Truck and Barter

Neither YAY or NAY -- but FACEPALM

Government policy has already made it customary and relatively cheaper (if not easier) to have medical insurance cover and pay for every medical service. So insurance dominates the finance and provision of even the routine medical services market -- e.g. seeing a doctor for an earache and obtaining medicine.

The consumer situation in medical care has become radically different from other types of transactions; under a regime of medical insurance, there is little to no incentive for people to care about or respond to price, outside of copayments and coinsurance; there isn't even a simple and widely accepted way to talk about price of most medical services; bills are written to get insurance companies to pay up, not to provide a clear record of the services performed, and at what prices.

The situation is so different from other transactions based on people paying their own way, that some people without insurance are actually scared just to go see a doctor, and rightly so. This is a terrible madness. And while at first glance, it looks like a subsidized insurance mandated appears to solve the problem, I think in the future, it will further empower Congress, not the people. The consumer will become ever more reliant on other people to make decisions about what care he can access.

Medical insurance was already heavily regulated. It will now be further subsidized by taxation and even higher premiums for others. This will increase "access", as some people will now get insurance (and medical services) who otherwise wouldn't, but at a real cost to others.

But while this policy will increase the quantity of medical services that will be provided, it will increase prices. While some people will now use insurance to get necessary services, many more will get even more unnecessary services. What is necessary? We are already at the point that insurers and regulators determine this more than a consumer advised by a doctor. Is it not plainly obvious that fewer and fewer people will have personal financial incentives to keep cost down?

The only way to lower cost is to simply let almost all people pay for the vast majority of their own routine medical services, like almost all pay for their own food. Of course, the entire medical culture would have to shift towards a framework of clarity in price and competition in quality.

I yearn for a future where people can find out the price of an MRI just as easily as the price of an iPad.

Random thoughts on Electronic Medical Records

Regardless of the lawsuit implications, I am not so sure of the benefits of EMRs.

I would be all in favor of a private and complete electronic medical history for each person, but the EMRs I have seen are neither private nor complete, and tend to reinforce formulaic medical practice, as opposed to discovery, discussion, and intelligent understanding.

Broadly, my concerns with EMRs:

First, GIGO. I was enthusiastic about Kaiser-Permanente's electronic medical records until I saw garbage being put into the system by well intentioned folks. This translated into outputs that incommensurable over time.

Second, ownership. I should own my EMR, because I own myself and manage my own care.

Third, format. My preferred EMR would have a wiki template, because I should be able to add my observations to my EMR, and anyone who sees it will know how to access the most relevant information. I would keep mine up to date with a current status report up on top.

Fourth, interpretation. This is fundamental. Regardless of data quality, ownership or format, new doctors (say the harried folks in the ER) will not know how to interpret and use the data from all the other doctors. In fact, I've seen this first hand. It is very hard to practice medicine wisely in the short-run. Doctors disagree with one another on observation and diagnosis of the simplest things. Even when there's agreement, notes are always incomplete and cryptic, many times providing negative information.

If you were to look at my KP medical records, you will have almost no idea of interventions or medications or lifestyle changes that I've ever taken, or why all my basic measurements improved drastically over a one year period.

We should be looking at how patients, doctors, bureaucrats, politicans, and insurance companies use EMRs in the real world. This cannot be a pretty picture. Personally, I now focus far more on the meaning of test measurement, how doctors know what they say they do ( when and why they started believing it as well as causes of justified variance in opinion), and far less the alleged expert opinion that I should just trust.

Access to Healthcare

It turns out that "access to healthcare" is actually an incredibly complex sociological concept:

Facilitating access is concerned with helping people to command appropriate health care resources in order to preserve or improve their health. Access is a complex concept and at least four aspects require evaluation. If services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may 'have access' to services. The extent to which a population 'gains access' also depends on financial, organisational and social or cultural barriers that limit the utilisation of services. Thus access measured in terms of utilisation is dependent on the affordability, physical accessibility and acceptability of services and not merely adequacy of supply. Services available must be relevant and effective if the population is to 'gain access to satisfactory health outcomes'. The availability of services, and barriers to access, have to be considered in the context of the differing perspectives, health needs and material and cultural settings of diverse groups in society. Equity of access may be measured in terms of the availability, utilisation or outcomes of services. Both horizontal and vertical dimensions of equity require consideration.

And here I thought "access to healthcare" meant you could get whatever medical services you want, and somebody else would pay for them.

Completely Backwards

Various surveys have found that 20 million to 50 million family members in the United States provide care that has traditionally been performed by nurses and social workers.

-- Jane E. Brody, NYT, "When Families Take Care of Their Own", 11/10/2008 (emphasis added)

That has it completely backwards.

In the past century or so, nurses and social workers are have been providing care that has, for thousands of years, been performed by family members. Modern capitalist economies in democratically run countries have produced a wildly different outcome than traditional societies. The extraordinary wealth required to have other people look after your family members was once had only by the elite. How strange to see the modern specialization and division of labor in healthcare called "traditional".

Family caregivers are, in effect, home-based representatives of the patient’s medical team. They provide medical services, make assessments of the patient’s well-being and determine when to call the doctor or bring the patient to the emergency room. Yet they often lack 24-hour access to professional advice and clear instructions about when and whom to call for help.

The medical establishment-centered view of care seems to overestimate the relative value of the judgments of medical professionals. Yet, I think analysis should be done to assess the relative cost and quality of care provided by "home-based representatives" versus "professionals".

Still, something doesn't sit right with me about this. Aha! Wait a minute. All these people being cared for at home by family members have suddenly become "patients"! That's pretty slick, Ms. Brody!

Food Policy

Over at Mark's Daily Apple, there is discussion of those calorie-posting requirements for restaurants.

I have several concerns about these requirements: they are an example of 1) a completely ineffective policy 2) imposed through a mindless requirement on chain-store operators, 3) seemingly ignorant of the results of similar interventions. I think this policy is entirely ineffective, and should be laughed at. Even those who disrespect economic liberty should demand a regulatory policy based on more than the whims, hopes, and dreams of light-weight health lobbyists.

So my comments began "Repeat after me: THIS IS INEFFECTIVE GOVERNMENT POLICY!" And I'd like to expand on them here.

Well, my comments were about the obese. While activists and policymakers do want to modify the food intake of everyone, they justify their interventions as actions taken for the otherwise helpless obese.

My main concern is one I think all should share, regardless of view about the propriety of government intervention in the market: there is no solid evidence that calorie posting is a meaningful private health intervention.

I don't believe there's any good reason to support the notion that the trend of higher obesity rates will be reversed by increasing the supply of nutritional information about prepared restaurant food; there's already plenty of data about raw ingredients out there for anyone really interested in preparing themselves for eating in a complex world.

In particular, the idea that mandating the posting of total calories will change the behavior of people who've demonstrated through their eating habits that they don't otherwise care enough about their health to modify their own diet, is, in my mind, utterly unsound.

This is a particularly unsound idea because (I might be wrong here, but think this is so) there was no measurable effect in reducing obesity since the requirement of nutritional labeling on all those bottled, boxed, bagged, containerized, canned, and jarred foods. If posting calorie data were effective at all, shouldn't we have seen SOME effect?

Again, all I really wanted to point out was that government policy should be based on ideas that have a solid foundation in science, or at least be borne out by recent social experience. By that standard, big-board nutrition labeling is not a start to something bigger, bolder, and badder, it's merely a pointless exercise in information saturation.

I don't have solid evidence, just personal experience, to support my claim of policy ineffectiveness. However, advocates don't even bother to claim they have any evidence whatsoever. In my view, they manner in which this policy is being pursued makes this a first step in the in the entirely wrong direction.

Some people, like me, do use detailed nutritional data to help make some choices, but the availability of the data didn't CAUSE me to want to eat better. I cannot disagree that meal-specific nutritional data expand the meal choices of those dedicated to health maintenance. It appears to me that the calorie-posting requirement is actually going to help the people who need help the least!

In fact, one could sensibly argue that while big-board calorie posting won't lead obese people to modify calorie consumption, it will gradually make them believe that all sources of calories have the same impact on health.

Quote of the Day...

Tongue-softly-in-cheek:

in this global economy we simply cannot afford to be instilling bad taste in our children.

Hillary's Healthcare Plan v2.0

Oy vey, it cites RAND research, so I can't discuss it.

Why I Don't Like "Happiness Research"

Surveys in general suffer from the fact that self-reported data is always seriously problematic. And that's even when asked questions with demonstrably true or false answers, such as "What is your income?" But couple surveys with the fuzzy-edged notion of "satisfaction" or "happiness", and you get this (with the added bonus of a small sample size):

South Korean gangsters get more satisfaction from their line of work than the police, according to a survey published on Tuesday in local dailies.

The article even suggests satisfaction is correlated with income (gangsters make more than the police, natch), which isn't what other places are telling us.

For more on the topic, see Wilkinson.

