Something Not Unlike Research

We are joining the Inequalities blog

Paul Kelleher and I have decided to join Brendan Saloner, Ben Baumburg, and many other brilliant bloggers at Inequalities: Research and Reflection from both sides of the Atlantic. There may be an occasional post here at Something Not Unlike Research, but we expect to be principally blogging at Inequalities. From Inequalities statement of purpose:

This blog was set up by a bunch of young researchers – sociologists, political scientists, geographers, demographers, social policy scholars, economists – from universities on both sides of the Atlantic who wanted to create…

… a space to critically discuss research on inequality, both our own research and the most interesting research we come across; and

… a community of people who want to try and tackle the injustices they see in the world by shedding light on things that would otherwise be invisible.

We thank all readers and commenters for their attention, and we hope that you will read (subscribe to the RSS feed of) Inequalities (http://inequalitiesblog.wordpress.com/). 

Medication and the hidden structure of experience

I woke up this morning in the hospital, feeling a lot better. It was a reminder about how our given world -- the world of experience -- is not the world. The fundamental fact about the world, it seems, is that we actually dream it.

I had been admitted yesterday to change my anti-arrhythmia medication. Over the last year I've steadily lost ground in my ability to control my heart rhythm, to the point where I have been in atrial fibrilation about 20% of the time, despite a pacemaker and diltiazem. Fibrilation is a sustained high (e.g., 180 beats / minute) and erratic heart rate. I don't suffer, exactly, but it is debilitating. There wasn't a crisis that led to the admission. It just took some time to acknowledge that the old therapy was no longer working. 

So now, following the advice of Dr. Charles Love, my awesome electrophysiologist, we are pulling out a higher caliber weapon and switching to propafenone. Bigger drugs have bigger risks and you have to start propafenone in the hospital to make sure you can tolerate it.

And so far, so good. My heart is STABLE. This is revelatory:

Then felt I like some watcher of the skies
 When a new planet swims into his ken;
 Or like stout Cortez when with eagle eyes
 He star'd at the Pacific — and all his men
 Look'd at each other with a wild surmise —
 Silent, upon a peak in Darien.

What I hadn't understood was how much of my attention had been focused on my cardiophysiology. Even when I was thinking about other things, part of me worried about whether a mild flutter was about to become a hammering effort regain a steady beat. Or whether just standing up from a chair would lead to a sudden loss of blood pressure and syncope. Those concerns are gone. I'm able to be here in a way that I wasn't yesterday. All the metaphors about character and the heart are true: When you can't count on your heart, it's difficult to be steadfastly present.

The person I was yesterday had forgotten what it was like to have a steady heart. I am now back in the world; and I hadn't recognized the degree to which I was gone. The former state seems like a dream state although at the time it seemed wholly real. Our experience is constructed, and we only see the moving parts when something like a change in heart points it out to us. When you encounter another person, be gentle. He is in a dream and so are you.

UPDATE: Thanks to Dan, Austin, Paul, & Brad for their kind wishes. As it happens, I had a stress test right after the post and went right back into atrial fibrilation. So much for the hopes that profanenone (aka rythmol) would be sufficient. Looking at a ablation procedure on Monday.

Seven-fold increase in antipsychotic prescriptions to children and youths

How do you handle a really difficult child or youth? A child prone to uncontrollable rages, a child who is violent against his or her peers in a frighteningly unpredictable way. What do you do if the child is being raised by parents with limited control over their impulses, with a truncated sense of responsibility for the child, and who discipline the child with a wild savagery? Parents who may not even be present much of the time? How do protect such a child from harm?

Here are some things we should do. If the child is from a disordered home -- this is not always the case -- we should see what can be done to help the parents sort out their employment problems, their housing, their substance abuse, and their disordered characters. We should get them some training in effective parenting. We should look carefully to be sure that the child is not suffering physically, for example, from the chronic pain of abscessed teeth. We should get the child with a therapist who can train him or her in effective strategies to manage negative affect and interpersonal conflict. If necessary, we should place the child in therapeutic residential care.

