Something Not Unlike Research

The cost of health care from the viewpoint of the poor

post by Bill Gardner

Austin Frakt noted today that health coverage cost 30% of the income for the median family of four. 

It is informative to make the same comparison for a family at the poverty line. Poverty, for a family of four, is $22,314 total income. This is about 16% of the US, almost 50 million people. From Austin's post, a family of four would pay $19,393 for care from a preferred provider organization (PPO), that is, 87% of their income. You will likely qualify for Medicaid in this situation, so you would not actually be in this market. Poverty in the sense defined by the Affordable Care Act (ACA) is 133% of the poverty line. Then PPO coverage would cost 65% of your income. 

What does this exercise show? First, it shows why Medicaid, or some replacement safety net insurance program, is a necessity for the poor. An old friend of mine is an activist for the conservative policy organization ALEC, and during the debate around the ACA she asked, "Why should I have to pay for someone else's health care?" The answer is that the cost of American health care is such that either the rest of us pay for the health care of the poor, or they do not get it.

Moreover, consider that if your family earned just a bit more that the ACA limit, and did not otherwise qualify for Medicaid or receive benefits through your work, it would cost you almost 65% of your family's income to join the PPO. This comparison shows that the poverty line defined by the ACA still leaves families who, if they do not have workplace insurance benefits, cannot afford health insurance.  In Canada, we do not have this problem.

Let them eat precepts

Ron Haskins of the Brookings Institutions says that a principal cause of inequality and poverty is the failure of the poor to marry and form stable families, leading to adverse consequences for their children. This failure occurs because these parents are irresponsible:

The most shocking failure of individual responsibility is the decline of marriage and rise of nonmarital births. Brookings data show that if the same share of adults were married today as in 1970, poverty would be reduced by more than a quarter. And yet young women who have a high school degree or less education increasingly do not marry, and about 40 percent of their babies are born outside marriage, quadrupling the chance that they and their babies will live in poverty. Children from single-parent families have, on average, more developmental problems, including lower educational achievement, than children of married parents. This perpetuates poverty and lack of mobility into the next generation. 

Yes, the nation needs its safety net, but improvements in personal responsibility would have a greater and more lasting impact on poverty and opportunity. This is the message that our presidential candidates, media and educational institutions should emphasize — not the misleading focus on the lack of opportunity in America.

Heather MacDonald, writing in the City Journal, agrees and thinks that single moms should be called on it:

It is time, therefore, to tackle the problem of out-of-wedlock births head-on. And that means remoralizing the discourse around child-bearing. When DeParle [in The New York Times] profiles a 21-year-old mother of two as a victim of welfare reform because she is allegedly forced to live with an ill-tempered boyfriend now that her welfare payments have run out, conservatives can legitimately ask what has become a taboo question: “Why didn’t you think of that before you had the children?”

So, there is something to this. Social skills, self discipline, and the ability to exercise self-control are critical skills for educational success, economic success, and avoidance of criminal behavior. These traits also contribute to delaying childbearing and, I will speculate, finding and keeping a spouse. Maybe it will help if elites start lecturing the poor about having children out of wedlock. It's unlikely that it will be news to a poor kid that his or her betters think that its necessary to have a job and a spouse before having children, but frequent reminders might help. A tiny bit. 

However, cultural norms are just one factor affecting children's acquisition of self-discipline. Poor kids are less likely to receive supportive parenting -- so how about placing visiting nurses in communities to counsel young parents on how to provide a nurturing environment for their children? Good pre-schools help kids get a taste for learning and skills at how to comply with positive group norms -- so how about providing pre-schools in every neighborhood in the country? We can best shape character by cultivating environments where children get morally authoritative yet supportive parenting and good early preparation for schooling. 

So, yes, children's personality and character, shaped by family environments, are important determinants of how will those children will do. And, yes, parents who make poor choices are part of the problem. Let's definitely re-moralize the discourse around families and children. And when we do that, let's ask ourselves whether lecturing parents about their irresponsibility actually benefits the children. The irresponsibility of parents may be a relevant reason to oppose welfare payments to those parents. It is not a relevant moral reason to oppose investments in early childhood development.

 

Two approaches to reducing inequality

post by Bill Gardner

Suppose you were a government policy maker, you had $1 to spend, and you wanted to reduce inequality. What would you do?

You could send the dollar to somone earning below the poverty level. In a sense, putting cash in someone's hands is the best way to reduce inequality. That person knows better than you what they most need, so it would seem likely that they would spend it in the way that best improves their well-being.

What I would do, however, is spend it on a program that improves the health and school-readiness of children in impoverished families. For example, I would increase access to pre-school education, support programs that improve elementary schools, or fund programs to help expectant mothers stop smoking. In a sense, this is inefficient, because a lot of my dollar will be consumed in paying the professionals who run these programs. So why do it my way?