Prohibition Nation

New York went trans-fat free today. And I now have a new litmus test for figuring out of if you're too much of a meddling, know-it-all, self-righteous ass to grant you any sort of assumption of intelligence: if you say you agree with government bans on trans-fats, ding, you're the next contestant on "Soft Facism TV"!

Aside from the disturbingly twisted logic it takes to think that your publicly elected officials have the right to police your favorite eating establishment's cubbards for things they don't like, let's look the effectiveness of the policy itself. How can we do that? By looking at the first country to make such a ban legit: Denmark.

Even consuming less than five grams of trans fat - the amount found in one piece of fried chicken and a side of french fries - a day has been linked with a 25 percent increased risk of heart disease.

It is still too early to tell if removing trans fat from food in Denmark has improved the country's health.

Although the Danish health ministry reports that cardiovascular disease has dropped by 20 percent in the last five years, similar reductions have been reported in other countries that are making an effort to combat heart disease by measures such as regulating the food and tobacco industries, and by educating the public about the need to exercise. In countries that are making no effort to regulate the amount of trans fat in food, heart disease rates have continued to climb.

So, if you're fool enough to lunch at KFC everyday, this might help your heart. But in the aggregate, it's not worth the greasy wax-paper it was written on. But NYC heard it, and thought it sounded like a good idea.

Something else to stick in your fryer: trans-fat is cheaper to make and lasts longer. So who does eliminating it affect? The people who consume food with high levels of processed ingredients and who do not cosume what they buy on the day they bought it, i.e., the poorer folks in society. Since the yuppies strolling through Dean and Deluca find it just a shame that people don't eat more fresh food have decided that it really is ok for people to pay a premium to satisfy their societal whims, it's now incumbent on those folks consuming fast and packaged foods to pick up more of the bill for a law that has had no demonstrable societal benefits.

Spiffy work, folks.

And if you're part of the "but natural foods are so much healthier" crowd, try this article: "Organic chicken less nutritious."

Don't want the health care system to be burdened with the costs of a generation of obese people? Then don't make me pay for what you shove down your cake-hole. Take a look at the wreck of regulation and subsidy busy-bodies akin to the ban-supporters in NYC have made of the health care system, and start cutting away the red tape.

If the people lamenting the existence of folks who adhere to the myth of creationism think so highly of natural selection and evolution, let people do what they want with whatever foods they want. After a few generations of 20-year olds having heart attacks, I'm betting people will start figuring it out.

The Benefits of Obesity: Part II

Three and a half long years have passed since I insisted that there must be some benefit to obesity (namely the enjoyment of food), and finally the headlines seem to agree with me. But the article entitled Odd benefit to obesity glosses over the price the obese must pay to get their benefit:

Overweight heart patients were about 75 percent less likely to die than their underweight counterparts during a five-year study because they were given aggressive medical procedures, a new study found.

Obese patients, who are often younger and have fewer unrelated health concerns, often are better candidates for intensive and invasive therapy for coronary artery disease than underweight patients, who are most likely older and in worse health, according to a study presented yesterday at an American Heart Association meeting in Chicago.

In other words, obese people have heart problems much earlier in their lives than the non-obese, and because they're not yet suffering from other problems, they're given more severe treatment and respond better to it.

A heart problem in one's 60s is one hell of a cost to bear to get the benefit of better response to treatment.

UPDATE: Here's a cute argument. Obesity + Liposuction = Stem Cells. With bonus quote from the Koran:

"…It may happen that you dislike a thing which is good for you,

and it may be that you love a thing which is bad for you.

Allah knows, while you know not." Qur'an [Surah Baqara 2:216]

Some Podcasts

Andrew Leigh interview about Milton Friedman (second item on the podcast)

Interpreting culture
The distinguished American anthropologist Clifford Geertz died last month. This week, we take a respectful but sceptical look at his work, its origins in philosophy and its consequences for philosophy. Savage Minds have more Clifford Geerz.

"Shifting aims, moving targets: on the anthropology of religion"- a lecture by Clifford Geertz

Postmodern Theory

Imps of the Mind Gone Awry: Obsessive Compulsive Disorder
Rituals, checking the stove, repetitive thoughts. Everyday patterns for all of us, but when they go awry, the impact of these imps of the mind is devastating and life-consuming. This week, a provocative theory with new, convincing science - could Obsessive Compulsive Disorder in some children be triggered by a common bout of strep throat? And, nipping the obsessions and compulsions in the bud - one parent's story, and a pilot project already changing the lives of young people plagued by OCD. More links here.

The State of Russia
Professor Christopher Read examines the current state of Russia and its changing political and economic position

Libertarian Paternalism Is Not an Oxymoron
Cass Sunstein, professor of Jurisprudence at the University of Chicago Law School

Chart of the Day- Deaths of poor in rich neighborhoods

“By living in a well-to-do neighborhood, poor people increase their risk of death, according to a new study by School of Medicine researchers to be published in the December issue of the American Journal of Public Health.”
- Death rates for poor higher in rich neighborhoods

Via Columbia Sat Blog and Michael Stastny

Here is the abstract of the paper;

Low Individual Socioeconomic Status, Neighborhood Socioeconomic Status, and Adult Mortality;
Objective; We examined whether the influence of neighborhood-level socioeconomic status (SES) on mortality differed by individual-level SES.
Methods. We used a population-based, mortality follow-up study of 4476 women and 3721 men, aged 25-74 years at baseline, from 82 neighborhoods in 4 California cities. Participants were surveyed between 1979 and 1990, and were followed until December 31, 2002 (1148 deaths; mean follow-up time 17.4 years). Neighborhood SES was defined by 5 census variables and was divided into 3 levels. Individual SES was defined by a composite of educational level and household income and was divided into tertiles.
Results. Death rates among women of low SES were highest in high-SES neighborhoods (1907/100000 person-years), lower in moderate-SES neighborhoods (1323), and lowest in low-SES neighborhoods (1128). Similar to women, rates among men of low SES were 1928, 1646, and 1590 in high-, moderate-, and low-SES neighborhoods, respectively. Differences were not explained by individual-level baseline risk factors.
Conclusion. The disparities in mortality by neighborhood of residence among women and men of low SES demonstrate that they do not benefit from the higher quality of resources and knowledge generally associated with neighborhoods that have higher SES.

Google’s next product- Google Medicine?

Would Google replace doctors?

“Doctors facing a patient with unusual symptoms could well be advised to use Google to try to pinpoint the cause, a study published by the British Medical Journal (BMJ) suggests.

Australian doctors were given 26 real-life cases of individuals who had fallen sick with relatively rare disorders.

They were not told what diagnoses had been given in these case reports but did a Google search based on the symptoms that were presented.

Google returned the right diagnosis in 15 out of the 26 cases – an accuracy rate of 58 per cent.”

Cost-Benefit of Sex

The benefits of sex according to this article;

“In one of the most credible studies correlating overall health with sexual frequency, Queens University in Belfast tracked the mortality of about 1,000 middle-aged men over the course of a decade. The study was designed to compare persons of comparable circumstances, age and health. Its findings, published in 1997 in the British Medical Journal, were that men who reported the highest frequency of orgasm enjoyed a death rate half that of the laggards. Other studies (some rigorous, some less so) purport to show that having sex even a few times a week has an associative or causal relationship with the following:

- Improved sense of smell:….
- Reduced risk of heart disease: …
- Weight loss, overall fitness: Sex, if nothing else, is exercise. A vigorous bout burns some 200 calories--about the same as running 15 minutes on a treadmill or playing a spirited game of squash. The pulse rate, in a person aroused, rises from about 70 beats per minute to 150, the same as that of an athlete putting forth maximum effort. British researchers have determined that the equivalent of six Big Macs can be worked off by having sex three times a week for a year. Muscular contractions during intercourse work the pelvis, thighs, buttocks, arms, neck and thorax. Sex also boosts production of testosterone, which leads to stronger bones and muscles. Men's Health magazine has gone so far as to call the bed the single greatest piece of exercise equipment ever invented.

-Reduced depression: …
- Pain-relief: …
- Less-frequent colds and flu: …
- Better bladder control: …
- Better teeth: Seminal plasma contains zinc, calcium and other minerals shown to retard tooth decay. Since this is a family Web site, we will omit discussion of the mineral delivery system. Suffice it to say that it could be a far richer, more complex and more satisfying experience than squeezing a tube of Crest--even Tartar Control Crest. Researchers have noted, parenthetically, that sexual etiquette usually demands the brushing of one's teeth before and/or after intimacy, which, by itself, would help promote better oral hygiene.
- A happier prostate?

Costs? I leave up to the reader. Shouldn’t government be subsidizing it then?

Micro health insurance

An interesting article on health financing among the poor in India;

“India is a world leader in this emerging field, with 5 to 10 million people enrolled in micro health insurance nationwide. Fewer than 10 percent of India's 1.1 billion people have any sort of health insurance, much of which covers only government employees. Poor people usually work in informal jobs or are self-employed, so they are extremely unlikely to be included in employment-related plans.