These things rarely happen, because these services are expensive. Increasingly, what we do instead is sedate these children with powerful antipsychotic drugs. Antipsychotics are expensive as drugs go, but they cost less than mental health care professionals or residential therapy centres. And they make the problem go away. Sort of.

Using data from the National Ambulatory Medical Care Survey, Mark Olfson and his colleagues report the trends in the prescriptions of antipsychotics in youths and adults (where youth means 20 years old or younger). Looking from the period from 1993-1998 to 2005-2009, there has been an almost seven-fold increase in the proportion of medical visits for children that involve an antipsychotic prescription (see, the graph, prescriptions of antipsychotics for adults have doubled over the same period.) This is not because antipsychotics are being used more extensively in the treatment of psychosis: that hasn't changed. What is happening is that antipsychotics are being used more frequently with children with no psychotic disorder (a greater than seven-fold increase).

Antipsychotics do not teach interpersonal skills. They do not, to my knowledge, increase the child's ability to modulate emotions when they are not sedated. Antipsychotics are powerful tranquilizers; so they make certain problems go away. When used to quell a violent patient on a ward, they are referred to, without irony, as "chemical restraints."

Antipsychotics have extensive side effects: they impair movement, they promote rapid weight gain, and they lead to metabolic disorder and diabetes. The use of these drugs is too new for us to be certain of the long term effects on the development of children's brains and bodies, but the initial evidence suggests that the damage may be extensive. When psychiatrists use these drugs, they rarely test for these side effects.

Antipsychotics are typically prescribed without any particular plan for how or when they will be discontinued. Similarly, it seems that we have come to this strategy for managing difficult children without any plan for discontinuing it. Will we continue to sedate them through adulthood? Is there some point where the rapid growth in the use of antipsychotics even slows down? Do we intend to keep an increasingly proportion of the population chemically restrained for their whole lives? 

Why are antipsychotic prescriptions to children increasing? In part because they have been pushed by pharmaceutical manufacturers, often using deception. But largely because we are unwilling to pay the cost of providing good care.

 

On Chris Hayes's reformation

post by Bill Gardner

I have just finished Chris Hayes's Twilight of the Elites. It's great. The only possible disappointment is the title: Be aware that it is not a paranormal romance about aristocrat vampires. Here is a summary of the argument, from an excellent review by Aaron Swartz at Crooked Timber:

Hayes pins the blame on an unlikely suspect: meritocracy. We thought we would just simply pick out the best and raise them to the top, but once they got there they inevitably used their privilege to entrench themselves and their kids (inequality is, Hayes says, “autocatalytic”). Opening up the elite to more efficient competition didn’t make things more fair, it just legitimated a more intense scramble. The result was an arms race among the elite, pushing all of them to embrace the most unscrupulous forms of cheating and fraud to secure their coveted positions... This creates a unitary elite, detached from the bulk of society, yet at the same time even more insecure. You can never reach the pinnacle of the elite in this new world; even if you have the most successful TV show, are you also making blockbuster movies? bestselling books? winning Nobel Prizes? When your peers are the elite at large, you can never clearly best them.

The result is that our elites are trapped in a bubble, where the usual pointers toward accuracy (unanimity, proximity, good faith) only lead them astray. And their distance from the way the rest of the country really lives makes it impossible for them to do their jobs justly—they just don’t get the necessary feedback.

Whether elites were somehow better before meritocracy doesn't matter: This book gets at what is wrong with the elites that we have now.

So what do we do about it? Hayes argues for increased equality of outcomes, for example through redistributive taxation. I'm for it.

It is important, however, to make sure that Hayes's proposed reformation is read in the way that I think he intends it. He writes that

The first step is persuading the public -- including the elites themselves -- that the ideology of meritocratic achievement stands in the way of social progress. The first commandment of the post-1970s meritocracy can be summed up as follows:

"Thou shall proclaim equality of opportunity to all, regardless of race, gender, or sexual orientation but worry not about equality of outcomes."

