Something Not Unlike Research

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.

Reihan Salam, Paul Ryan, the Safety Net, and Public Sector Profiteers

post by Bill Gardner

Reihan Salam recommends two lines of argument that he attributes to Rep. Paul Ryan:

• "[C]onservatives shouldn’t attack the safety net."
• Rather, they should "Attack Public Sector Profiteers... and the lack of spending restraint that actually exacerbates cost growth in health, education, and other domains."

I agree that conservatives should not attack the safety net, so a good first step would be to just stop doing it. Ryan's proposal would leave the safety with a gaping hole. There are more than 45 million Americans without health insurance. This number will decresease because of the expansion of Medicaid under the Affordable Care Act, but Ryan would repeal that. Among the uninsured, there are healthy Americans who could afford health insurance but elect not to purchase it, and some of them would likely be induced to purchase it through Ryan's tax credit scheme. However, the majority of the uninsured are at less the 200% of the Federal poverty level, and cannot realistically afford private health insurance under Ryan's plan. We do not yet have a real safety net if large numbers of poor families fall through it.

OK, how about "Attack public sector profiteers"? Umm... let's see, which side is promoting class warfare here?  (And how well did that work out?) 

First, what could "public sector profiteers" mean? I think public sector would include not just government employees, but also private sector workers whose income depends on government programs. In Canada this would include nearly all doctors and nurses; both are unionized, even the residents have a union. It includes many health care providers in the states. What does it mean to call them profiteers? I doubt that Reihan Salam is challenging the right of teachers or health care providers to better themselves. "Profiteering" comes from war time, when military suppliers exploit an emergency to get enrich themselves by unethical means.

So what is unethical about how public sector workers pursue their interests? I will stipulate to the following:

1. Public sector demands for income or restructured work conditions sometimes harm the populations they are employed to serve.
2. By voting as a bloc, by making political contributions, by gaining great influence in left political parties, and by cloaking their self-interests under the needs of their vulnerable clients, public sector health care providers achieve considerable leverage over government. When they use that leverage to raise taxes, they are raising their incomes by taking money from taxpayers. 

These are tendentious arguments, but that does not mean they are wrong. On point 1, medical guilds and unions often structure care in ways that increase guild members' incomes but harm patients. If this seems implausible to you, read Atul Gawande's famous article about health care in McAllen, TX. Point 2 is just, I think, a fact.

So why won't I join in an attack on public sector privateers? I think there are cases where teachers unions or health care workers unions take the wrong side of an issue, and there I side with management in the interests of students or patients. But I wouldn't single them out as profiteers. Pharmaceutical and device manufacturers, hospital owners, insurers all pursue policies in their self-interest that compromise the best interests of patients (point 1). And they have vastly greater resources to influence the political process (point 2). So unless we want to routinely refer to all stakeholders as profiteers, it is not clear to me that the word has much application.

Moreover, our views about the motives and moral integrity of stakeholders give us zero useful information about how to reform health care. Consider this argument:  

1. Defense manufacturers and contractors sometimes produce weapons that earn them huge profits, but actually diminish national security and the safety of armed services members. 
2. By making political contributions, by gaining great influence in right political parties, and by cloaking their self-interests under the banner of patriotism, defense manufacturers achieve considerable leverage over government. When they use that leverage to raise taxes, they are raising their incomes by taking money from taxpayers. 

These points are both true, but they do not tell us what weapons we need to purchase, or how high to set the defense budget. "Attack the Defense Profiteers" is not a plan to make America more secure, and a plan to "Attack the Public Sector Profiteers" will not make it healthier.

The morality of health-care priority-setting

post by Paul Kelleher

I'd bet a tidy sum that the most cited thought experiment in contemporary moral and political philosophy--aside from Rawls's Original Position, perhaps--is T.M. Scanlon's Pious Aid Recipient example. Google Scholar says the source paper has only 310 citations, which I believe raises pressing questions about the reliability of Google Scholar. In any case, here it is:

The strength of a stranger's claim on us for aid in the fulfillment of some interest depends upon what that interest is and need not be proportional to the importance he attaches to it. The fact that someone would be willing to forego a decent diet in order to build a monument to his god does not mean that his claim on others for aid in his project has the same strength as a claim for aid in obtaining enough to eat (even assuming that the sacrifices required of others would be the same).