Consequently, health financing poses an acute problem for India. About one-fourth of hospitalized Indians fall below the poverty line as a direct result of their hospital expenses, according to a 2002 World Bank report. Many people take out steep loans or sell their homes in order to pay. And for the poor, losing even a day's wages while waiting in the hospital can be devastating.”

Related;
UpLift India Association
News Roundup: Risk-Reward Edition
Micro-insurance: Extending Health Insurance to the Excluded
Healing Fields Foundation
Community-Based Health Insurance in Rwanda
Public Health Services in India

Breast Milk good for Babies motor

According to a new study;

“Social epidemiologist Yvonne J. Kelly of University College London and her colleagues were aware of studies that had suggested neurological benefits from breastfeeding. However, notes Kelly, those earlier analyses tended to be small and done in special populations—such as preemies. They also failed to rule out many factors that might account for differences in a child's developmental skills. Among such possible confounders: race, parent's education, family income, parenting attitudes, depression in the mother, characteristics of childcare, or the baby's overall health.

Kelly and her coauthors had access to information on such features for the families of 18,000 infants from throughout the United Kingdom. The scientists also had motor-development data from in-home interviews with the families of those children when each baby was between 8 and 11 months old. The data were collected as part of the still-ongoing Millennium Cohort Study begun in 2000.

Among these children, 9 percent exhibited gross motor delays, which means being late in reaching such major milestones as sitting up, proficient crawling, or standing. Six percent also showed delays in fine-motor coordination—such as clapping hands, transferring an object from one hand to another, or efficiently using the thumb and forefinger like pincers to pick things up. Only 1 percent of the infants showed both types of delays, the scientists report in the September Pediatrics.

When the researchers began their work, they were skeptical of a link between breastfeeding and motor skills. "Although we thought we'd initially see some kind of effect, we had expected to be able to later explain it all away when we [adjusted for] covariants," such as a family's income or mother's mental health, Kelly says.

To the researchers' surprise, Kelly notes, children "were about 50 percent less likely to have a [developmental] delay if they had prolonged, exclusive breastfeeding when compared to those who were never breastfed." They defined breastfeeding as prolonged when it had lasted at least 4 months. Even babies receiving mother's milk for a short while—2 months or less—were 30 percent less likely to have a developmental delay than those who received solely infant formula, beginning right after birth…”

Via Mind Hacks

Related;
The Allen brain atlas

Bipolar Disorder Guide

BBC has published a guide on bipolar disorder;

“It takes a detailed look at the symptoms and diagnosis of bipolar disorder, medical treatments and how to self-manage the condition successfully.”

Related:

A Psychiatrist Is Slain, and a Sad Debate Deepens
Psychiatrist Is Among Five Chosen for Medical Award

Multimedia

The Secret Life of the Manic Depressive

In the Family - A Journey through Madness
“This week, a candid family story of life inside. Inside psychiatric hospitals, inside schizophrenia, and inside a remarkable journey towards compassion, activism and understanding. Penelope and Lloyd met and married after years of cycling in and out of Perth's psychiatric institutions. Penelope's 19-year-old daughter, Tynx, reveals a wisdom beyond her years about the impact of growing up with a parent with mental illness. They join Natasha Mitchell in conversation with a story that is sure to move you.” Listen to the podcast.

The dream debate-'The nature of dreams has long fascinated philosophers and of course it lies close to the heart of Freudian psychoanalysis. This week, in the year of Freud's 150th anniversary, we hear a debate on the subject between a psychoanalyst and a professor of psychiatry'

Ageing to Sage-ing;"We now live longer, but it need not be a prolonged denial of the ageing process. Embrace your age, your wisdom, and your elder status and become a mentor to the younger generations. Turn ageing into sage-ing. Reb Zalman Schachter-Shalomi teaches people how to be spiritual elders, not only for their sake but for the sake of the planet. And while Dementia can spell the end of wisdom for many people, for Christine Bryden it was a journey to self understanding and spiritual growth." Listen to the podcast.

Your Guide to Getting an Electric Shock

Editor of the Philadelphia Weekly and mental health campaigner Liz Spikol, is you-tubeing about her experiences with mental health. (via Mind Hacks)

The statistics are quite alarming;

“A recent survey estimated that nearly half of all Americans will suffer a mental illness during their lifetimes. Harvard Medical School professor of health policy Ronald Kessler headed the two-year study, which polled 9,000 adults across the country, varying in age, education level, and marital status. Researchers conducted home-based, face-to-face interviews, using the World Health Organization’s (WHO) diagnostic mental-health survey. They found that 29 percent of people experience some form of anxiety disorder, closely followed by impulse-control disorders (25 percent) and mood disorders (20 percent). Most cases begin in adolescence or early adulthood, and often, more than one disorder will strike simultaneously.”

Related;

Two recent podcasts from the Health Report;

Only one in two patients receives the healthcare they should receive according to the evidence. One in ten patients receives care that isn't recommended and which is potentially harmful. In the first part of this series about getting health professionals to practice with evidence, Associate Professor Alex Barratt takes a close look at the catastrophic errors that have occurred when evidence has been ignored, and why evidence based practice is still not being implemented in consultation rooms near you. Listen to the podcast.

In part two of Facing the Evidence patient advocates argue that we all have a role in supporting the change to evidence based health care, so we get the care we need and we don't get treatment that's useless or dangerous. Patient advocates explain how to ask your doctor or health professional for evidence about your proposed treatment.

Smoker’s International Airways

It’s about time you had an airline for smokers;

“With a growing number of countries choosing to ban smoking in public places, it is an idea that might seem inopportune. But Mr. Schoppmann, a German entrepreneur, is hoping to take advantage of smokers’ resentment at efforts to further curb where they can smoke by giving them their own airline, Smoker’s International Airways.

As the name suggests, the airline, known as Smintair, will probably not be for the faint of lung. The carrier, expected to begin luxury service with business and first-class seats early next year, plans daily flights between Mr. Schoppmann’s hometown of Düsseldorf and Tokyo — a 12-hour journey that, for some smokers, is simply not worth the nicotine-withdrawal headache.

“Many people simply don’t travel long distances anymore because they can’t smoke,” said Mr. Schoppmann, 55, who smokes 30 cigarettes a day in addition to the occasional cigar. “That has to be why they invented videoconferencing.”…

According to the International Air Transport Association, more than a million passengers traveled between Japan and Germany in 2004, a figure that is expected to increase by an average of 3.6 percent a year through 2009. While the majority of Japanese visitors to Germany are tourists, fully half of Germans traveling to Japan are there on business.

What’s more, about one-quarter of Germans smoke, while in Japan, 49 percent of men and 14 percent of women do, according to government surveys…”

Related;
Thank You for Smoking
Stephen Colbert - Civil Lights
One of the SMINTAIR Philosophies;

“Allowing our guests to smoke is one of the freedoms we are happily prepared to grant. Non-smokers will find the cabin air more refreshing than on any other flight with any other airline, as SMINTAIR adds fresh outside air to the conditioning system! This is more expensive, as it burns more fuel, but it is seen as an additional service to our guests.”

Podcast of the Day-Crisis of Abundance

Crisis of Abundance: Rethinking How We Pay for Health Care- Arnold Kling’s book presentation at Cato;

“If you follow the video or audio all the way through to the Q&A, you will hear a Congressional aide's rant against economic analysis of health care. I chose not to respond, and I think that was the right choice. The book explains why health care is an economic issue, and I would leave it at that. Frankly, I thought that the audience Q&A did not add much. Just as with comments on blog posts, the first one often sets the tone, so that it's important to get a good question first.”

Listen to the podcast. Here is a discussion of the book at Tech Central Station. Also a Cato interview Arnold Kling.

Related:
Podcasts; Cogan on Improving the Health Care System, The Economics of Medical Malpractice
Sylvia Allegretto, an economist at the Economic Policy Institute and author of "The State of Working America," talks with Bloomberg's Tom Keene from Washington about her analysis of the U.S. labor market. Listen to the podcast.

Dead Meat is a 25 minute short film which shows the reality of health care under Canada's socialized medical system
Economics of Obesity
In praise of US health care
Unhealthy America
Charlie Rose interview with New York City Commissioner for Health & Mental Hygiene, Thomas Frieden
Economics of Health Care posts at Econlog, Economist’s View, Café Hayek, Marginal Revolution
Healthcare Economist blog
Health Courts: Exploring the Concept
The Health Report- podcasts from Radio National.
Voluntary C-Sections Result in More Baby Deaths
Health Care Costs

Health Financing Revisited: A Practitioner's Guide
Health Insurance in Francophone Africa

GAO reports;
Hispanic Access to Health Care: Significant Gaps Exist
Preventive Health Care for Children: Experience From Selected Foreign Countries
Canadian Health Insurance: Lessons for the United States
Health Care Spending Control: The Experience of France, Germany, and Japan
Health Insurance: Bibliography of Studies on Health Benefits for the Uninsured

Breast-Feeding haves and have-nots

“I feel like I had to choose between feeding my baby the best food and earning a living,” said Jennifer Munoz, a former cashier at Resorts Atlantic City Casino.