That is,

1. Continue to fight for equality of opportunity.
2. Resume fighting for greater equality of outcomes. There was nothing about the meritocratic ideal that required us to ignore gross inequality of outcomes.

Point 1 is perhaps under-emphasized by Hayes, but it remains extraordinarily important, for the following reasons:

• The US has nothing like a "level playing field." Inequality is baked in at birth, and not just because the poor may somehow have worse genes. Making professional schools open to both genders and all races is just the beginning. 
• As Hayes notes, inequality of opportunity and inequality of outcomes are causally interdependent, and you cannot make things equal for children without making things more equal for their parents.
• Part of making outcomes more equal is achieving greater equality in the human capital held by Americans. Tax redistribution alone would be inefficient and politically unacceptable.

Hayes praises the Brazilian Bolsa Familia program, but frames it as an example of successful redistributive taxation. It is that, but the more important thing was that it directed the redistributed resources to the improvement of the health and education of poor young children.

 

Paul A. Samuelson on "You Didn't Build That"

post by Paul Kelleher

Economist Paul A. Samuelson (Economics, p. 484):

Many ingenious ways have been suggested for measuring this consumer's surplus, but they are of no particular significance. The important thing is to see how lucky the citizens of modern efficient communities really are. The privilege of being able to buy a vast array of goods at low prices cannot be overestimated.

This is a humbling thought. If ever a person becomes arrogantly proud of his economic productivity and his level of real earnings, let him pause and reflect. If he were transported with all his skills and energies intact to a primitive desert island, how much would his money earnings buy? Indeed, without capital machinery, without rich resources, without other labor, and above all without the technical knowledge which each generation inherits from society's past, how much could he produce? It is only too clear that all of us are reaping the benefits of an economic world we never made.

This basic fact is well stated in the following quotation:

The organizer of industry who thinks that he has "made" himself and his business has found a whole social system ready to his hand in skilled workers, machinery, a market, peace and order---a vast apparatus and a pervasive atmosphere, the joint creation of millions of men and scores of generations. Take away the whole social factor and we have not Robinson Crusoe, with this salvage from the wreck and his acquired knowledge, but the naked savage living on roots, berries, and vermin.[1]

[1] L. T. Hobhouse, "The Elements of Social Justice," pp. 162-163, Henry Holt and Company, Incorporated, New York, 1922.

Concentrated Medical Spending, Accountable Care Organizations, & Outcomes Measurement

post by Bill Gardner

Health care spending is highly concentrated in a small portion of the population (see the graph of the cumulative distribution of US health care spending, from the National Institute for Health Care Management). This concentration has consequences for policies to reduce national health care spending.

Notice that half the population -- the group on the left in the graph -- accounts for < 3% of the total spending. Aaron Carroll argues that

When we talk about incentivizing people to forego care, we’re talking mostly about healthy people. When we talk about consumer directed health care, we’re talking mostly about healthy people... The problem is that healthy people consume so little care to begin with. If we could incentivize the healthier half of people to forego all their personal health care spending, we’d spend $36 billion less out of a total $1.259 trillion in personal health care spending. That would be a drop in the bucket. 

OK, so we can't find significant health care savings in the healthy population. We do not want to deny care to the sick. So how are we going to bend the health care cost curve? 

First, we need to shrink the percentage of the population that has expensive chronic illnesses. Almost all of us will eventually acquire one or more chronic illnesses, but delaying these illnesses even a few years would reduce the overall cost of care. My bet is that the breakthrough here will be finding ways to shift our diets away from simple carbohydrates. This would, over time, significantly reduce rates of diabetes and hypertension, which are key cost drivers among the chronically-ill population. But even if we can make this work, these are savings that we collect only in the medium to far future.

