Something Not Unlike Research

Beyond the ACA, Beyond the USA

post by Paul Kelleher

UPDATE: A mistaken citation has been corrected.

Despite having been ruled (mostly) constitutional by the Supreme Court, neither the Affordable Care nor the cause of universal insurance coverage in America is a sure thing. So much depends on the outcome of the November election, both at the national level and at the state level. And it's possible that many largely Republican states will drag their feet and find other ways to delay or derail implementation of the law.

Given how much supporters of the Affordable Care Act have poured into the fight to pass and implement it, it is completely reasonable that they would want to keep fighting, to see it through to the end. But other options are also available. After all, the world is a large place, and the suffering faced outside our borders is horrendous and of a scale few Americans can really imagine. Some ACA supporters will wonder, therefore, what obligations they have to poor foreigners, and whether those obligations are consistent with expending so much time and effort (and so much additional time and effort) bettering the lives of comparatively well-off Americans.

What we owe to foreigners depends of course on the reasons we have to turn our attention to them. It's possible that our duties to poor Americans are stronger than our duties to poor foreigners, but this should not be taken as a given. Political philosopher Charles Beitz breaks down the sorts of reasons we may have to turn our attention outside or borders:

The possibilities begin with two limiting cases. One is autarky; here, by hypothesis, there are no reasons other than those of beneficence in play. The other is benign interdependence, in which poor and non-poor societies cooperate as equals. The most important reasons in this case have to do with the fairness of individual transactions and of whatever cooperative practices and institutions there are. These polar cases are, however, unlikely. There are several intermediate and, on the whole, more likely possibilities which I hope can be suggested with descriptive labels: for example, harmful interaction, historical injustice, non-harmful exploitation, political dependence. Each pattern evokes a different kind of reason for action: for example, not to cause harm, to compensate for the results of harm done earlier, not to exploit one’s bargaining advantage, to respect the interest in collective self-determination. This does not exhaust the possibilities but it will illustrate the point. The relationships that characterize the various dyads of interacting poor and affluent societies are diverse, not only in the patterns of interaction they instantiate but also in the reasons why these patterns are morally salient.  p. 171)

The duty "not to exploit one's bargaining advantage" is particularly salient in the context of Chief Justice Roberts's majority opinion in the ACA case. Roberts declared a provision in the ACA unconstitutional because, in his words, it put a "gun to the head" of states by forcing them to choose between expanding their Medicaid programs or losing all federal Medicaid assistance. While the Chief Justice was unwilling to “'fix the outermost line' where persuasion gives way to coercion," he nevertheless declared that "wherever that line may be, this statute is surely beyond it." Compare this to the way the United States has dealt in the past with reluctant trading partners over whom it wields significant bargaining power:

This trade and investment framework [negotiated in the Uruguay Round, and administered by the WTO] has been shaped by threats of exclusion or discrimination, through which major developed countries take advantage of the especially urgent need of developing countries for access to developed countries' markets. In the Uruguay Round negotiations, from 1981 to 1994, the United States frequently used threats of devastating trade discrimination---for example, U.S. Trade Representative Carla Hills' flamboyant warning that if others held out the U.S. would start "trade wars over all sorts of silly things," or Secretary of State James Baker's more measured but no less ominous intimation, "we hope that this follow-up liberalization will occur in the Uruguay Round. If not, we might be willing to explore a 'market liberalization club' approach, through minilateral arrangements or a series of bilateral agreements." The resulting regime has been sustained by similar bullying. For example, after a coalition of developing countries united in insistence on an end to rich-country farm subsidies in the Cancun WTO conference of 2003, Robert Zoellick, the U.S. Trade Representative (who was to become President of the World Bank four years later), noted that "the transformation of the WTO into a forum for the politics of protest ... dismayed" the United States, and announced an American commitment "in our hemisphere, and with sub-regions or individual countries ... to move towards free trade with can-do countries" excluding the "won't do" countries that had held out for an end to the subsidies. As intended, the threat led countries such as Costa Rica, highly dependent on access to U.S. markets and without good alternatives, to cave in and leave the [protesting] coalition. (Richard W. Miller, Globalizing Justice, p. 70)

Is this behavior by the U.S. morally wrong? It's certainly hard to say with a straight face that it amounts to persuasion rather than bullying and coercion. But in any case, exploitive bullying is just one reason Americans may have to feel morally bound to promote well-being abroad. All possible reasons should be given serious consideration in a full analysis of what we might owe others in the world.

