when I go the farmer’s market that you know, they just brought it in that day.”
“I have to say, it’s just a luxury to be able to do that,” Stahl remarked.
“In a sense it is a luxury,” Waters agreed.
Michael Bloomberg and David Paterson announced a proposal yesterday to ban the purchase of soda with food stamps. It is sure to be controversial, but is it a good thing?
At the very least, if the government is determined to try and reduce decrease public expenditures on health care by reducing soda consumption, than this is a preferrable approach to a soda or sugar tax. A first best approach would be to tax individuals who a) are drinking enough soda that it increases their risk of illness, and b) with some probability part of their health care costs will be born by public.
Since foods stamp recipients seem like a likely target for b), this at least meets one criteria. In contrast a general soda tax falls on everyone, and meet neither criteria. Even with the more targeted food stamp approach, people whose soda consumption is at safe levels or who have private insurance will be inefficiently restricted by this.
I have not looked at the data myself, but the conventional wisdom and the contention of the proposed law is that a) is very much true.
The whole discussion of course presumes that the law actually reduces soda consumption. For one thing, if individuals are paying some non-soda food costs with cash they can just shift to spending that cash on soda. There are also ways to trade around this: I buy $10 worth of soda with cash, you buy $8 worth of food with food stamps, and we trade. In either case though, transaction costs have been raised, although in the former the amount may be very slight.
Another problem is that individuals may respond to the lower calories by simply consuming more calories. While researching the health effects of soda for my recent defense of diet soda, the literature appeared mixed as to whether switching from regular to diet soda caused weight loss because of the calorie substitution problem. Perhaps Karl will chime in on this; he is much more knowledgeable about all things obesity.
The final question to ask is whether this policy is simply too paternalistic? I have to say I don’t think it is. Food stamps by themselves are already highly paternalistic. Essentially they tell low-income people that on average they will not spend cash in a way that best benefits them and their family. The government defines a subset of goods and tells them “you will be better off if you stick to these goods instead of buying what you want”. The marginal paternalism of reducing the size of the goods the government allows is slight compared to the paternalism food stamp recipients are already enduring. If your significant other tells you that you have to go to bed between 9:30 and 10 that is highly paternalistic. If they further refine that and decide it has to be between 9:40 and 10 it’s not that much more paternalistic. Perhaps this graph will help:
Another issue that you are free to reject, as it just reflects my diet soda bias and my love of delicious aspartame, is that I suspect much of the continued preference for regular soda over diet soda despite the health advantages is motivated by a lack of understanding of the safety of diet soda. Fear not New Yorkers, despite the email chain letters and urban legends, diet soda is not bad for you.
Overall though we should be weary of this kind of paternalism, and the desirability depends on how effective it would actually be. However, given the high level of paternalism in food stamps already I don’t consider this marginal paternalism to be that troubling.
While critics are wont to cite Medicare Part D as an expensive Bush handout to drug companies, it has received praise in the past from others. For instance, here is Tyler Cowen:
I’d just like to note that — relative to its reputation — the Medicare prescription drug benefit is one of the most underrated government programs of our time. If the goal is to cut or check Medicare spending, and I think it should be, we should do it elsewhere in the program.
It’s also possible that the prescription drug benefit will do more for peoples’ health (as opposed to their financial security) than will the Obama plan.
However, a new NBER paper suggests that the program increased spending by previously the uninsured without any improvement in health outcomes:
In this paper, we provide an assessment of the effect of Medicare Part D on the previously uninsured…We find that gaining prescription drug insurance through Medicare Part D was associated with an 63% increase in the number of annual prescriptions, but that obtaining prescription drug insurance is not significantly related to use of other health care services or health, as measured by functional status and self-reported health.
In short, what it provided was more medical spending without better health outcomes, what you might call a Hansonian result. I would be curious to know if this changes Tyler’s assessment.