So we have to find near-term ways to make caring for the sick less expensive. One approach is deliver care through Accountable Care Organizations (ACO = "a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population;" Rittenhouse, Shortell, & Fisher). In brief: Set the incentives so that health care providers make money by devising less expensive ways to deliver better care. Although some health care regulation is necessary, this is fundamentally a market solution, in which ACOs compete for contracts and prosper through successful innovation.

However, the ACO idea only works if we can objectively measure the quality and outcomes of care. We need those measurements to enforce contracts with the ACOs to take good care of their populations. If we can't measure the quality of what the ACOs deliver, then the ACOs' incentives are just to reduce costs. We will be back to Managed Care and routine denial of care, which is much easier than delivering good, efficient care. We need objective, transparent, and public measures of the quality and outcomes of care regardless of whether you support payer-driven or individual-consumer-driven health market reforms (or both!).

Developing and validating technologies for measuring the quality and outcomes of care are among the principal goals of the Agency for Health Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute (PCORI). And this is why the effort to eliminate AHRQ and PCORI is so stupid. Valid measurement technologies for the quality and outcomes of care are essential to market-based health care solutions. Measuring the quality and outcomes of care is like certifying the accuracy of gas pumps at service stations: It makes the market work for purchasers.

 

Alex Tabarrok on Economic Mobility

 post by Bill Gardner

Tabarrok is interested in the moral significance, if any, of economic mobility. He first contrasts two societies, "Stasis" and "Churn".

In society one there is no generational mobility, each generation has the same income as the previous generation. Let’s call this society Stasis.

Society Stasis
Family	Generation 1	Generation 2
A	100	100
B	50	50
C	25	25
Total	175	175

In the second society, some generations rise and some generations fall but there is no growth, let’s call this society Churn.

Society Churn
Family	Generation 1	Generation 2
A	100	25
B	50	50
C	25	100
Total	175	175

He argues that there is little to prefer between Stasis and Churn. But there is a reason to prefer Churn: Relative to Stasis, the deprived of Generation 1 have the compensation of knowing that their children will do well. A and C are symmetrical: A does well in Gen₁ and poor in Gen₂, while the reverse is true for C. If you view families as bearers of well-being across generations, then the utilities of A and C accumulated across generations are equal and B is not too far behind. In this sense, Churn is fairer than Stasis. 

Perhaps the idea of families as bearers of utility is problematic. Tabarrok seems to assume that utility = income in each generation. But this is not necessarily the case: Suppose that the utility function for a parent in Gen₁ is

Utility(Gen₁) = a * Income(Gen₁) + (1 - a) * Income(Gen₂), 0 < a < 1.

Then the average utility is unchanged but the range and variance of utilities in any generation is less in Churn than in Stasis. If that matters to you, Churn is fairer. It might not matter to you: A utilitarian could well argue that such utility functions are wrong. This is because the function gives higher weight to the well-being of my children, violating the principle of treating each other person as having equal moral worth.

Otherwise, Tabarrok is right: Mobility in and of itself is not important to justice. We value mobility because, as one of his commenters points out, societies without mobility almost certainly lack fair equality of opportunity or, as Tabarrok points out, liberty.

He then considers a third society, Growth.

Society Growth
Family	Generation 1	Generation 2
A	100	200
B	50	100
C	25	50
Total	175	350

Growth seems clearly better than Stasis, because everyone is better off in Gen₂ in Growth than they would be in Stasis. Would Growth be still better if we added some Churn? Just a bit, I would say, for the reasons advanced above. However, seeking to add random Churn would be crazy. It would not improve fair equality of opportunity and would likely compromise liberty.

The problem with Growth, from a liberal egalitarian point of view is not that it lacks mobility. The key problem is that the worst-off group gains the least from Gen₁ to Gen₂. Rather than add random Churn, a sane liberal policy would look for ways to increase the gains for C. I think that Taborrak would agree that this, rather than mobility, is the fundamental problem with Growth. Of course, the next and harder questions are whether attempts to do this would increase or decrease average utility, and if so, how much decrease we can accept to achieve a more just distribution of gains. 

