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.

Ubel on Bloomberg's Soda "Ban"

post by Paul Kelleher

Peter Ubel writes:

Unfortunately, the Big Gulp ban is a bad idea.

...

Where the trans-fat and soda bans differ, however, is in the coherence with which New York City officials can explain how they draw the line between banned and unbanned goods.

...

Coke and Pepsi are artificially manufactured processed foods, too. And they contain an undeniably harmful substance. But herein lies the problem. The harmful substance is sugar, and the sugar in Coca-Cola is no more harmful than the sugar in apple juice or a milkshake.

This is understandably confusing to the public, who can’t understand why New York City is planning to ban large sodas but not triple-decker chocolate cakes, or why the 280 calories in a 24-ounce Coke are somehow worse for them than the 330 calories in a Starbucks peppermint mocha.

The success of most policies depends upon public support. But incoherent policies are difficult to embrace.

If Mayor Bloomberg were defending his policy in front of the Supreme Court, the justices would be asking him for a limiting principle – a rationale that would help us know where this policy begins and ends. The ban on large sodas doesn’t pass this test.

I think a lot more rides in this case on pragmatic and context-specific considerations than Ubel acknowledges here. Ubel adopts the language of the Supreme Court oral arguments over the ACA when he says that Bloomberg cannot provide a "limiting principle" that explains why large sodas should be banned but not Starbucks peppermint mochas. But I wonder: is there a limiting principle that explains why one can buy Tylenol over the counter but not fentanyl patches? Each one can be very harmful if used improperly, and each works by containing narcotics, just as both soda and milkshakes taste delicious because of their sugar content. This suggests that sometimes pragmatic, context-specific considerations can serve to justify otherwise "incoherent" policies governing the sale of similar substances. A paradigm example of a pragmatic consideration is how likely it is that Tylenol (or soda) will be consumed in degrees that trigger the public's interest. Another example may well be how likely it is that a key demographic--kids and adolescents, e.g.--will overconsume one product rather than another. (Another may concern the degree to which specific consumption patterns negatively impact the already cash-strapped budgets for essential social services.)

I'm not yet saying that the consumption patterns of soda raise do in fact raise pragmatic concerns that render Bloomberg's specific proposal justified in the final analysis. (I need to read more of the empirical work on the issue.) I'm only pointing out that sometimes pragmatic considerations can justify a policy response that can't be neatly expressed in a tidy limiting principle.  

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.

'Health Shock': How childhood chronic illness affects children's schooling and adult employment

Pediatrics is sometimes treated as the least important branch of medicine. This kind of makes sense, because children are mostly healthy. Focusing just on health outcomes, however, is terribly short-sighted. As Jason Fletcher and Michael Richards show, chronic diseases that begin in childhood have powerful effects not only on children's adult health, but also on their non-medical development and achievements. 

Fletcher and Richards looked at the association between the 'health shock' of  getting diabetes in childhood and achievements in schooling and work for more than 15,000 children. They found

effects in several measures of educational attainment, including a high school dropout rate that was six percentage points higher than among young adults without the disease. We also found lower employment and wages: A person with diabetes can conservatively expect to lose more than $160,000 over his or her working life, compared to a peer without the disease. 

This is an observational study, so whether diabetes causes these effects is a matter of inference and interpretation. Fletcher and Richards used a data set that included detailed information on the children's family backgrounds, the health of parents, and other diseases that children had; and their estimates include statistical controls for such factors. We cannot necessarily infer that an intervention that prevented diabetes in a child would increase the years of schooling they would achieve, or how much they would earn as adults. But based on these data, it would be worth a shot.

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.

Health services research: After the money's gone

post by Bill Gardner

My recent post on the reduction of grantmaking by the Agency for Health Research and Quality must have hit a nerve, based on how frequently the link was retweeted. Many health services researchers make their living by winning research funding competitions. As a PhD, you cannot aspire to a tenured position in a school of medicine or public health without some victories. But you can't win a competition that isn't being held.

So if the money's almost gone, and you are an American health researcher, and you do not yet have a secure position, what should you do?

Consider working for  an accountable care organization. They need your skills. As Elliott Fisher, Mark McClelland, and Dana Safran write in the current NEJM,

Even integrated [ACOs], however, are finding that they need substantial time and resources to develop the informational, technical, financial, and professional capabilities required to provide and reward coordinated, longitudinal, population-based care. 

The emergence of the ACO is the best attempt yet by Americans to achieve the goals of population health. Implementing better care might be a better job than the one you thought you were training for.

When the high price of health care is a good thing

post by Paul Kelleher

If an [Implantable Cardiac Defibrillator] were a buck and a quarter, would we have gone through this entire process of reviewing the evidence at all? Maybe not. But because it's a bit more than a buck and a quarter we wanted to make sure the evidence was clear and that it was a benefit. We don't use cost to decide the evidence issue, but we do use cost to decide if this is important enough to address.

That is Dr Steve Phurrough, then-acting director of the Centers for Medicare and Medicaid Services Coverage and Analysis Group, speaking in 2003. I find this quotation shocking, and I wonder if others do as well.

I have no idea if things at CMS have changed since 2003, but this strikes me as illustrating one reason why it can be good for health care to be pricey. I do not claim that this reason makes it true, all things considered, that health care is so expensive. But its just not clear that we would be better off if health care grew on trees. 

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.

Social microstructure and health behavior change

post by Bill Gardner

Fighting chronic illnesses and curbing rising health care costs will require that we change health behavior on a population scale. How do we do this? There is lots of smart work on how to use incentives and persuasive health communications to induce people to change. But we also need to understand how change diffuses through a population. 

The importance of the microstructure of your social network for health behavior change was demonstrated in a brilliant set of experiments by the sociologist Damon Centola, reported in Science. By all means, read the whole thing.

What Centola did was create artificial social networks. In each network, each participant is connected to 6 other participants. The network on the left consists of neighborhoods of 6 persons with many connections to each other, and fewer connections to others. On the right, people also have 6 connections, but they are distributed across the population so as not to create clusters. People in the left are close to a small group, but far away from everyone else. People are the right are closer to a randomly chosen population member, but they do not belong to a close group. 

Strangers were recruited to serve at nodes in the network. What they were asked to do was to decide whether to perform a health behavior, specifically to sign up for an online health forum. If a person decided to join, messages were sent to his 6 neighbors informing them of the decision. The question is, given that one person decides to join the health forum, in which network did the behavior spread faster? What he found was

Individual adoption was much more likely when participants received social reinforcement from multiple neighbors in the social network. The behavior spread farther and faster across clustered-lattice networks than across corresponding random networks... My findings show that, not only is individual adoption improved by reinforcing signals that come from clustered social ties but this individual-level effect also translates into a system-level phenomenon whereby large-scale diffusion can reach more people and spread more quickly in clustered networks than in random networks. 

So, changing health behavior is not just a matter of incentives and persuasion. These tools work better if their power is focused, when all your friends change together.

Centola suggests that public health programs target "clustered residential networks," but is this going to work if we are increasingly bowling alone? To my mind the obvious target is the workplace. Workplace wellness programs may work not just because the boss holds the levers, but because workplaces are often the locus of our most important social networks. But where will we be if workplace-based insurance ends, and these programs go away?