The question to ask, in my view, is "inequality of what"? Transferring money through welfare and a progressive tax system is the best way to reduce inequality in what citizens can buy, at least right now. That's a good thing. But you will have to make the same transfer next year, because earnings will be highly skewed toward the rich again. Moveover, we are looking at a future in which the returns to low-skill employment will increasingly decline, increasing the inequality of earnings.

My view is that it makes better sense to decrease inequality in the human capital that people bring to the job market, and investment in early child development is the best way to do that. This should help equalize what people can earn. And because human capital can be inherited, this will effect what their children can earn. Finally, by increasing the average level of human capital, it should raise the earnings of the children of the poor. Increasing the total population stock of human capital will have spillover effects that make all of us more productive, and make the pie bigger for everyone. Of course, we can't just invest in early childhood. Even an optimal program of investments in early child development will leave considerable inequality, so investments in disadvantaged children are not perfect substitutes for transfers. But they are where I would spend the marginal dollar. 

Most importantly, equality is not, in my view, primarily about wealth and income, but rather about human capabilities, about what you can do and who you can be. Cash can help you expand the space of what you can do and who you can be. However, having more social and cognitive skills and mastering more of your culture is an increase in capability. This is what we should seek above all to equalize.

The ethics of a blood test for depression

post by Bill Gardner

Jesse Singal writes in the Daily Beast about our recent article, "Discovery of blood transcriptomic markers for depression in animal models and pilot validation in subjects with early-onset major depression," in Translational Psychiatry (also discussed here, here, and here; and see also commenter Will on the last link).

Singal quotes Michele Goodwin, a law professor and bioethicist at the University of Minnesota.

If diagnosing depression shifts from a mostly interview-based process to a more quantitative, blood-based one, she said, the potential for overdiagnosis—and overmedication—will grow, especially in vulnerable populations.

This is especially troubling given the United States’ track record in this area, Goodwin said.

“It has to be understood within the context of our culture,” she said. “In a culture that’s so quick to medicate on everything, including on cases where it might appear quite problematic that we would choose medicine over other alternatives, then there might be cause for some concern.”

Goodwin cited the example of K-12 schooling in the United States, where children are often routed into special-ed programs based not on specific learning disabilities, but on behavioral problems. The system overwhelmingly lumps poor kids, and particularly poor minority kids, into that category. And from there they are often put on medication at a very young age.

“We’re a nation of shortcuts,” Goodwin said. “So however we think about what ideally we would want to do, the reality is that we are in a space of doing something different.”

First, I must restate that we did not announce a blood test for early-onset depression. What we found was that a gene expression profile based on factors identified from animal models and other data was able to discriminate between depressed and non-depressed adolescents. This is a first step, but it needs to be both reflined and replicated in a larger sample before the finding has any clinical application. Unfortunately, many preliminary findings like ours do not pan out. I am sure that Singal and Goodwin both get this.

Next, the concerns that Goodwin raises about over-medication of disadvantaged children are well-grounded. With another group of colleagues, I am beginning health services research on the use of atypical antipsychotics in the foster care population, where there is great concern that children may be medicated too frequently with these drugs.

Having said this, I am puzzled why Goodwin believes that having a biological test would exacerbate this problem. It may be that we are currently over-diagnosing several conditions. (I think this is likely, at least for some populations; other populations are likely under-diagnosed.) But this problem of mis-diagnosis is occurring already with interview-based methods. Assuming we were able to validate an assay, having both interview and physiological data should make diagnosis more rather than less accurate.

Our goal in this research is to develop a tool that would help clinicians identify those children who would be most likely to benefit from mental health care. This care could be either psychotherapy or anti-depressant medication -- there is nothing about a positive blood test that implies that a medication is the necessary treatment. An accurate blood assay should not only find new cases of children who need mental health care but also reduce inappropriate or excessive treatment. 

Blood transcriptomic markers for early-onset major depression

post by Bill Gardner

One of the privileges and joys of my life is that part of my job is doing research with my wife, Dr. Kathleen Pajer. Here is the abstract from an article of her's and her colleague Eva Redei (I contributed some writing and statistics):

Early-onset major depressive disorder (MDD) is a serious and prevalent psychiatric illness in adolescents and young adults. Current treatments are not optimally effective. Biological markers of early-onset MDD could increase diagnostic specificity, but no such biomarker exists. Our innovative approach to biomarker discovery for early-onset MDD combined results from genome-wide transcriptomic profiles in the blood of two animal models of depression, representing the genetic and the environmental, stress-related, etiology of MDD. We carried out unbiased analyses of this combined set of 26 candidate blood transcriptomic markers in a sample of 15–19-year-old subjects with MDD (N=14) and subjects with no disorder (ND, N=14). A panel of 11 blood markers differentiated participants with early-onset MDD from the ND group. Additionally, a separate but partially overlapping panel of 18 transcripts distinguished subjects with MDD with or without comorbid anxiety. Four transcripts, discovered from the chronic stress animal model, correlated with maltreatment scores in youths. These pilot data suggest that our approach can lead to clinically valid diagnostic panels of blood transcripts for early-onset MDD, which could reduce diagnostic heterogeneity in this population and has the potential to advance individualized treatment strategies.