If we do find that we have compelling reason to help others abroad, what is a conscientious American to do? After all, it is hard enough to get fellow Americans on board with helping other Americans. How in the world are we going to get them on board with helping others in the world? This is not a question that moral and political philosophy can answer on its own. Perhaps, when all the psychological facts are in, the best we can hope for is to make small improvements at home, since those are the only projects we can get Americans to embrace and/or abide. It is also possible that whatever we try to do, we will just make matters worse (as William Easterley has argued is the case with foreign aid.) Political philosopher Thomas Pogge has thought a lot about this question, and here are his tips for selecting morally worthy projects and reforms that are, in his words, "realistically feasible" while still being of benefit to poor folks abroad, to whom he believes we owe very strong duties (these are rough quotations, from about the 33min mark of this lecture):

1. These projects/reforms must benefit also at least some segment of the global elite (which includes normal Americans who are vastly better off than poor people abroad).

2. These projects/reforms must be scaleable, so that they can start small and then be expanded in light of what worked and what did not.

3. The projects should empower those whom we wish to protect, so that they can find their own voice and fend for their own intersts.  

4. The projects should be the first steps in a path of reform that can ultimately reverse the relevant spiral of injustice and neglect. 

I know it may sound silly to some, but in light of the recent weather across the US, I can't help but wonder whether the cause of greenhouse gas mitigation can become the sort of project that could satisfy Pogge's first condition. It is certainly an issue that has tremendous bearing on health worldwide, especially for the world's poorest countries who are most dependent on stable weather patterns and least prepared to adapt to new ones. It is also an issue that affects middle-income countries like China, as China's economic growth would not be what it is today if not for policies that are pretty bad for the environment. In short, climate change will affect everyone, and the world's worse off individuals have a serious interest in overall mitigation while retaining a serious interest in being able to do things that contribute to the problem.

Climate change is going to hit poor countries hard, and the negative impact on health worldwide will probably dwarf the positive impact that something like the ACA has in the US. As I have indicated, it is a very hard question whether (and to what extent) we are justified in continuing to spend so much time and effort on health care for Americans. (And---just so there is no confusion---by "a very hard question" I mean one that I do not have the answer to.) But despite appearances, tackling the problem of climate change may end up being exactly the world-enhancing project we can get Americans to sign onto---not necessarily today, of course, but perhaps soon. However, we may know whether it is only after some of us turn our attention away from health care for Americans and toward this other pressing issue. A fateful choice awaits.

Population Health, Health Inequality, and Leveling Down

post by Paul Kelleher

The British epidemiologist Geoffrey Rose made the following simple but powerful observation:

a large number of people at a small risk may give rise to more cases of disease than the small number who are at a high risk.

The point can be usefully illustrated with a toy example. Suppose the population of your country has a ritual of tossing coins at noon, and suppose you are a policy maker wanting to maximize the number of coinflips in the population that turn up heads. The vast majority of the population usually flips fair coins (50% chance of landing on heads, 50% chance of landing on tails), while a small segment of the population has coins with tails on both sides (giving them a 100% chance of getting tails). Assume that you can choose one of two options in your quest to maximize the number of coinflips turning up heads: (1) You can replace the coins held by the majority with coins that come up heads 51% of the time (rather than 50%); or, (2) You can replace the tails/tails coins held by the minority with heads/heads coins, changing their probability of flipping a heads from 0% to 100%. Now ask: Which strategy should you choose if your goal is to maximize the number of coinflips that come up heads? The answer, Rose tells us, is that in a very large population, you should pick option (1), since the 1% change in probability for the vast majority will yield more additional cases of heads than a 100% change for a much smaller group. Similarly, reducing the majority's average cardiovascular risk by a small amount may prevent more deaths than eliminating altogether the high risk faced by a disadvantaged minority.