Scanlon states his point succinctly, but let me repeat it: to determine which duties we have to others, we should look at the claims they have on us, and not merely at the strengths of their preferences. Someone may want help building their religious monument more than they want to be adequately nourished, but my main duty is to respond to their claims, not to their preferences. This does not mean that there are no claims to have one's preferences satisfied, but note that this would still give priority to the underlying claims and not to the preference themselves.

Scanlon's thought experiment came to mind when reading this post by Leo Katz. Katz asks us to imagine Al, a pianist, who has a finger badly injured in a traffic accident. The only doctor around must choose between helping Al, or helping Bea, who faces paralysis in one of her legs if not helped immediately. Many would say that Bea should receive priority, since losing the use of a leg is in general worse than losing the use of a finger. Of course, to Al, this isn't so. But the doctor's question is who has the stronger claim on the doctor's help, and many would say that Bea does. (If you doubt this, ask yourself: should the doctor interrogate Bea to determine whether her leg is as important to her as Al's finger is to him?)

But there is one more piece to Katz's story. Just before making his decision about whom to help, the doctor sees that Al has another injury that will lead to paralysis in both his legs if not addressed immediately. Now the doctor must choose between three courses of action: (1) save Al's finger; (2) save Al's legs; or (3) save Bea's leg. Here is Katz:

How can he [the doctor] treat Al’s finger when Bea’s more serious leg injury needs attention? How can he treat Bea’s leg injury when Al’s far more serious leg injury isn’t getting treated? How can he treat Al’s leg injury when Al clamors to have his finger treated instead? We are in a sort of cycle.

How is it to be broken? At least one plausible way of breaking it, my own guess is that it is the most plausible, is to not let Al opt for getting his finger treated. He retains his priority over Bea only if he has is leg injury treated, not otherwise. But that means that we are rejecting a win-win transaction. For that is what the doctor’s treating Al’s finger rather than his legs surely is...The reason, in brief, is that Al has a strong claim on the doctor’s attention for his serious injury and a much weaker claim for his less serious injury.

I think Katz is correct to invoke the Scanlonian notion of claims here. I am less sure, however, that treating Al's finger really should be considered a "win-win" that creates the problematic "cycle" Katz describes. Fixing Al's finger is a win-win only if Bea is no longer in the picture. For if Al is the only relevant patient, then it might well be true that the doctor should help Al in whatever way Al prefers (unless fixing his finger is much more costly than fixing his legs). But Bea is never "out of the picture." It is Al's legs, and not Al or Al's preferences, that generate the claim that overrides Bea's claim. If Al's legs-based claim is ignored, then Bea's leg-based claim is the strongest claim remaining. Within the Scanlonian framework of claims, fixing Al's finger while Bea suffers paralysis in her legs is in no sense a "win-win."

The morality of claims and claims-adjudication is essential to the morality of priority-setting in the health care setting. And things can get philosophically hairy very quickly. I will be posting a good deal on these issues in the coming weeks.

Mankiw vs. Nozick on Just Deserts

post by Paul Kelleher

The short version: Greg Mankiw believes people should get what they deserve, and that what people deserve is based on the economic value of what they contribute to social production. Mankiw attributes this view to libertarian philosopher Robert Nozick. But Nozick explicitly rejects the view, noting a problem with it that Mankiw never addresses.

Students of economics learn that, under a certain set of assumptions, a competitive market economy leads to an efficient allocation of resources. However, since economic efficiency may not the only thing we care about, many economists are careful to note that there may be equity-based reasons to condemn otherwise efficient arrangements. Harvard economist Greg Mankiw thinks this is a mistake. In "Spreading the Wealth Around: Reflections Inspired by Joe the Plumber", Mankiw argues that when competitive markets promote efficiency, they do so by rewarding factors of production (including labor) in proportion to their productive contribution. Mankiw thus extols "the inherent equity of the competitive market": the market ensures that factors of production are paid what they deserve.

