Something Not Unlike Research

Bachmann's Other Argument Against the HPV Vaccine

post by Paul Kelleher

Michelle Bachmann went on Jay Leno's show last night and commented on the vaccine for HPV, which the CDC recommends for girls 11 or 12, and which was mandated for all sixth grade girls in Texas under an executive order issued by Rick Perry. (Perry's order allowed parents to opt out and was overturned by the Texas legislature). HPV is a sexually transmitted infection that can cause cervical cancer, and the point of the vaccine is to protect girls before they become sexually active.

Speaking to Leno, Bachmann, who has been using the issue to attack Rick Perry from the right, said this:

The concern is that there's, you know, potentially side effects that can come with something like that. But it gives a false sense of assurance to a young woman when she has that that if she's sexually active that she doesn't have to worry about sexually transmitted diseases.

Bachmann's false claim about side-effects has been well debunked already. But what about her other argument: that the vaccine will, on net, lead to more risky and dangerous behavior? Two thoughts. One, it's unclear that the girls receiving the vaccine at the effective request of their parents will even know what's going on. If they don't, the fact that they are vaccinated will not influence their future behavior. But let's assume they have full knowledge of what's going on. Even in that case, Bachmann's worry strikes me as no more or less cogent than the following:

But getting young girls in the habbit of wearing seatbelts gives a false sense of assurance to a young woman when she does that that if she gets her drivers license that she doesn't have to worry about staying in her lane or turning on her headlights at night.

 The only difference is that teenagers are required by law to learn how to drive safely, while in many states, the law forbids schools from teaching them about safe sex.

The Medicare eligibility age and the life course path of health

post by Bill Gardner

Most of us begin life with excellent health but -- breaking news! -- it declines over time. As it does, we have increasing needs for health care. However, some people get sick faster as they age, and hence are likely to need more health care sooner. This needs to be considered in the debate about raising the age of eligibility for Medicare.

Here is a graph from Anne Case and Angus Deaton of data from the National Health Interview Survey. The horizontal axis is the age of the person being interviewed. The vertical axis is self-reported health status (SRHS), running (confusingly!) from Excellent at the bottom to Poor at the top. This means that a rising curve means declining health. Please keep this in mind in what follows.

Nevertheless, the pattern in the graph is clear. The top lines are the SRHS of women and men in the lowest income quartile, and the bottom lines are SRHS from the highest income quartile. If you are in the lowest quartile, you enter the work force with less health than those in the highest quartile. Moreover, as you age, your health declines more rapidly than someone in the highest quartile. The largest income-related difference in SRHS is at age 60.

So, people in the lowest income quartile need health care at younger age than do those in the highest income quartile. They are also likely to have to pay more for their health care as a percentage of their income. Finally, despite Medicaid, having less income means you are less likely to be insured (see the bar chart to the right, based on 2009 data from the U.S. Census). The point, then, is that a reduction in the age at which you qualify for Medicare will hurt those in the lowest income brackets much harder than those in the upper brackets, because they need health care at a younger age, they have to pay more of their income for health care, and they are less likely to have other health insurance. 

Important caveat: The Case-Deaton graph doesn't quite show the life course paths people take, because of a problem called age-period-cohort confounding. This means, among other things, that older people have less health than younger people both because they are older, and because they were young in a (possibly) less healthy historical era. For example, if early childhood nutrition was worse in 1940 compared to 1990, that may have adversely shaped the development of a person who is 70 and in poor health today.

Health care costs and tragic incentives

post by Bill Gardner

Paul had a great post last week that discussed the overuse of expensive technology in health care, in situations where less intensive or cheaper care would be as effective. 

the failure to prescribe beta-blockers for heart attack patients is just unconscionable. Beta blockers are super cheap but can reduce mortality associated with heart attacks by 25%. Still, Garber and Skinner report that the use of beta blockers "varied from just 5 percent of patients in McAllen, Texas, to over 80 percent in Rochester, New York, during the mid-1990s."

I want to point out that the situation is sometimes worse -- or perhaps just more tragic -- than he described.

I have had the privilege of working for several hospitals, including some that were non-profit in spirit as well as law, that is, with a strong commitment to the health of the populations they served. At one, I got to know the Chief Financial Officer quite well, because I regularly came to him with proposals for improving the quality of pediatric mental health care. After children get through early childhood, mental health problems are the most important source of pediatric morbidity. I needed his commitment to small capital investments for clinical process innovations. Here is our dialogue, digested across several conversations and with the diplomacy edited out.

CFO: "I am already losing money on community mental health care." [A sad truth]

Me: "So what? We are trying to prevent adolescent suicides." [My cause of the month...]