This is a powerful insight. It leads to the conclusion that if we wish to maximize population health, the best strategy may be to bring about small but favorable shifts in the entire curve (i.e. the population's distribution of risk), rather than focus all our efforts on those folks with the highest risks who reside in the "tail" of the curve. Here's how that might look (figure taken from Frohlich & Potvin). Note, the x-axis measures the relevant health risk factor, with "bad" to the right and "good" to the left; and the y-axis measures the percentage of the population that carries that level of risk:

The before-and-after depicted above shows the effects of a population health intervention that reduces everyone's risk by the same degree. That is what is meant by saying that the entire curve has been shifted in a favorable direction. But sometimes our best bet for boosting population health comes from interventions that do more for the advantaged majority than they do for disadvantaged minorities. Here's what that would look like.

The above before-and-after reflects an intervention that actually widens inequality at the same time it boosts population health. Indeed, population health is boosted even as those with the highest risk (i.e. those residing in the rightmost tail of the distribution) are not helped much at all. This raises the question of whether and how the goal of boosting population health should be balanced against the goal of constraining health inequality.

In a recent paper that will become a staple in my course syllabi, Joan Benach et al. provide a useful typology of different ways in which changes in population health can be paired with changes in health inequality. In the following scenarios (click to enlarge), the solid lines represent the starting distribution and the dotted lines represent the distribution after the intervention. In general, distributions that move to the left signify an improvement in population health, while a flatter resultant distrubtion signifies increasing inequalities.

The authors discuss each scenario with reference to real-world interventions that have or might have affected popluation health in the manner depicted. For example, in the context of scenario (e), where population health improves while inequality increases, Benach et al. note that it mirrors "the historical effects of anti-smoking campaigns, in which there is an overall improvement in the population health, but mostly for the better-off." 

Consider now what Benach et al. say about scenario (g):

Scenario (g) portrays a complex picture in which health inequalities are reduced but overall population health remains the same in such a way that for social groups with better health outcomes, the situation worsens. This scenario contrasts with the so-called “leveling up” approach, which argues that inequalities must be tackled by improving health levels for less privileged groups without damaging the situation of the better-off, and therefore that a “leveling down” approach is not equitable under any circumstances.

I don't agree with the  authors' claim that (g) is an example of "leveling down." To see why, consider a passage from Whitehead and Dahlgren (pdf), which is the source Benach et. al. cite as making the case that "a 'leveling down' approach is not equitable under any circumstances" (emphases added by me):

Policies Should Strive to Level Up, Not Level Down

Nobody would seriously suggest trying to close the health gap by bringing healthier people down to the level of the least healthy. A worsening in the infant mortality rate of the babies of rich parents, for example, with no change in the mortality rate of poor babies, would not be seen as a success, but would rather be seen as a tragedy – even if it led to a narrowing of the differences between the two groups, purely in terms of measurement. Yet, opponents of an equity policy have warned of this danger. Therefore, to make it absolutely clear, the principle set out in this paper emphasizes that the only way to narrow the health gap in an equitable way is to bring up the level of health of the groups of people who are worse off to that of the groups who are better off. Levelling-down is not an option.

The example of leveling down given by Whitehead and Dahlgren is one in which inequality is lessened by worsening the health of rich persons' babies while holding the health of poor babies fixed.  Here's what that would look like:

In (i), inequality is reduced solely by increasing the health risks of the better off. In my view, the term "leveling down" should be applied only to (i), not to (g). So Benach et al. can rest assured that in supporting some interventions that look like (g), they are not supporting leveling down. The example they give is resdistributive policies designed to improve the health of the worst off, but which carry the side effect of reducing the health of the better off (mediated through a relationship between income and health). If there is something morally problematic with this sort of policy, it cannot be because it amounts to leveling down.

I'm for raising taxes on the affluent. Am I a hypocrite?

post by Bill Gardner

I support an increase in the taxes paid by the wealthiest and highest income Americans. I want this to happen to reduce the deficit and to fund some essential services to benefit the poor. This is not retribution. I don't think incomes are or could be based on what people 'deserve.' Finally, I am not motivated by envy, because I am in the group that should be taxed.

At this point, you may respond, "If you believe in increased taxes on persons like yourself, take the option to give the government more." And if I do not take that option -- which I do not -- I am a hypocrite.