John Broome on an Irony of Welfare Economics

post by Paul Kelleher

Bill and I are currently reading and studying John Broome's new book Climate Matters: Ethics in a Warming World. It is an excellent if deceptively challenging book (Broome's prose is so effortless that one can be led to think mastering the ideas will be, too). I am certain the book will shape the way I think about virtually all matters in public and population health. Indeed, I am currently writing a paper on its main themes that I hope to post here in a week or two.

Broome's chapter on discounting future goods is among the best in the book. He notes that discounting is a common practice in cost-benefit analyses of climate change, and the debate over the proper discount rate has been viewed by many as the ethical question raised by global warming (although Broome would not agree with that, I don't think). I have discussed the issue of discounting a couple of times on the blog, but if you have to choose, read what Broome has to say (naturally). 

Broome explains that cost-benefit analysis is a kind of shortcut: economists want to understand the impact that various policies will have on society, and the gold standard would be a way to assess the impacts they will have on individuals' well-being. But economists are notoriously pessimistic about being able to measure well-being directly, so they use a proxy: they measure what individuals are willing to pay for commodities, since these commodities can serve as a proxy for the human well-being they produce in those who enjoy them. The more someone is willing to pay for a given commodity, the more well-being it would produce for that person (if she were to acquire it). 

Broome points out what all economists already understand: other things equal, the same commodity will produce more well-being if enjoyed by a poor person than if enjoyed by a rich person. This phenomenon is known as diminishing marginal utility, and it can be present even when the rich person is willing to pay more than the poor person for commodity. So unless the economists' short-cut for measuring well-being takes this phenomenon into account, the shortcut will likely be biased in favor of policies that benefit the rich, since their higher willingness to pay will be interpreted as a higher capacity to benefit. Broome remarks, "Cost-benefit analysts have ways of correcting for [this bias in favor of the relatively rich], but in practice they rarely take the trouble to do so." I have discussed this fact about cost-benefit analysis at length elsewhere. 

There is an irony here, however. For Broome also notes that economists standardly discount the importance of future benefits at some positive rate. This practice gives more weight to the enjoyment of a commodity here and now relative to the enjoyment of the same commodity in the future. And one key economic rationale for doing this is that people in the future are expected to be richer. Broome goes on:

If people are richer in the future, that means additional commodities bring less benefit on average to future people than the same commodities bring to present people. A kilo of rice in one hundred years will contribute less on average to the well-being of the people who eat it than a kilo contributes today. This is a good reason for discounting future commodities. Ironically, although cost-benefit analysts generally ignore the diminishing marginal benefit of money when they are aggregating value across people at a single date, their main case for discounting future commodities is founded on this diminishing marginal benefit.

Broome does not pull punches when he goes on to note that the effect of this irony is that it protects the current rich on two fronts: it downplays the case for transfers from the current rich to the current poor (since it ignores the greater capacity of the poor to benefit from the same expenditure), and it downplays the case for transfers from the current rich to future generations (since their well-being is discounted relative to well-being here and now). Broome's view is that if people in the future really will be better off than we are, then we really do have reason to discount the value of future commodities. But this same reason suggests that cost-benefit analysis should no longer ignore the fact that the same commodity brings more benefit to the current poor than it would if enjoyed by the current rich.  

Taking death panels seriously

post by Bill Gardner

One of the important decisions that will be made across the US in the next years is whether states will expand Medicaid coverage to include more uninsured patients. The Affordable Care Act provides increased federal funding to do this, but the decision in National Federation of Independent Business v. Sebelius permits states to refuse to expand Medicaid and cover these patients.

There are many things at stake here. Randy Barnett thinks that the ACA expands the power of the federal government. Tyler Cowen (@tylercowen) points out that spending more state revenue on Medicaid may require spending less on education or other desirable programs. Josh Barro (@jbarro) argues that taxation to expand public spending on health care creates significant dead weight losses of utility. 