This is really preliminary: translational, but not yet close to clinical application. What is exciting is the possibility of a for-real biological assay for depression.

Make them pay

post by Bill Gardner

Risperdal (aka Risperidone) is an antipsychotic medication used to treat schizophrenia, bipolar disorder, and irritability associated with autistic disorder. It was heavily promoted for many years by its manufacturer, Johnson & Johnson, leading to extensive off-label use. Hundreds of thousands of children have been given Risperidal. 

Many of the patients given Risperidal had severe mental disorders that were resistant to other forms of treatment. However, the drug has severe adverse side effects, including rapid weight gain, metabolic disorder, and muscular tics. Many of us have believed that the dramatic increase in the use of atypical antipsychotics among children (at least) was not justified in light of the clear data about the severity of the side effects. Moreover, we felt that the companies and researchers promoting widespread use of these powerful drugs overstated their benefits and understated their harms.

And a court in Arkansas is doing something about this:

A state judge in Arkansas ordered Johnson & Johnson to pay a $1.1 billion fine after a jury found the company had minimized the risks of its antipsychotic drug Risperdal.

Judge Tim Fox determined that J&J and its Janssen Pharmaceuticals unit repeatedly broke the state's Medicaid fraud law, the Associated Press reports. One big issue: a letter sent to thousands of doctors in the state 2003 that said Risperdal was safer than rival medicines, according to Bloomberg.

Each Risperdal prescription for a Medicaid patient during a 3½-year period represented a violation of state law. Multiply $5,000, the minimum fine, by more than 200,000 prescriptions, and you get the lion's share of the penalty.

$1.1 billion can, as they say, concentrate the mind.

 

The deteriorating international health ranking of the US

post by Bill Gardner

Stephen Bezruchka:   

In the 1950s, the United States, having among the lowest mortality and other indicators of good health, ranked well among nations. Since then, the United States has not seen the scale of improvements in health outcomes enjoyed by most other developed countries, despite spending increasing amounts of its economy on health care services. Trends in personal health-related behaviors are only part of the explanation. Structural factors related to inequality and conditions of early life are important reasons for the relative stagnation in health. 

Even though our life expectancy is improving, it is improving less quickly than comparable developed countries. He summarizes the possible reasons for this, about which there is great uncertainty. The health care system is probably not the principal cause of the problem. The high rates of homicides and completed suicides may be important. Americans are more obese but smoke less than many countries, so it is not clear whether health-related behaviors can explain our comparative lack of progress in health. Note also that the US accepts fewer immigrants than many substantially healthier countries, such as Canada.

Bezruchka speculates that

An explanation of the relative health decline may come from a population health approach that highlights the importance of structural, economic, and political factors that govern the level of inequality tolerated in society. Early life may be when these factors matter most. The United States demonstrates among the worst inequalities in outcomes for children of all rich nations.  

Ummm... I sort of/kind of agree. In my view, however, the problem is less inequality per se than childhood poverty and adversity. If I understand the Pikety-Saesz data, the recent rise in inequality has been driven by in the increase in the share of wealth and income held at the top of the social ladder. It is not clear to me how growth of wealth and income at the top of distribution would lead to stagnation in life-expectancy improvement for everyone else.

Rather, it seems more plausible that it is the stagnation of improvement in economic well-being for the 99% that slows their improvement in life expectancy. To understand this we should look at the circumstances of those at the bottom of the social ladder. Because I think that much of our health trajectory is set in early childhood, the life circumstances of children are particularly important.

It seems plausible to me that the stagnation of economic well-being for the least-advantaged Americans is in large part a result in the decline of the value of their labor in an economy of services and highly-automated manufacturing. If so, the long run improvement of their well-being and life-expectancy will depend on whether today's poor and middle class children can do a better job of acquiring cognitive skills, social skills, and related human capital than their parents did. Just off the top of my head, we should

• Reduce unplanned and teen-aged pregnancies through both the promotion of abstinence and the subsidization of the use of reliable, long-acting birth control.
• Implement universal maternity leave, and subsidize high-quality child care for low-income working mothers.
• Implement universal, high quality preschool.
• Improve elementary schooling, which could be advanced right away by shedding the bottom 5% of the current cohort of teachers.