NYT reports on a new inequality that has been breeding;

“When a new mother returns to Starbucks’ corporate headquarters in Seattle after maternity leave, she learns what is behind the doors mysteriously marked “Lactation Room.”

Whenever she likes, she can slip away from her desk and behind those doors, sit in a plush recliner and behind curtains, and leaf through InStyle magazine as she holds a company-supplied pump to her chest, depositing her breast milk in bottles to be toted home later.

But if the mothers who staff the chain’s counters want to do the same, they must barricade themselves in small restrooms intended for customers, counting the minutes left in their breaks.

“Breast milk is supposed to be the best milk, I read it constantly when I was pregnant,” said Brittany Moore, who works at a Starbucks in Manhattan and feeds her 9-month old daughter formula. “I felt bad, I want the best for my child,” she said. “None of the moms here that I know actually breast-feed.”

Doctors firmly believe that breast milk is something of a magic elixir for babies, sharply reducing the rate of infection, and quite possibly reducing the risk of allergies, obesity, and chronic disease later in life.

But as pressure to breast-feed increases, a two-class system is emerging for working mothers. For those with autonomy in their jobs — generally, well-paid professionals — breast-feeding, and the pumping it requires, is a matter of choice. It is usually an inconvenience, and it may be an embarrassing comedy of manners, involving leaky bottles tucked into briefcases and brown paper bags in the office refrigerator. But for lower-income mothers — including many who work in restaurants, factories, call centers and the military — pumping at work is close to impossible, causing many women to decline to breast-feed at all, and others to quit after a short time…

In corporate America, lactation support can be a highly touted benefit, consisting of free or subsidized breast pumps, access to lactation consultants, and special rooms with telephones and Internet connections for employees who want to work as they pump, and CD players and reading material for those who do not. According to the nonprofit Families and Work Institute, a third of large corporations have lactation rooms…

…73 percent of mothers now breast-feed their newborns, according to the Centers for Disease Control and Prevention. But after six months, the number falls to 53 percent of college graduates, and 29 percent of mothers whose formal education ended with high school. In a study of Oklahoma mothers who declined to breast-feed, nearly a third named work as the primary reason…”

Related;
States promote nursing, protect moms
The Case for Breastfeeding
Breastfeeding Legislation in the U.S.
Grey Market in Breast Milk

Traffic Fatalities and Corruption

An interesting paper- Traffic Fatalities and Public Sector Corruption by Nejat Anbarci, Monica Escaleras, and Charles Register. Abstract;

“Traffic accidents result in 1 million deaths annually worldwide, though the burden is disproportionately felt in poorer countries. Typically, fatality rates from disease and accidents fall as countries develop. Traffic deaths, however, regularly increase with income, at least up to a threshold level, before declining. While we confirm this by analyzing 1,356 country-year observations between 1982 and 2000, our purpose is to consider the role played by public sector corruption in determining traffic fatalities. We find that such corruption, independent of income, plays a significant role in the epidemics of traffic fatalities that are common in relatively poor countries.”

Related;
World report on road traffic injury prevention;"Every day around the world, more than 3000 people die from road traffic injury. Low-income and middle-income countries account for about 85% of the deaths and for 90% of the annual disability adjusted life years (DALYs) lost because of road traffic injury. Projections show that, between 2000 and 2020, road traffic deaths will decline by about 30% in high-income countries but increase substantially in low-income and middle-income countries. Without appropriate action, by 2020, road traffic injuries are predicted to be the third leading contributor to the global burden of disease and injury."

Multi-country study on helmet wearing

Ten Leading Causes of Death- US

'Psychological' traffic calming

International Road Traffic and Accident Database (IRTAD)

Competition and Pandemic Control

Recently I watched the TED speech of Larry Brilliant where he talked about the importance of ‘early detection and early response’ as key for any pandemic control plan. He also talked about the role of public databases like GPHIN in early detection of pandemics and competition it brought to reporting of pandemics. The following article from The Economist summarises some of current data sharing efforts on pandemic diseases;

“The Global Pandemic Initiative, formed in May, is a collaboration between the WHO and the CDC, together with IBM, a large computer firm, and over a dozen other groups. It is intended to develop “the use of advanced analytical and computer technology as part of a global preparedness programme for responding to potential infectious disease outbreaks.” One approach IBM hopes to take is to develop software that will help predict how diseases might spread.

Another new group wants to turn the entire process of identifying outbreaks on its head. Larry Brilliant, a former WHO official who helped to eradicate smallpox in India, dreams of an open-source, non-governmental, public-access network that would help the world move quickly whenever potential pandemics start brewing. He looks for inspiration to the Global Public Health Intelligence Network (GPHIN), an obscure programme run by the Canadian government that searches public databases in seven languages looking for early signs of disease outbreak.

Dr Brilliant, who is now the head of Google's philanthropy arm, made his wish known at the Technology Entertainment Design conference, an annual gathering in California of leading entrepreneurs and thinkers from the information-technology and entertainment industries. His speech so galvanised the gathered titans that he now has the backing of Sun Microsystems, Google and several big Silicon Valley venture-capital funds and investors. They are helping to develop a new “web crawler” that will expand GPHIN to track newspapers and internet blogs in 40 to 100 languages.

A reasonable objection to such a system is that it is based on press reports, not verified scientific data. Even so, its supporters argue that it could prove valuable. Press reports have the virtue of immediacy, and its results will always be subject to verification by the WHO and government authorities, of course. But its very existence might persuade them to act more promptly. After all, that is what GPHIN did a few years ago during the SARS outbreak, when it sounded the alarm and forced the authorities to respond. The direct result, in Dr Brilliant's words: “SARS is the pandemic that did not occur.”

Related;
A Summary of Larry Brilliant’s speech

My avian flu policy paper- Tyler Cowen

Avian Influence information; from CDC, WHO, World Bank, Wikipedia, Fluwiki, Pandemic News, BBC, National Geographic Multimedia, InterAction, US Government, FAO

Data sharing; GISAID, International HapMap Project

Support Builds For Pre-Pandemic Vaccination

Warnings of a Flu Pandemic-Web Focus from Nature

Bird flu data liberated

WHO changes H5N1 strains for pandemic vaccines

Pandemic flu: fighting an enemy that is yet to exist

Pandemic Influenza Plans- US, US States Plans, UK, Canada, New Zealand, Australia, Singapore, links to other National Influenza Pandemic Plans

Blogs; H5N1, Ethics of Vaccines

BirdLife Statement on Avian Influenza; 'Globalisation has turned the chicken into the world’s number one migratory bird species'

Analysing the Avian Flu Threat- Charlie Rose

A History of Boredom

“When hit by boredom, let yourself be crushed by it; submerge, hit bottom. The sooner you hit bottom, the faster you surface.”- Joseph Brodsky

A review of the book A Philosophy of Boredom by Lars Svendsen;

“Any concept that attracted comment from Kant, Goethe, and other giants accomplished enough to be identifiable by one name must be complex, profound, and worthy of attention even in a sweltering August.

(If you immediately think, "Wait, there's probably some other concept that's drawn attention from other single-named giants such as Beyoncé, Madonna and Brittany - like bling - that's utterly simpleminded," then you possess a genuine philosophical aptitude and should continue reading.)

"Very few people," writes the witty Norwegian philosopher Lars Svendsen, "have any well-thought-out concept of boredom." That hasn't stopped folks from trying to capture it in a phrase or tossed-off digression.

Kierkegaard declared it "the root of all evil," following on church fathers who condemned its forerunner, the sin of acedia. Svendsen, a professor at the University of Bergen, cleverly updates that, noting that boredom has been accused of causing such modern ills as "drug abuse, alcohol abuse, smoking, eating disorders, promiscuity, vandalism..."

Schopenhauer thought boredom "a tame longing without any particular object." For Kafka, it was "as if everything I owned had left me, and as if it would scarcely be sufficient if all of it returned." Theodor Adorno blamed boredom on alienation at work. Russian poet Joseph Brodsky suggested boredom taught us "life's most important lesson... that you are completely insignificant."

Via Distributed Presses and 3 Quarks Daily

Experts in Boredom;

“Politicians are experts in boredom. To sit through a select committee on local transport issues needs superhuman boredom defences, or a vat of Red Bull. And the aura of boredom is the mark of death to a politician. Some have tried to turn their own lack of lustre to advantage. “I am a quiet man,” Iain Duncan Smith said, attempting to disguise his own worthy dullness under a thin euphemism. From that moment, IDS was toast. “What’s wrong with being a boring kind of guy? ” wondered President George Bush Sr, shortly before he was ousted from the White House. Nothing is more hilarious than the spectacle of a naturally tiresome politician attempting to make himself seem interesting by, say, wearing an amusing hat.”