So, there is no question that I am not nearly as generous or charitable a person as I should be. But that is a separate issue. I want the US to be a society where every child gets essential health care and education. Charities have never achieved these goals. Governments funded by progressive taxation get closer, in many developed societies. 

Inequality? Oh we'd love to help, but...

post by Bill Gardner

Arnold Kling and Nick Schulz argue that the growth in US inequality derives from two factors:

• Technology that allows a few very able persons to achieve extraordinary things (think Sergey Brin), and
• Defective families and assortative mating based on ability that result in large groups of people at the bottom who lack the talent to produce much of value.

These are important causes of inequality. Kling and Schulz would do something about these things if they could, they really would, but 

there may be less that government can do than one might hope. Research from Heckman suggests that education is a relatively feeble remedy for the effects of family background (although Heckman believes that early intervention, in preschool or even before, shows promise). In order to make a dramatic impact on inequality, government would have to do something about the fundamental causes: technology and marriage patterns. However, putting a brake on technological progress seems hardly feasible or desirable. And forcing people to select mates at random rather than on the basis of similar backgrounds and tastes seems similarly unlikely. As much as inequality may be a problem, no real solution is in sight.

OMG, if the only alternatives are freezing technological progress or making people marry random partners (on second thought, this is the best explanation for my first marriage, and the kids turned out great anyway), then I guess there really is nothing to be done.

Or maybe we could try the following:

• We could give every mother good prenatal care, and institute programs to reduce premature delivery. 
• We could provide every child with universal, high-quality preschool education. Please, read Heckman for yourself. He isn't saying that early interventions "show promise." He's saying that "Early interventions promote schooling, reduce crime, foster workplace productivity, and reduce teenage pregnancy." 
• We could reform our criminal justice system. The US has 751 persons in prison per 100,000 population. Canada has 117. England's rate is 151; Germany's is 88; and Japan's is 63. Mexico has 204. The global median is 125. Are Americans really six times as violent and criminal as the rest of the world? The burden of US incarceration falls on the poor and above all on people of color. It destroys families. But it could be fixed.

America could do these things and it would still have considerable inequality. But these are solutions that would help and, contrary to Kling and Schulz, they are in plain sight.

The epigenetic lottery

post by Bill Gardner

Tyler Cowen discusses the (possibly diminished) US social mobility, and asks

How much of [social] immobility is due to “inherited talent plus diminishing role for random circumstance”?  Is not this cause of immobility very different — both practically and morally — from such factors as discrimination, bad schools, occupational licensing, etc.?  What are you supposed to get when you combine genetics with meritocracy?  I do not know how much of current American (or other) immobility is due to this factor, but I find it discomforting that complaints about mobility are so infrequently accompanied by an analysis of this topic.

So, the idea is that nature roles the dice and gives each child a set of genetic endowments. Families will also invest their resources in cultivating the children's talents. Then, as we become adults, 'society' (meaning the schools, job markets, etc.) places each of us in the social hierarchies of wealth, income, and power (the figure to the right is from Catherine Mulbrandon [@visualecon], and shows the 2005 income distribution among the bottom 98% -- adding the next 2% takes you way off the page). If societies are increasingly meritocratic, those outcomes will mirror the individual distribution of genetic talent and family resources to an increasing degree. So it could be that reduced mobility and increasing social inequality of outcomes reflects increasingly accurate meritocratic selection processes. And many would argue that such processes are not inherently unjust, so maybe we should just get over being upset about the worsening inequality of outcomes. If you add the ideas that genetic endowments are exogenous, and that trying to compensate for the inequality of family resources is either wrong or futile, then you have even stronger justifications for current inequality.

I don't buy these conclusions, for lots of reasons, but this post is not the place to provide the discussion that Cowen is calling for.

I want to raise just one objection here: The story about the genetic lottery is too simple. Our biology is less exogenous than most theorists believe. Michael Rutter explains that genes do not give us talents:

...although the DNA is what a person inherits, the effects of that DNA are dependent on a chain reaction that ends up with the expression of the products of the DNA in the structure and function of individual cells that is how environments alter genes (emphasis added).