What If People Don't Care?

post by Paul Kelleher (@kelleher_)

Defending President Obama's recent use of it, Jonathan Chait claims that the term "'social Darwinist' captures the prevailing Republican philosophy pretty well." Chait cites as evidence a paper by Romney advisor Greg Mankiw in which Mankiw defends a "Just Deserts Theory" of justice. (I have previously critiqued that theory on this blog). In response, Mankiw accuses Chait of unfair and selective quotation. Mankiw then highlights the following passage from his paper in his own defense.

What about transfer payments to the poor? These can be justified along similar lines. As long as people care about others to some degree, antipoverty programs are a type of public good. [Thurow 1971] That is, under this view, the government provides for the poor not simply because their marginal utility is high but because we have interdependent utility functions. Put differently, we would all like to alleviate poverty. But because we would prefer to have someone else pick up the tab, private charity can’t do the job. Government-run antipoverty programs solve the free-rider problem among the altruistic well-to-do.

According to Mankiw, a social darwinist is someone who believes (in part) that "the weak and unfit should be allowed to die." Now, I have no interest in wading into a discussion of whether "social darwinist" applies to Mankiw (or to anyone), but I will note that the passage Mankiw accuses Chait of ignoring does not entail that the poor (or the sick, etc.) must be helped as a matter of justice. Rather, it says that since the "altruistic well-to-do" happen to care about the poor, and since government can sometimes step in to help citizens achieve what they care about, government can step in to help alleviate poverty. This is quite consistent with the view that if the well-to-do did not care about the poor, there would be no good rationale for state-administered policies to help the poor. Indeed, Mankiw seems to admit this in his paper when he discusses tax policy that would be aimed at helping poor foreigners (emphasis added):

Imagine a candidate for president campaigned on a platform of imposing a one-third tax on the average American’s income and transferring the entire proceeds of the tax to poor nations around the world. Would you be inclined to support this candidate? I am confident that most voters would not. I say this because I know of no political candidate who has proposed something even remotely like this. Moreover, the foreign aid that the United States does provide to the world’s poor is far smaller than this and, even so, tends to be wildly unpopular. […]

The reason Americans are more ready to vote for transfer payments to the American poor than for foreign aid is simply that they care more about their own neighbors than they do about the poor abroad. As a result of these preferences, caring for the American poor is more of a public good than caring for the poor in other nations. 

Mankiw never suggests that it is wrong to care so little about the world's poorest individuals, or that it would be wrong to become indifferent toward the poor in America. Labels aside, this fact seems relevant to the substantive moral issues raised by the brief Chait/Mankiw dust-up. For many, justice is about what we must care about, not merely about what we happen to care about.

Why not 'Replace' instead of 'Repeal, Then Replace'?

US conservatives propose to repeal the Patient Protection and Affordable Care Act, and then replace it with an alternative health reform bill. This would be, perhaps, Rep. Ryan's plan to give each citizen a voucher (a "defined contribution") to purchase health insurance on the private market.

Experts such as Gail Wilensky support defined contribution schemes (others, of course, do not). More importantly, the Ryan plan is clearly superior to repealing the PPACA and leaving tens of millions of Americans without insurance. But that is what would happen if the PPACA was repealed and -- as almost always happens to health insurance bills -- the replacement bill was defeated. In fact, if you have the political capital to pass the Ryan plan, you can certainly pass the Ryan plan with a preamble that eliminated all or part of the PPACA.

So I am perplexed as to why anyone would argue on health policy grounds for 'Repeal, then Replace' instead of just 'Replace.'

The Rabbit Hole

post by Paul Kelleher (@kelleher_)

This tragic NYT op-ed is a must-read, as is Harold Pollack's reflections on it. 

The author frames the story as one about healthy folks who forgo health insurance to make ends meet, but who are terribly unlucky and then face a horrendous medical and financial future. Pollack adds that in addition to ensuring that people don't (or don't have to) take such gambles, health reform is also about taking care of one another.

I want to add one layer to what the author and Pollack say. The author of the op-ed says that it was a car accident that ruined her sister-in-law's life. Perhaps it was somebody's fault. But perhaps not. I do not want to live in a society where I can be the cause--perhaps negligent, but perhaps innocent--of someone else's medical and financial ruin in the blink of an eye. And yet any one of us, at any time of the day, in the blink of an eye, can go from happy, reputable member of the community to the person who was involved in ending someone else's life as they knew it. We are not the only potential victims of our own missteps. And still I am certain that my liability insurance certainly would not have begun to help this woman if, heaven forbid, I had been a partial cause in what she now faces. That is one reason (among so many others) to ensure that no one in our society is left to fall down the rabbit hole.