Related;
The Nature of Belief : Australian Science Festival Debate; Why do you believe what you do? Is the human mind an organ designed for belief? Why are we so convinced of the existence of things we can't prove or see? Are some beliefs healthy and others pathological? Margaret Wertheim, author of Pythagoras' Trousers, and The Pearly Gates of Cyberspace; cognitive scientist Professor Max Coltheart, co-editor of Pathologies of Belief, and theologian, film-maker and cult-buster, Reverend Dr David Millikan, join Natasha Mitchell to unravel the perplexing power of belief.

Is This What Happiness Looks Like?

Lionel Tiger on Pursuing Pleasure

Podcast of the Day- Patient from Hell

Climatologist Professor Stephen Schneider wrote a book called The Patient from Hell. During his treatment for lymphoma he discovered that the way doctors make decisions is seriously and deadly flawed. Listen to the podcast or see the transcript.

“Q. How does a person use a climate model to predict his own survival?

A. To start with, my wife, Terry Root, a biologist, and I went to the Internet for information. There's a lot of nonsense there, but it gave us a starting point. We then had meetings with my doctor where we'd discuss various treatment options. We used math models to argue for unusual therapies. When you're looking at global warming, climatologists don't have all the facts because certain things haven't yet occurred.

You feed information into a computer, you look to what you know and extrapolate: subjective probability analysis. For years, I have been advising governments to use it for climate change policy. That's safer than waiting for the climate system to perform the experiment on us.

Similarly, I wasn't going to wait 15 years for researchers to gather the data. I'd be dead by then.”
-From NYT interview with Stephen

The Man who invented McSurgery

“I am not an idea man, the task is not to aspire to some heaven but to make everyday life divine."- Dr. V

Wall Street Journal has an obituary of Govindappa Venkataswamy, eye-care pioneer (1918-2006), founder of the Aravind Eye Care System ;

“With 2.4 million served, the Aravind Eye Care System in India is in a way the McDonald's of cataract surgery: efficient, effective, influential and -- rare for health care in the developing world -- a clear financial success.

It began with one man, Govindappa Venkataswamy, an ophthalmologist who died July 7 at age 87 after a long illness. Dr. V, as he was universally known, created one of the largest eye-care systems in the world, catering largely to the poor in Tamil Nadu, a state in southern India. He was inspired, Aravind says, by the assembly-line model of McDonald's founder Roy Kroc -- learned during a visit to Hamburger University in Oak Brook, Ill.

Building on those lessons, he created a system for sight-saving cataract surgeries that produces enviable medical outcomes in one of the poorest regions of the globe. Its rapid expansion over three decades was not built through government grants, aid-agency donations or bank loans. Instead, Dr. V took the unusual step of asking even poor patients to pay whenever they could, believing the volume of paying business would sustain the rest. Poor people with cataracts in Tamil Nadu can get their sight restored for about $40. If they can't afford that, it's free."

"Starting with an 11-bed clinic in 1976, Dr. V's system is now a five-hospital system. His model became the subject of a Harvard Business School case study, and is being copied in hospitals around the subcontinent. The cheap, high-quality implantable lenses the system manufactures are exported to more than 80 countries around the world, Aravind says. Dr. Venkataswamy's basic insight was that health care can be marketed to the poor if a program is closely tailored to a local niche, something that has come to be known as social marketing. In a country with, by some estimates, 20 million blind eyes -- 80% of them due to curable cataracts -- the appeal for patients was financial. "A blind person is a mouth with no hands," is an Indian saying that Dr. V liked to quote. In India, health professionals say, the years of life left to those who go blind can be counted on one hand. With sight restored, the patient can return to work.

The Aravind system offers services that range from a simple pair of spectacles to optical oncology. The bulk of surgeries are to treat cataracts -- removing the cataract and replacing it with an artificial intraoptical lens.

The assembly-line approach is most evident in the operating room, where each surgeon works two tables, one for the patient having surgery, the other for a patient being prepped. In the OR, doctors use state-of-the-art equipment such as operating microscopes that can swivel between tables. Surgeons typically work 12-hour days, and the fastest can perform up to 100 surgeries in a day. The average is 2,000 surgeries annually per surgeon -- nearly 10 times the Indian national average. Despite the crowding and speed, complication rates are vanishingly low, the system says.

Outside the operating rooms, conditions are as spartan as the tables at a fast-food restaurant: Often only a straw mat on a ward floor for postsurgical recovery. Patients who pay more than the basic $40 -- about 30% of patients -- can receive cushier treatment such as private rooms for extended recovery, and hot meals…”

Via Acumen Fund Blog.

Related;
Yesterday, a great hero passed away
The Perfect Vision of Dr. V.
From socialist rags to competitive riches

Multimedia;
A Discussion the Dr. V
See also this TED speech by Larry Brialliant

Yerkes-Dodson law and War in Iraq

NYT has an article on a study of the effects of military duty in Iraq and its effect on mental capacity;

“A large study of Army troops found that soldiers recently returned from duty in Iraq were highly likely to show subtle lapses in memory and in ability to focus, a deficit that often persisted for more than two months after they arrived home, researchers are reporting today…

The research team led by Dr. Vasterling administered a battery of mental tests to 654 male and female soldiers who served in Iraq at various times from April 2003 to May 2005. The tests, more than 20 in all, were given before and after deployment, and included one in which participants had to pay close attention to a computer screen as letters flashed by, waiting to flag each F they saw. In another test, they were asked to memorize simple diagrams and try to recreate them 30 minutes later.

The soldiers did significantly worse in tasks that measured spatial memory, verbal memory and their ability to focus than did 307 soldiers who had not been deployed to Iraq.

But the returning soldiers scored about the same as their peers on most of the other tests. And they outperformed those who had not been deployed in a test of reaction time, measured in the fraction of a second it takes to spot a computer icon and react. This finding in itself suggests that the soldiers’ minds had adapted to the dangerous, snap-judgment conditions of war, experts said. ..

In effect, the brain, like the rest of the body, builds the muscles it most uses, sometimes at the expense of other abilities, say psychologists who study short-term memory and concentration. If reaction time is more critical to survival than verbal memory, the brain will devote its limited resources to that mental quickness.”

Via The Frontal Cortex blog; a commentator invokes the Yerkes-Dodson law to explain the effect.

I wonder whether there were marked differences among the sexes.

Related; Differences between the sexes; The mismeasure of woman- an article from the latest edition of The Economist, the chart above from the article.

A bird flu vaccine breakthrough

BBC reports;

“GlaxoSmithKline believes it has developed a vaccine for the H5N1 deadly strain of bird flu that may be capable of being mass produced by 2007.

The vaccine has proved effective at two doses of 3.8 micrograms during clinical trials in Belgium, BBC business editor Robert Peston has learned.

It is the size of the dose that is highly significant, Glaxo explained.”

Related;

Bird flu: risks, laws and rights

Responding to the Threat of a Pandemic Influenza- Frederick G. Hayden, Prof. of Clinical Virology in International Medicine at U. of Va. School of Medicine, considers the effectiveness and potential for resistance offered by antivirals.

The popular Avian Flu blog is now dormant.

How the Bird Blue has spread

Some Password Security, Please

I've been unamused by the lack of password security in many of the workplaces I've been to lately. A perfect example: a couple of months ago, as I was waiting for 15 minutes, alone, in one of my healthcare provider's exam rooms, I snapped this photo:

I gather that the computer could have been used to access -- and modify -- all of my health records. I did not try to see if the login and password worked... but I was alarmed nonetheless.

Demand and Supply of Nurses

Source; U.S. Plan to Lure Nurses May Hurt Poor Nations (via Poverty & Growth blog)

A Shocking Fact about Sub-Saharan Africa

Mankiw declares the war on poverty is being won citing Xavier Sala-i-Martin. Harry Clarke earlier cited the same paper.

But we have a long way to go. I was shocked to see the accompanying chart about Sub-Saharan Africa ( in most recent Global Monitoring Report). The report quotes, ‘Africa has been at the forefront of innovation in water and sanitation for the last 20 years by replacing central planning approaches with community-based management of village water supplies and by implementing technologies like easy-to-maintain hand pumps and low-cost pit latrines” (p.40).

Over 30 percent having no access to any form of sanitation is quite shocking.

Related Multimedia;

Is Global Inequality Rising? – an economic forum at IMF

What Are the Major Advances in Growth Theory since Solow?

Perspectives on Growth, Inequality and Poverty

Understanding the Growth, Poverty, and Inequality Nexus

Easterly Urges Independent Evaluation of Foreign Aid

Robert Bates on Governance Systems and Political Effectiveness

A couple of blogs discussing similar themes; Africa Unchained, Poverty and Growth blog, The World Economic Forum blog- they have got a new 'white papeer' on Strengthening Healthcare Systems in Sub-Saharan Africa.