Mankiw claims that this "Just Deserts Theory" can be found in the work of the libertarian philosopher Robert Nozick (among others). But in fact, Nozick believed the area of economics that Mankiw draws on--Marginal Productivity Theory (MPT)--cannot reliably be used to assess individuals' productive contributions. Nozick did think that MPT could explain why individuals get what they get in market distribution, but this was not because Nozick thought the market does or should reward people in accordance with their contribution. Rather, Nozick's view is that people are entitled only to what others are willing to give them (either as gifts or in economic exchange). MPT helps us understand who will be willing to give what to whom, but that is it. So Nozick would say Mankiw is wrong on two counts: (1) people are not in fact entitled to their "Just Deserts"; (2) even if people were entitled to their just deserts, MPT cannot be used to identify what it is people deserve in Mankiw's sense.

Let me explain Nozick's argument for this second point. Nozick agrees with Mankiw that (at least under a set of "idealized circumstances") MPT can be used to predict the wage that rational firms will be willing to pay to a worker for performing a specific job. To illustrate, consider the following graphic*:

For economic reasons that Mankiw and Nozick agree upon, a rational firm will pay all laborers a wage equal to the value of the output generated by adding the last laborer, depicted here as laborer #10. To use some economic jargon, firms will pay a wage equal to the marginal value product of labor. Where Nozick and Mankiw disagree is on how this economic jargon should be interpreted. According to Mankiw, when wages are set in this way, it ensures that "each person's income reflects the value of what he contributed to society's production of goods and services...[E]ach person receives his just deserts" (emphasis added). Nozick claims that this is not an accurate characterization. Here is why: all we know from the graphic is that after adding the 10th laborer, the total product went up by 6 bushels of corn; but we don't know exactly how that outcome arose. For example, it might have been achieved by the 10th laborer simply producing 6 extra bushels all by himself. Or, those 6 extra bushels might have resulted from the 10th laborer producing 16 bushels while some other laborers simultaneously reduced their collective output by 10 (perhaps because they reduced their effort when the 10th man was added). In this case, the marginal value product of labor will still be defined by MTP as 6 bushels, and all the workers will still be paid a wage equal to the value of 6 bushels. But it will nonetheless be false to say (as Mankiw does) that "each person's income reflects the value of what he contributed." While it is true that adding the 10th laborer resulted in a net increase of 6 bushels, we cannot deduce any worker's actual contribution from this fact. 

Nozick summarizes this point in a footnote to p. 187 of Anarchy, State, and Utopia:

Thus marginal productivity theory is not best thought of as a theory of actual produced product...but rather as a theory of the difference (subjunctively defined) made by the presence of a factor.

Paul Samuelson makes the same point here:

In our example, output increases from ten bushels to eighteen bushels when one adds the second man not because the second man only adds eight, but rather because his presence on the field makes the situation such that the total output of both men is eighteen...[W]hat we wish to note is that by adding the second man, output was increased by eight. Thus, the marginal product of the second man is eight. But his actual contribution may be very different than this.

If Mankiw is right that each person's income should reflect the value of what s/he contributed, it does not seem that marginal productivity theory can tells us what we need to know. Importantly, this worry arises even if we grant the many unrealistic assumptions MPT seems to require for its validity. Of course there may be even more problems with using MPT as part of a theory of just income distribution. Amartya Sen discusses several of these in a very nice 1985 paper called "The Moral Standing of the Market" (which Mankiw doesn't cite).

 

*This figure comes from p. 28 of David Schweickart's After Capitalism.

DeLong's Ad Hominem Against Libertarianism

post by Paul Kelleher

Brad DeLong has a piece in the Boston Review symposium on libertarianism. T. M. Scanlon, who wrote the symposium's lead essay, says in a follow-up that "I agree with almost everything Brad DeLong says." I am surprised to hear this. 