Referring to this account of the interaction of nature and nurture, James Heckman writes

The field of epigenetics surveyed in Rutter (2006) demonstrates how genetic expression is strongly influenced by environmental influences and that environmental effects on gene expression can be inherited (emphasis added).

He then argues that there is evidence

that high quality early childhood interventions foster abilities and that inequality can be attacked at its source.  

and we are therefore not absolved from responsibility for the inequitable distribution of adult talent visible in infancy and early childhood.

The problem I'm pointing to in the meritocratic argument is that there isn't really a genetic lottery  in the way we imagine: and to the degree there is, the dice are loaded in the womb. If Heckman is right, there is much more we can do about inequality than most of us are willing to acknowledge.

However, if Heckman is right, it is also the case that much if not most of what we can do is equalize the epigenetic and child developmental lotteries that will govern inequality among future generations. And we have to decide whether we are motivated to struggle for equality in that future, a promised land that we will not see.

Prohibiting Anti-Smoker Hiring Policies is Not "Leveling Down"

post by Paul Kelleher

Bill responds today to my view that anti-smoker hiring policies are unfair to those who smoke. I have argued that many smokers are victims of social arrangements that confine them to highly constrained socioeconomic situations. These situations are highly correlated with smoking uptake, and since smoking (and/or just feeding an addiction) relieves stress, many smokers are doing nothing irrational or particularly worthy of condemnation. I have made the point that anti-smoker hiring practices promise to make many already disadvantaged smokers even worse off by erecting further barriers to scarce employment opportunities. I would rather see a more compassionate approach that actively helps smokers quit without making them worse off economically. (I do not doubt that Bill also wants to put compassion at the fore, although his last paragraph here does sound a bit harsh to me given that smoking is an addiction that most smokers acquire before they are considered wise enough to vote).

Against my view, Bill claims that the policies I favor amount to "leveling down": my preferred policy is said to sacrifice improvements in average and overall economic well-being for the sake of a narrower variance in social outcomes (assuming, that is, that non-smokers are more productive). Indeed, Bill argues that I favor less variance in social outcomes at the cost of both fewer economic and fewer health improvements, since an increasingly anti-smoker society would contribute to less smoking overall. Bill concedes that less inequality can sometimes justify a loss in aggregate or average outcomes, but not in this case. 

Bill hasn't got the dynamics of my argument quite right. I am not in favor of leveling down. I am not, for instance, in favor of intentionally harming the better off in order to reduce the inequality between them and those worse off. Nor am I arguing here for policies that harm the better off as a side-effect of improving the situation of those worse off (although I am in favor of other policies fitting this mold, as I assume Bill is). Each of these sorts of policy would bring the top down and would thereby decrease inequality. But I am advocating for neither. Rather, I am arguing that it is unjust to make the worst off even worse off than they already are. I do concede that this might lead to lower overall health or welfare, at least in the short to medium term. How much lower aggregate health of welfare? Who knows.

My argument type is, then, the third on this list:

1. Worsen the better off in order to reduce inequality.

2. Worsen the better off as a side-effect of policies designed to improve the worst off. 

3. Prevent worsening the worst off, even if that interferes with potential improvements for the better off.

In my view, (1) is the hardest to justify and (3) the easiest; I think most would agree with me on at least that. If the worst off referred to in (3) are indeed absolutely badly off for reasons of injustice, then we see that the issue is not as clear cut as simply "mean vs. variance." Mine isn't an aesthetic thesis about the virtue of flat distributions. Nor am I wholly insensitive to foregone improvements for the better off. Instead, I am focusing on a third factor: what we owe to those who already experience the brunt of injustice.

I am therefore against anti-smoker hiring policies for both reasons of compassion and reasons of justice. That does not mean that I think smoking should be "a lifestyle choice that we want to protect" (to quote Bill). I am fine with less draconian attempts to turn people off smoking, such as higher cigarette taxes (used in turn to fund smoking cessation programs) and even greater health care cost sharing for smokers. Erecting greater barriers to employment is, however, going too far in my opinion.