Medical History of the Heart

The latest ‘In Our Time’ program from the BBC talks about the heart;

The 17th century physician William Harvey wrote in the preface to his thesis On the Motion of the Heart and Blood in Animals, a letter addressed to King Charles I. 'The heart of animals is the foundation of their life, the sovereign of everything within them...from which all power proceeds. The King, in like manner, is the foundation of his kingdom, the sun of the world around him, the heart of the republic, the foundation whence all power, all grace doth flow'.

Harvey was probably wise to address the King in this manner, for what he laid out in his groundbreaking text challenged scientific wisdom that had gone unquestioned for centuries about the true function of the heart. Organs had been seen in a hierarchical structure with the heart as the pinnacle. But Harvey transformed the metaphor into something quite different: the heart as a mechanistic pumping device.

How had the Ancient Greeks and Islamic physicians understood the heart? What role did the bodily humours play in this understanding? Why has the heart always been seen as the seat of emotion and passion? And why was it that despite Harvey's discoveries about the heart and its function, this had limited implications for medical therapy and advancement?

Contributors include David Wootton, Anniversary Professor of History at the University of York, Fay Bound Alberti, Research Fellow at the Wellcome Unit for the History of Medicine at the University of Manchester and Jonathan Sawday, Professor of English Studies at the University of Strathclyde.

Related Links;

Panic Disorder and Heart Disease; Recent studies by Australian researchers suggest that the risk of cardiac problems is increased in patients with panic disorder

Scientific Poetry: Bad for the Digestion? Associate Professor and Chair of Medieval and Early Modern Studies at the University of Western Australia, Yasmin Haskell, talks about how poetry has been used to teach people about science.

The drawing above is from William Cheselden: Osteographia, or The anatomy of the bones.

The Cost of Safe Sex

To reduce AIDS transmission, it is important that ‘commercial sex workers’ practice safe sex. In this study authors estimate the compensating differential for condom use among sex workers in Calcutta. To identify the relationship between condom use and the average price per sex act, they follow an instrumental variable approach, exploiting an intervention program focused on providing information about the AIDS virus and about safe sex practices. Using this method, they found that sex workers who always use condoms face a loss of 79 percent in the average earnings per sex act;

“In many ways the market for sex work is simply another labor market. Sex workers in the red light area of Sonagachi in Calcutta who are the focus of this paper are almost always part of a brothel under the ownership of a madam or pimp. They are required to pay fifty per cent of their earnings as rent and "protection" to the person controlling the brothel. The market is quite competitive with over 4,000 sex workers working in 3 70 brothels servicing about 20,000 clients a day. Calcutta is one of the world's largest cities with an estimated population 13 million of which 31 per cent are migrants. This results in a male dominated sex ratio with 0.83 females for every male in the population that in turn causes the demand for sex work to be consistent and high. Sonagachi is the oldest and best established red-light area in Calcutta and has been in existence at least for 150 years. It is located close to Calcutta University which provides a steady source of clients, and like many other older Calcutta neighborhoods consists of a dense network of narrow, winding streets lined by two and three story buildings. The brothels are supported by a number of restaurants, teashops, bars and other businesses that serve sex workers and their clients in the area…..While rates are to some extent determined by negotiation, the market is large and competitive and there is a good sense of the "correct" wage or price with differences arising from the sex workers age, physical attributes and her level of education.”

Some Policy implications;

“Some thought may also be given to the fact that sex workers may suffer large economic losses during the initial years of the intervention. This could be circumvented either by direct compensation or by a large scale program which results in a quick increase in condom use so that competition between sex workers does not drive down the price of safe sex.”

For Comment: Could such a compensation scheme have an effect that is not intended?

Related: The Independent goes RED

Incredible India

India has got a lot more challenges that we thought as a recent World Bank report on malnutrition highlights (I can’t guarantee the World Bank link will work, they don’t seem to be able to get their website to work properly);

“The prevalence of underweight among children in India is amongst the highest in the world, and nearly double that of Sub-Saharan Africa. In 1998/99, 47 percent of children under three were underweight or severely underweight, and a further 26 percent were mildly underweight such that, in total, underweight afflicted almost three-quarters of Indian children. Levels of malnutrition have declined modestly, with the prevalence of underweight among children under three falling by 11 percent between 1992/93 and 1998/99. However, this lags far behind that achieved by countries with similar economic growth rates.

Undernutrition, both protein-energy malnutrition and micronutrient deficiencies, directly affects many aspects of children’s development. In particular, it retards their physical and cognitive growth and increases susceptibility to infection, further increasing the probability of malnutrition. Child malnutrition is responsible for 22 percent of India’s burden of disease. Undernutrition also undermines educational attainment, and productivity, with adverse implications for income and economic growth.

Disaggregation of underweight statistics by socioeconomic and demographic characteristics reveals which groups are most at risk of malnutrition. Most growth retardation occurs by the age of two, and is largely irreversible. Underweight prevalence is higher in rural areas (50 percent) than in urban areas (38 percent); higher among girls (48.9 percent) than among boys (45.5 percent); higher among scheduled castes (53.2 percent) and scheduled tribes (56.2 percent) than among other castes (44.1 percent); and, althoughunderweight is pervasive throughout the wealth distribution, the prevalence of underweight reaches as high as 60 percent in the lowest wealth quintile. Moreover, during the 1990s, urban-rural, inter-caste, male-female and inter-quintile inequalities in nutritional status widened….

Micronutrient deficiencies are also widespread in India. More than 75 percent of preschool children suffer from iron deficiency anemia (IDA) and 57 percent of preschool children have sub-clinical Vitamin A deficiency (VAD). Iodine deficiency is endemic in 85 percent of districts. Progress in reducing the prevalence of micronutrient deficiencies in India has been slow. As with underweight, the prevalence of different micronutrient deficiencies varies widely across states.”

A related post at Spontaneous Order.

Thank You for Smoking

This month WHO will be celebrating the World No Tobacco Day, declaring;

“Tobacco addiction is a global epidemic that is increasingly ravaging countries and regions that can least afford its toll of disability, disease, lost productivity and death. The tobacco industry continues to put profits before life; its own expansion before the health of future generations; its own economic gain ahead of the sustainable development of struggling countries.

…The purpose of World No Tobacco Day 2006 is to encourage countries and governments to work towards strict regulation of tobacco products. We will do this by raising awareness about the existence of the wide variety of deadly tobacco products. Regulation should also help people get accurate information, remove the disguise and unveil the truth behind tobacco products – traditional, new, and future.”

My suggestion on how to celebrate the day; watch the movie, Thank You for Smoking (hat tip: Tom Palmer)

One reviewer comments;

“Although the movie doesn't stake out much new ground in the tobacco debate, Reitman delivers an explicit message of personal responsibility and individual choice that rarely comes from Hollywood and is almost never associated with smoking in polite company. Whereas the novel's version of Nick Naylor views personal responsibility as a convenient diversion from the unfortunate lethal side-effects of smoking, Reitman's Naylor comes to see that it's the other way around: The emotional nature of the health appeals obscures the importance of individuals taking responsibility for their own choices—and parents taking responsibility for teaching their kids to make informed decisions.”

Related Links:

- The film director’s blog

- Tradable smoking pollution permits (via Idea Shop)

- The Marlboro Man – (this is one of my favorite Art blogs)

- Economics of Tobacco Control Toolkit – development community are crazy about Toolkits

- The Millennium Development Goals and Tobacco Control

- The tobacco atlas

- 5 Year Anniversary of the Tobacco Settlement; Since 1998, an arbitration panel has awarded more than $13 billion in fees to lawyers who represented states in litigation against Big Tobacco.

- An earlier post about personal choice and responsibility

A Growth Curve for the 21st century

WHO recently released new international Child Growth Standards for infants and young children which would provide evidence and guidance about how every child in the world should grow. For all these years WHO has been recommending the Child Growth Charts of US National Center for Health Statistics which now seems to have had some issues. The WHO Multicentre Growth Reference Study (MGRS) was undertaken between 1997 and 2003 and establish the breastfed infant as the normative model for growth and development. The video documentary on the study represents a good case study for statistics teachers (hat tip; UN Pulse).

For more on development milestones see this blog by a Maldivian pediatrician based in Australia.

History of Immunisation

In 1717, Lady Mary Wortley Montagu, the wife of the British Ambassador to the Ottoman Empire, wrote a letter to her friend describing how she had witnessed the practice of smallpox inoculation in Constantinople. This involved the transfer of material from a smallpox postule into multiple cuts made in a vein. Lady Montagu had lost her brother to smallpox and was amazed that the Middle Eastern practice of inoculation rendered the fatal disease harmless. In Britain, the practice was unknown.

Inoculation was an early attempt at creating immunity to disease, but was later dismissed when Edward Jenner pioneered immunisation through vaccination in 1796. Vaccination was hailed a huge success. Napoleon described it as the greatest gift to mankind, but it met unexpected opposition after it was made compulsory in Britain in 1853.

How did a Gloucestershire country surgeon become known as the father of vaccination? Why did the British government introduce compulsory smallpox vaccination in 1853? What were the consequences of those who opposed it? And how was the disease finally eradicated?