Scanlon's essay was a methodical attempt to pick apart three potential arguments for libertarianism. In contrast, DeLong focuses not on the weakness of this or that argument, but on what he sees as a telling weakness in the people who make these arguments:

When the chips are down and libertarians are faced with the potentially monstrous consequences of overvaluing individual autonomy or rights to non-interference, they almost invariably...retreat to claiming not fiat libertaria ruat caelum ["Let (libertarian) justice be done though the heavens fall"] but rather that such situations would never arise in practice, because libertarian policies do produce the greatest good for the greatest number.

DeLong goes on to suggest that we don't need to take libertarianism seriously, because people who call themselves libertarians are systematic self-deceivers about the ancillary benefits of libertarianism or about the imagined bad effects of alternative political arrangements. In Logic 101, we teach students that this type of argumentation is called argumentum ad hominem, and that in most cases it's a logical fallacy. For instance, suppose I argue that theism is false because believers in God shockingly claim their faith grows even stronger when God permits great evil to befall them. The correct reply to my argument is that nothing about the existence of God follows from facts about the psychology of the people who believe in him. Unfortunately, this is precisely the fallacy DeLong commits in his essay. 

Take DeLong's central example, the libertarian philosopher Robert Nozick. He notes that immediately after concluding that "the minimal state remains as the most extensive state that can be justified," Nozick remarks:

Our normative task in these two chapters is now complete, but perhaps something should be said about the actual operation of redistributive programs. It has often been noticed, both by proponents of laissez-faire capitalism and by radicals, that the poor in the United States are not net beneficiaries of the total government programs and interventions in the economy. Much of government regulation of industry was originated and is geared to protect the position of established firms against competition, and many programs most greatly benefit the middle class. The critics (from the right or the left) of these government programs have offered no explanation, to my knowledge, of why the middle class is the greatest net beneficiary.

Here is DeLong's appraisal of this passage:

This statement [that the poor are not net beneficiaries of redistributive policies] is empirically false...The major government programs...benefit the middle class and the poor, largely by raising those who would otherwise be poor into the middle class, and protecting the middle class from the danger of falling into poverty.

Given the passage’s empirical falsity, the interesting question is why Nozick felt that he had to make it. Weren't his arguments strong enough without it? Wasn't he happy saying that a libertarian society is a just society—even if (or rather though) it grinds the faces of the poor in the dirt and makes their lives nasty, brutish, and short? He was not. Nozick felt that his argument for libertarianism was incomplete without the empirical claim that libertarian society is good for the poor.

DeLong's diagnosis is that Nozick couldn't stomach the possibility that a libertarian state might leave the poor worse off than some more interventionist state. So Nozick deceived himself into thinking that libertarianism will always be better for the poor. But, DeLong suggests, if libertarians have to deceive themselves like this, libertarianism can't be a theory worth taking seriously. 

Suppose we grant DeLong's premise about Nozick's self-deception. Even so, the argument falls apart if we can find some other libertarian (or--gasp!--two) who's willing to own up to the bad consequences that libertarianism may have for the poor. This more stalwart libertarian will simply say that Nozick's backbone was no match for his intellect. And DeLong has given us no ammunition with which to reply to this. That is the problem with ad hominem arguments.

As it turns out, I highly doubt that anything about Nozick's backbone is revealed in the passage DeLong jumps on. If you actually read the entire short section in which it appears, you get the impression that the passing remark about net beneficiaries simply provides an excuse for Nozick to address "the puzzle" of why the bottom 51% of the voters don't just "vote for redistributive policies that would greatly improve their position at the expense of the best-off 49 percent." That, of course, is actually an interesting question, and no self-deception about libertarianism is needed to see it as something worth investigating.