CFO: "You know that MRI machine you bothered me about last week? The imaging studies that, in your non-medical opinion, are over-prescribed? What do you imagine is paying for the community mental health care?" 

The CFO was fully committed to children's well-being. However, the incentives that he faced were wrongly calibrated. The excessive profit he made on imaging was used to subsidize mental health, where he was under-compensated. Because he manages a budget, however, all his choices are interdependent. Correcting the overuse of expensive technology is, sometimes, harder than it looks.

Positive feedback mechanisms in weight gain

post by Bill Gardner

The Lancet has a superb series on the global obesity epidemic, including an article summarizing the nonlinear dynamics of metabolism that govern weight loss. One key point is that there is a vicious feedback mechanism in weight gain:

increased daily energy intake will result in greater weight gain in the 100 kg man than in the 80 kg man and a greater fraction of the weight change will be body fat

That is, the more body fat you already carry, the easier it is for your body to convert extra calories into additional body fat. The reason is that a kg of fat burns less energy in a given day than does a kg of lean flesh, so as the proportion of lean body fat declines, your body burns energy less intensively. 

The problem is that eating just a bit more than we need seems to give us a feeling of well-being. If you are lean, a small overshoot will produce a small weight gain. As you get fatter though, the small overshoot that signals satisfaction will lead to accelerating weight gains. If I've understood this right, this may explain why it seems to so hard to recover lean weight following large weight gains.

This is clearly a problem at any age, but it really freaks me out thinking about kids. Modest weight gains set them up for worse problems as adults.

 

Living young and reckless

post by Bill Gardner

Reading Aaron Carroll on the consumption of sugared drinks by young males, I had a thought about why the young are reckless with their health -- adolescence is the peak time for initiation of health risk behaviors. There is a lot of work on problems of time discounting and other problems of self-control, which are more severe for adolescents. What occurred to me, though, was a sense in which it is rational to be reckless with your health when you are young.

I have in mind a simple model in which a person holds two stocks of resources that they can expend to obtain well-being: money and health. The person converts these resources into well-being by engaging in activities. Suppose there are two such activities: drinking Coke and eating at world class vegetarian restaurants. Drinking Coke costs very little, but if you consume a lot of it you are spending down your stock of health. Eating at Greens costs a lot of money but little if any health. The young, of course, have seeming limitless health, but little cash. (It is often said that the young think they are immortal, is this what that stupid phrase means?) Consuming Coke is, therefore, much cheaper than gourmet vegetarian food, when we consider cost as including both cash and health. As you age, most of us get more income, while our health dwindles, and high-end vegetarianism becomes increasingly attractive. So it is rational to specialize in health-destroying behaviors when you are young. 

This is obvious, and likely has been written about many times before. The point is just to underscore the challenge of promoting healthy behavior in kids.

Like a cricket match in hell

Kevin Outterson has a great post today on how industries that market junk food to kids are opposing the US federal government's draft guidance on a voluntary program restricting the advertising of unhealthy foods to children. If you are concerned about childhood obesity, read it. My title is from his description of the industry's strategy in this fight:

But lobbyists also play long ball, games that last years, even decades. Like a cricket match in hell.

Specifically,

For more than a decade, the Washington Legal Foundation has filed legal cases and briefs advancing the “commercial speech” theory of the First Amendment, an idea that was unanimously rejected by the Supreme Court in 1942. But today, commercial speech is a profound de-regulatory tool, striking down regulation of tobacco ads, pharmaceutical data mining, liquor stores, and other products. Millions of dollars, invested strategically over many years, is now bearing fruit as judges use “commercial speech” to strike down public health rules.

And now they come for childhood obesity.

So I was curious, and took a quick look at two legal briefs written by well-known law professors, arguing the case for the junk food manufacturers, or the "Sensible Food Coalition," as they style themselves. Several arguments caught my eye.

First, they have a reasonable argument, that there should be no regulation unless there is good evidence that advertising unhealthy food to children contributes to childhood obesity. The authors, however, seem to think that there is conclusive evidence that advertising does not have such an effect. I'm skeptical, and hope to look at the data they cite soon.

What was most striking to me, however, was the preposterously strident civil libertarian tone of these arguments. Federal guidelines on marketing junk food to children are, apparently, the top of a slippery slope to "manipulating citizen behavior through the selective suppression of speech advocating lawful action." Each notes the obvious counter example, which is that the pornography industry is not allowed to market its products to children. I had always thought that such limits on pornographers were a good thing, but Professors Redish and Sullivan offer no reason I can find why we shouldn't similarly free the pornographers from the oppression of tyranny.