Listen to latest podcast of the BBC’s In Our Time program to get the answers.

Related Links:

- Smallpox- online exhibit at UCLA

- Edward Jenner Museum

- Smallpox: eradicating the scourge

- The first physician to differentiate between smallpox and measles- Abu Bakr Muhammad Ibn Zakariya al-Razi (?850-923)

- An earlier post on the role of personalities in medical breakthroughs

- Speeches by Nobel laureates; How to Win a Nobel Prize and How Advances in Science are made (webcasts at Singapore National University)

Does the Sex of the Doctor Matter?

“A recent study in Brazil found that women spent longer in consultation with each child under five years of age (an additional minute, on average) than their male counterparts, even adjusting for other determinants of time inputs such as patient loads. The difference was more pronounced for providers trained in the Integrated Management of Childhood Illness protocols, suggesting that the influence of training might also differ according to the sex of the practitioner.

In the United States, women were more likely to undergo screening with Pap smears and mammograms if they were seen by female physicians, and this was more evident with internists and family doctors than with specialist obstetricians and gynaecologists. Female patients, especially those seeking gynaecological and obstetric advice, reported greater satisfaction with female than male physicians.

Taken together, these findings suggest that certain aspects of the care rendered by women health workers can, in specific circumstances, be more responsive to the needs of patients than the care provided by male physicians. These differences could be important for the development of the health workforce, but need to be better understood.”

-page 71, The World Health Report 2006 - working together for health

So next time you visit the doctor, remember that.

Mixed Emotions on Cancer Death Numbers

Ok, so I accept from the outset that I may be engaging in a morbid train of thought. But I can't help wondering if there is something more to be said regarding the decline in cancer deaths in 2003. Specifically: is it really a good thing?

As recognized in the article, and detailed in this data from the American Cancer Society, and as would seem to be common sense, older people are more prone to get cancer. Which means that more old people than young are treated for cancer. Which, of course, means that the improvements in treatment mentioned in the article are more heavliy distributed among care for the elderly.

We've certainly not cured cancer. The improvements are in treatment, making variants of the disease more of a chronic condition than the outright killer it once was. The issue, however, is that this increased longevity in the face of a formerly fatal disease means a greater expenditure for end-of-life care -- an expenditure that thrives in the oddly-constructed health insurance system we currently have. From Andrew Samwick:

The third mistake is to force young workers to subsidize older workers in group health-insurance markets. Insurance is supposed to transfer resources from those who have unpredictably low expenses to those who have unpredictably high expenses. But the differences in average expenses by age are predictable. Under the current system, young workers with lower average incomes subsidize older workers with higher average incomes -- the opposite of what we would expect. Lowering premiums for younger workers would draw them into the insured sector and hopefully keep them there.

Put bluntly, medical improvements in treatment often mean more spending at the end, rather than the beginning, of life. Given the distortions such as tax incentives that entrench employer-sponsored coverage, public funds like R&D spending focus on those for whom the return on the investment is lowest (to be crass, who would society get more from: 10,000 healthy kids, or 10,000 ill but "comfortable" retirees?).

While I'm thrilled at medical improvements (hey, I have grandparents too), there's something about this "success" in the war on cancer that strikes me as representative of bigger problems.

100% Employer Paid Health Insurance

Here's an interesting Discussion Paper from the Census' Center for Economic Studies: Contributions to Health Insurance Premiums: When Does the Employer Pay 100 Percent? by Alice Zawacki and Amy Taylor. The abstract:

We identify the characteristics of establishments that paid 100 percent of health insurance premiums and the policies they offered from 1997-2001, despite increased premium costs. Analyzing data from the MEPS-IC, we see little change in the percent of establishments that paid the full cost of premiums for employees. Most of these establishments were young, small, singleunits, with a relatively high paid workforce. Plans that were fully paid generally required referrals to see specialists, did not cover pre-existing conditions or outpatient prescriptions, and had the highest out-of-pocket expense limits. These plans also were more likely than plans not fully paid by employers to have had a fee-for-service or exclusive provider arrangement, had the highest premiums, and were less likely to be self-insured. [Emphasis added]

The dataset provides information on establishments and on the health insurance plans offered by each "The MEPS – IC collects data on premiums for single and family coverage, contributions by employers and employees, provider type, plan enrollment, deductibles, and copayments."

In essence, firms that contribute 100% of premia are more likely to offer higher-priced plans, but these same plans offer some contraints -- more need for referrals, higher out-of-pocket expenses, lower coverage of pre-existing conditions, and lower coverage of outpatient prescriptions. (Granted, the absolute differences don't seem all that large, even where they are statistically significant).

Which leads me to ask, what's going on here? For firms that pay 100%, higher premia appear to be buying plans with -- on average -- slightly smaller benefits. The authors note this is partly due to firm size -- smaller firms are more likely to cover 100% than larger firms. So there might be some scale effects on costs.

But the analysis also notes that 100% employer paid plans have FAR lower self-insured indemnification -- 13% of plans instead of 29% -- meaning that liability for excess medical costs is shifted from employer to health insurer far more frequently when employers are paying 100% of the premium than otherwise. In other words, employers paying 100% less frequently need to buy stop-loss insurance, and more frequently shift the risk of excess coverage to insurance companies within the health insurance contract. I'd say that's what they're paying the extra dough for, but that's just a hunch.

Interesting stuff.

(Alternate copy of the paper here).

Is it Healthier to be Fatter or to Sometimes not Eat Breakfast?

I'm looking for leads here.

Over the past two months, I have frequently gone to work before the rest of the family awakens. To not make noise, I leave without eating breakfast -- usually some cereal, juice, and a bagel or toast, sometimes much more evil foods. By not eating these several hundred calories, I have lost roughly seven pounds over that period (and I'm still overweight). Note that not eating breakfast doesn't effect the size of the lunch or dinner I have... Naturally and thankfully, my wife is concerned that I'm eating too little.

So my questions are, what are the relevant margins here? And what are the costs and benefits at those margins? Am I hurting myself by not eating breakfast more than benefiting myself with lower weight? Can science answer these questions?

UPDATE: I think we can score one for the Healthier to be Fatter team.

How Dare You Offer Healthcare for Profit!

What a lovely editorial in the Toronto Star today:

Let me get this straight. A Vancouver businessman is preparing to open three medical clinics in Ontario where he'd charge patients at least $2,300 a year — before they could even see one of his doctors. Health Minister George Smitherman says, correctly, that this would break provincial law as well as the Canada Health Act governing medicare. But at the same time, Smitherman says he can't do anything until one of these clinics actually opens.

It's like saying you can't deal with someone who openly boasts about his plans to rob a bank until the safe is blown.

I could be wrong, but I gather that even in Canadian culture, robbing a bank is considered slightly more sinister than selling medical services to those willing and able to pay for them. Now, I don't doubt that these clinics violate the spirit and intent of Canadian healthcare legislation, but if there is no cost accounting requirement for these clinics, and they insist on annual fees allegedly for luxury non-medically-related services, they might very well meet the requirements of legislation.

Mr. Copeman's clinic wanted money upfront in addition to an annual fee, but that upset non-clients as well, so he decided to add it to the annual contribution.

BC's Opposition Health Critic David Cubberley sees the Copeman Clinic as "setting a dangerous precedent.”

Exactly so.

“Charging patients a fee for faster and better access to medically insured treatment is something to be worried about,” he said.

That's half right -- but not being allowed to charge such fees is also something to be "worried about".

Of course, the Canadian government is not serious about restricting the options of the rich and impatient, since it is not yet a felony for a Canadian to have medically necessary care performed outside of Canada.

A Deeper Look at the VHA

Via MR I saw this post at Brad DeLong's place reprinting the content from a Krugman piece at the NYT (RR, but included for completeness).

The crux of the point, in case you don't feel like backtracking through all of that, is that Krugman is suggesting that the Veteran's Health Administration is a model of efficient, effective health care, provided by the government to boot.

Last year customer satisfaction with the veterans' health system, as measured by an annual survey conducted by the National Quality Research Center, exceeded that for private health care for the sixth year in a row. This high level of quality (which is also verified by objective measures of performance) was achieved without big budget increases. In fact, the veterans' system has managed to avoid much of the huge cost surge that has plagued the rest of U.S. medicine.

To what can we attribute this, you might ask? Why, to the very fact that it's entirely centralized and run by the government!

The secret of its success is the fact that it's a universal, integrated system. Because it covers all veterans, the system doesn't need to employ legions of administrative staff to check patients' coverage and demand payment from their insurance companies. Because it's integrated, providing all forms of medical care, it has been able to take the lead in electronic record-keeping and other innovations that reduce costs, ensure effective treatment and help prevent medical errors. Moreover, the V.H.A., as Phillip Longman put it in The Washington Monthly, "has nearly a lifetime relationship with its patients." As a result, it "actually has an incentive to invest in prevention and more effective disease management. When it does so, it isn't just saving money for somebody else. It's maximizing its own resources. ... In short, it can do what the rest of the health care sector can't seem to, which is to pursue quality systematically without threatening its own financial viability.