The great irony here is that it's the user of ad hominem arguments that comes off looking desperate. Such arguments signal that one has no substantive reply to uncomfortable conclusions, which in DeLong's case isn't actually true. But the fact that DeLong has substantive things to say about Nozick's libertarianism makes it even more curious why he is so keen on the ad hominem. So keen is he, in fact, that this is not the first ad hominem he has pressed against Nozick's libertarianism:

[A]rguments that are deployed only when they count on the side one has already pre-chosen are not really arguments. [...]

This point was brought home to me most powerfully when I discovered that the critique of Robert Nozick's Anarchy, State, and Utopia that was most effective in providing my students with the proper critical distance from the book were not any of the critiques of Nozick's philosophy...but was instead a little piece, "Anarchy, State, and Rent Control" in the New Republic...about how Robert Nozick used the Cambridge Rent Control Board to squat in Eric Segal's apartment until he had extorted $30,000. [...]

Whenever I teach "Anarchy, State, and Rent Control," odds are that the class will then have a furious argument over whether Nozick's failure to take his own libertarian principles very seriously should or should not be taken as a reason to distrust Nozick's book. I have, after much thought, decided that it should be taken as a strong reason to distrust Anarchy, State, and Utopia.

I'm sorry, but this really is a waste of valuable class time. When DeLong's students later encounter someone who is attracted to something like Nozick's libertarianism--maybe this libertarian has never even heard of Nozick--nothing constructive will come from the student's conviction that Nozick was some sort of cheat or scoundrel. If the conversation is to be constructive, it will proceed as Scanlon's lead essay does: point by point, logical move by logical move. It will proceed by avoiding ad hominem arguments.

Corporate coercion and health behavior: Is it really coercion?

post by Bill Gardner

Yesterday, I summarized a meta-analysis that suggested that corporate wellness programs provide a positive return on investment by controlling employee's health care costs. Today I want to look at whether these programs are coercive.

Ezra Klein raised this concern in his post on the successful Cleveland Clinic employee wellness program:

[C]onsider what [changing health behaviors] actually entails: Changing habits. Breaking addictions. Getting people to the gym. Who wants to hear about any of that from their employer? The clinic, however, didn’t give employees a choice. “First thing we said was we had to make our institution toxin free,” [Cleveland Clinic Chief Wellness Officer] Roizen said. “The biggest toxin we have in the U.S. is tobacco. So we began offering free tobacco-cessation programs to our employees. Then we banned smoking on campus. You can’t even smoke in the parking lot in your car. The first offense you get a warning, and the second you get fired. We fired two high- profile physicians who refused to quit. Then they knew we were serious.”

Klein (see also here and here) noted that

Whether [the Cleveland Clinic's] success is a model for American health care or a preview of a dystopian surveillance state is an open question.

Let's step back, though, and ask what 'coercive' really means. Suppose someone confronts you in the dark with a pistol and says, "Your money or your life." This is coercion. Now suppose you are diabetic and need insulin, but your pharmacist won't give it to you unless you pay for it. In both cases, you are in life-threatening circumstances, unless you give someone money. But in most cases we feel that even though the pharmacist may be pressuring the diabetic, he isn't coercing her. The reason is that we view a threat with a gun as an illegitimate form of pressure, whereas barring dire emergency we believe that pharmacists have the same right to require payment as any other merchant. We distinguish coercive situations from legitimate pressures based on our moral judgments. 

So is what the Cleveland Clinic does coercive? Americans have complex views about what norms employers can legitimately require you to conform to, but in general your employer has wide scope to regulate your behavior. Your boss can require you to be punctual, if that is essential to the functioning of the business. But you can't be discriminated against on the basis of your religion. Your employer can, however, require you to meet a dress code -- unless it's a matter of dress or grooming required by your religion. And so forth. How do we feel about pressure to conform to norms of healthy behavior? My sense is that as people come to understand that unhealthy behavior is a significant business cost, they will increasingly accept employers' monitoring and enforcement of norms about healthy behavior.  

But although I believe Americans would accept Cleveland Clinic style carrots and sticks as part of voluntary employment contracts, they would not accept them if they were imposed by the government. Citizenship isn't voluntary in the way that employment is.

 

 

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.