What is also at stake are some of the lives of people who would be covered by Medicaid if coverage expanded. To see this directly, consider what happens when a state contracts Medicaid coverage, as is happening in Arizona. A surgeon, Randy Oppenheimer, has made a video in which some of his patients -- working people who lack insurance and do not qualify for AZ Medicaid -- talk about the consequences of being uninsured. I warn you that the video includes disturbing images of cancer.

 

It's not my view that Oppenheimer's video makes a definitive case for expanding Medicaid coverage. Expanding Medicaid might rescue these patients, but what else would it do? Are we sure that Medicaid expansion would, when all consequences are registered, save lives? I expect, for example, that Barro would argue that the economic gains from reduced taxation would extend lives; perhaps even more than would be saved through the expansion of Medicaid. So it is not my view that Barnett, Cowen, or Barro are apologists for killing.

What I want is for everyone to see that decisions about Medicaid coverage are not simply opportunities to satisfy norms about the relationship between federal and state power or to resolve state budgets. They are also life and death decisions for human beings. Arizona has decided that having dependent children entitles you to lifesaving care, but being single does not. Look no further for a death panel.

And who was on that panel? State voters determine the extent of Medicaid coverage as much as anyone does. Do not imagine that the health care rationers are distant experts, like the to-be-named (and god help them when those names become public) members of the Independent Payment Advisory Board. The US has 50 death panels, the state electorates. We are rationing health care, we have always rationed health care, and the forthcoming decisions by the states about whether to expand Medicaid will be decisions about rationing health care. We are all on death panels, and we need to appreciate the responsibilities that come with that role.

h/t Ross D. Silverman (@phlu)

Thinking about the cost of global warming: Getting beyond GDP

post by Bill Gardner

Preventing (or mitigating) global warming is going to be expensive. But how much should we spend on prevention, and when? To answer that question it seems natural to first estimate how much global warming will cost. But to do that, we have to define a measure of such costs. And that's not easy.

One way to calculate the cost of global warming is to project future trajectories of global gross domestic product (GDP) based on different assumptions about how the climate works and different regimes of energy consumption and greenhouse gas emissions. So one idea is that we should pick the mix of prevention/mitigation strategies that maximizes long term GDP. This is appealing because it gives us a single dimension to rank solutions on. Nordhaus and Stern (I've read only the former) are comprehensive analyses of the costs of warming and preventing warming that measure harm using GDP. For a brief, thoughtful (and conservative) discussion, see Manzi. 

Unfortunately, looking only at GDP is an inadequate way to think about the cost of global warming, for several reasons.

1. GDP sums up the value of the goods and services we produce and consume. It takes no account of the particular individuals who gain and lose. Every analysis I have seen suggests that the current and future global poor will be harmed by warming significantly more than the global rich; whereas the global rich will benefit substantially more from global energy consumption. Even if we were to conclude that the aggregate harm of global warming was acceptable, the uneven distribution of those harms is likely to be unjust.
2. GDP has an uncertain relationship to human well-being, and it is human well-being that truly matters. There are scenarios for global warming in which large areas of the world that are currently temperate will experience sustained summer peak temperatures in the range of 35-40°C (95-104°F), resulting in significant ecosystem loss. This might not, however, dramatically reduce GDP, because all the efforts we have to undertake to adapt to increased global temperature will contribute to GDP. Suppose an increase in temperature kept GDP constant but shifted our economical activity toward producing powerful air conditioners, and away from other things. We would be worse off, whatever GDP says.
3. More importantly, global warming may produce effects on well-being that are not captured by GDP. The increasing concentration of CO2 is rapidly increasing the acidity of the ocean. There is a point where the pH will be incompatible with the survival of most ocean species. If the oceans die, would the resulting loss of GDP be our only loss of well-being?

GDP calculations are important, but they are not a sufficient basis for decision making about global warming.