Gender equity in the US and Canada

post by Bill Gardner

Aaron Carroll recounts an amazing incident (reported here by Carey Goldberg):

In 2007, Sophie Currier of Brookline, holder of M.D. and PhD degrees from Harvard, asked for extra time to take an all-day medical board exam. Her daughter was four months old at the time and exclusively breast-fed, and she needed more than the standard 45 minutes of total break time to pump her breast milk. The test’s overseers, the National Board of Medical Examiners, said no.

There are many things wrong with Canadian healthcare, but I would be deeply shocked if this happened here. The laws vary slightly across province, but mothers get a year's paid leave. Perhaps for this reason, there seem to many more female hospital CEOs and chiefs of medical departments here, compared to the US.

The point is that the problem may be bigger than just the need of physicians to haze their apprentices. The US should support parents with maternity and paternity leave rights comparable to those in Canada and Europe.

What causes racial inequities in health?

post by Bill Gardner

The image is a recruitment letter from the Tuskegee experiment.

I am reading Angus Deaton's working paper, "What does the empirical evidence tell us about the injustice of health inequalities?" He notes the pronounced racial difference in health in the US.

In 2006, life expectancy at birth was 4.1 years less forAfrican Americans than for white Americans. There are also pronounced racial  differences in treatment patterns, for example for cardiovascular disease... or knee arthoplasty...

Why does this happen?

The conventional explanation for these inequalities, endorsed by a 2002 report of the National Academies of Sciences..., is that the encounter between healthcare providers and patients leads to poorer treatment of African Americans by largely white providers. 

If you accept this explanation for racial disparities in health care, then you may believe that the solution is to train culturally-competent health care providers, that is, providers who are able to interact effectively with persons from different cultures to deliver care.

Deaton does not dispute the cultural incompetence explanation, but

there is another, perhaps more obvious explanation, which is that African-Americans receive worse health care because the hospitals and clinics that serve them are of lower quality than the hospitals and clinics attended by other Americans. Hospitals in the US are run on something close to an apartheid basis, with few white patients in the hospitals that treat mostly African-Americans, and vice versa...; doctors and nurses are much less segregated, with many white doctors in “black” hospitals, and African-American doctors in “white” hospitals. 

That is, because we live in a largely segregated society, race is highly correlated with geography. This point does not seem to be widely recognized in the literature on health disparities. (A technical implication is that a regression analysis of disparities that does not account for the spatial clustering of data is likely to omit an important variable.) This clustering matters because

The “black” hospitals have worse outcomes, are less well-provisioned, their pharmacies have fewer drugs, and their providers are less well-qualified... In consequence, people who live in cities with large African American populations—both African-Americans and whites who live in those areas—have poorer health.

Both the "doctors are culturally incompetent" and "hospitals serving blacks are under-resourced" causes for health disparities would represent gross injustices. Both could be true. My sense, however, is that the medical establishment and many disparities researchers have attached themselves to the cultural competence explanation. It is the kind of problem that seems like it could be fixed by HR department training, or continuing medical education. Providing facilities and providers of equal quality to everyone, regardless of race or income, would be both expensive and -- shall we say -- politically difficult.

h/t to Mike Foster, for helping clarify these matters for me.

 

It's good to be the King. Isn't it?

post by Bill Gardner

From Angus Deaton, in a manuscript about the health gradient, the finding that social advantage is associated with better health. The health gradient is found in societies through out the world; which makes us believe that it is somehow baked into social life. But health and social advantage have not always been associated.

It is sometimes supposed that the gradient has always been with us, that rich people have always lived healthier and longer lives than poor people. That this supposition is generally false is vividly shown by Harris (2004, Figure 2) who compares the life expectancies at birth of the general population in England with that of ducal families. From the middle of the 16th to the middle of the 19th century, there was little obvious trend in general life expectancy. For the ducal families up to 1750, life expectancy was no higher than, and sometimes lower than, the life expectancy of the general population. However, during the century after 1750, the life prospects of the aristocrats pulled away from those of the general population, and by 1850–74, they had an advantage of about 20 years. After 1850, the modern increase in life expectancy became established in the general population. Johansson (2009) tells a similar story for the British royals compared to the general population, though the royals began with an even lower life expectancy at birth.

I suppose we could have learned this from Shakespeare. 

The health gradient is, in my view, the central injustice. It has not always been here, so perhaps we can make it go away again.