Well, I can't claim to have any experience with theh VHA system. But I'm always a little leary about these "just-so" stories, especially when it involves government bureaucracy. So I just have a couple of points to make about the VA.

First, the potential usage pool is highly restricted. Because they treat only veterans, they don't have to deal at nearly the same level as other hospitals with the surges in demand, the heavy use of emergency rooms as just-in-time care for things that could have been treated sooner and far more cheaply. The drastically smaller size in population isn't a trivial factor; some things don't scale up as well as we'd like, especially under pressure from things like HMOs to prevent expensive unused capacity.

In addition, many of the vets treated by the VA are often covered by other forms of health care. Here are some statistics on coverage by alternative health care regimes for vets. Vets with alternate forms of coverage are clearly opting to alter between them when they see a better deal or better treatment. Non-vets don't have this option. With a unversal payer system, no one would have this option.

On those achievements "without big budget increases": we should account for the fact that the number of vets in the US is both aging decreasing. So as the population treated is going down, the cost of treating them is going up. (Link to 2005 CBO Report: "The Potential Cost of Meeting Demand for Veteran's Health Care.)

More from the CBO report (it's a long excerpt, but eliding too much would be misleading):

VA has had difficulties coping with the large influx of new users seeking pharmaceuticals and outpatient care. Although VA has substantial excess inpatient bed capacity in many facilities, the influx of new enrollees seeking pharmaceuticals and outpatient care has exacerbated waiting times for all veterans wanting to see a VA provider. By the end of 2002, about 300,000 enrolled veterans were on waiting lists for VA medical appointments.

Waiting times have been a long-standing problem for the department. In 1993, the General Accounting Office (GAO, now known as the Government Accountability Office) found that veterans frequently waited eight to nine weeks to obtain appointments at some specialty clinics.(8) In 1996, lawmakers enacted legislation requiring VA to serve veterans in a timely manner.(9) In response, the department initiated a number of actions to address waiting times and waiting lists, including better tracking, better scheduling, and use of a primary care model--that is, coordinated health care delivery through interdisciplinary teams.

Accompanying the rise in the number of veterans seeking care at VA facilities were substantial increases in the annual budget for VHA. Although VA medical budgets were relatively flat in real terms in the mid-1990s, they grew by an inflation-adjusted 4 percent to 10 percent each year from 2000 to 2004. Those budget increases were appropriated by the Congress to fund the rapidly increasing demand for VA health care that followed the change in eligibility rules after 1996.(10)

In part because of the long waiting lists and influx of new patients that VHA could not accommodate in a timely manner, in January 2003 then-Secretary of Veterans Affairs Anthony Principi decided to cut off enrollment of new P8 veterans--those without service-connected disabilities who have income above $25,842 per year (for a single veteran) and above a geographically adjusted means test. Veterans in that priority group who had already enrolled in the system were "grandfathered," however, and could continue to seek care from VA. According to the department, "Until the waiting time for medical appointments can be reduced to an acceptable standard, it would not be in the best interest of those most in need of care for VA to enroll additional priority group 8 veterans."(11)

So, there is some contradiction to Krugman's assertion that this success (of which there does appear to be some) without "big" budget increases. Of course, one Budget Office's "substantial" may not be another man's "big."

More importantly, however, a good deal of the success seems to have come at the cost of restricting access to care. The system was not working well with its current demand, so it was pared down to keep future demand limited. The flexibility to respond to changing demands required shifting care away from specific people. If a single-payer system becomes inefficient and ineffective much like how the commenters on DeLong's site all agree the VHA was a few years ago, would it be able to deny care to subsets of the population while it takes time to retool? Maybe a series of "rolling blackouts'" while the health care network tried to figure out how to expand capacity in time with soaring demand?

I don't dispute that there have been significant, benficial changes at the VHA. What strikes me as less clear, however, is that it has been an unmitigated success of policy. The only cost in restructuring the system hasn't been a "small" budgetary increase for the same or better level of care. And the increasing demand that has put strains on this system before isn't going to be exacerbated much (if at all) by returning vets from Iraq since, as the CBO points out, inpatient care is actually underutilized right now. It's the aging current vet population -- the population whose ailments are among the most expensive to treat in large part because they persist for quite a while -- that is going to test whether or not "one of the best-kept secrets in the American policy debate" is a stunning success or not.

Cover your wallet when you cough...

Scientists exploring the way disease spreads among humans have found a treasure trove of data from the site Where's George. From the introductory note at Nature:

Analysis of the trajectories of over half a million dollar bills shows that human dispersal is described by a 'two-parameter continuous-time random walk' model: our travel habits conform to a type of random proliferation known as 'superdiffusion'. And with that much established, it should soon be possible to develop a new class of models to account for the spread of human disease.

The only nit I can think to pick here is to question whether there is a difference in travel patterns between the average person and those 1)more likely to use a good deal of cash and 2) are likely to enter their dollar bill serial numbers into a website. This may, of course, be addressed in the article, to which I do not have access other than the first graf:

The dynamic spatial redistribution of individuals is a key driving force of various spatiotemporal phenomena on geographical scales. It can synchronize populations of interacting species, stabilize them, and diversify gene pools1, 2, 3. Human travel, for example, is responsible for the geographical spread of human infectious disease4, 5, 6, 7, 8, 9. In the light of increasing international trade, intensified human mobility and the imminent threat of an influenza A epidemic10, the knowledge of dynamical and statistical properties of human travel is of fundamental importance. Despite its crucial role, a quantitative assessment of these properties on geographical scales remains elusive, and the assumption that humans disperse diffusively still prevails in models. Here we report on a solid and quantitative assessment of human travelling statistics by analysing the circulation of bank notes in the United States. Using a comprehensive data set of over a million individual displacements, we find that dispersal is anomalous in two ways. First, the distribution of travelling distances decays as a power law, indicating that trajectories of bank notes are reminiscent of scale-free random walks known as Lévy flights. Second, the probability of remaining in a small, spatially confined region for a time T is dominated by algebraically long tails that attenuate the superdiffusive spread. We show that human travelling behaviour can be described mathematically on many spatiotemporal scales by a two-parameter continuous-time random walk model to a surprising accuracy, and conclude that human travel on geographical scales is an ambivalent and effectively superdiffusive process.

Hey -- did they say "decays as a power law"? Chris Anderson, please call your office. Someone would like to talk to you about the long tail of disease. (Easy to identify: the specialization of docs and drugs to ease the million small ailments that plague everyday life. Harder to assess: Since we don't truly face the costs of our own care in the developed world, it's a redistributive requirement that these ailments get treated, since they are more prominent as people age. And as social investment goes, old folks are nice, but see little to no return as compared to getting kids healthy and educated. If the money is spent -- distorted by the odd employer-based insurance program and the public funding system we have -- primarily on old age problems, then its in those specialties where the doctors will concentrate. Advancement in geriatric care at the expense of early preventative care. Are we still happy with the long tail when it's communal?)

NB: Nod to the FRIAM group's discussion list for the pointer.

Color Me Unconvinced

I do this at great caution, but I'm not certain I agree with the line of argument starting with Kevin Drum and echoed by Cowen at Marginal Revolution: Health Savings Accounts don't work because they "appeal more to healthy people", and that the "whole point of healthcare is to take care of sick people".

I was under the -- perhaps naive -- impression that preventive care is one of the most important aspects of health care, as well as being among the most cost-effective. Engaging in better habits, visiting doctors more often, and including check-ups in your routine means identifying problems early, when they are generally more treatable with less expensive measures.

From a CDC report:

"Approximately 95% of the $1.4 trillion that we spend as a nation on health goes to direct medical services, while approximately 5% is allocated to preventing disease and promoting health. This approach is equivalent to waiting for your car to break down before you take it in for maintenance. By changing the way we view our health, the Steps initiative helps move us from a disease care system to a true health care system."

If this is true, then couldn't it be considered an improvement over the current system to incentivize the more routine use of less-expensive preventive care? Also at issue, then, is the fact that the poor might well have worse general health outcomes because of a lack of attention to preventive care. (By only seeing doctors when insurance is certain to cover the visit -- acute problems, emergencies, etc -- poor people may be opting away from spending on preventive options.) I'm not sold on HSAs either, but I'm not at all convinced that the reasons Drum cites (and Cowen points favorably towards) are strong knocks against them. Health care isn't really only about "taking care of sick people". That turns the profession into some sort of trauma-response system.

Drum notes that "adverse selection is a bitch" when citing an article that talks about more healthy than sick people opting into HSAs. But one can't ignore the fact that healthcare insurance carries its own massive adverse selection issues as well; insurance also includes massive moral hazard problems. I've never found a good refutation of the argument that people, knowing they have insurance to cover problems, engage in riskier behavior. Indeed, returning to the possibility that the poor don't spend time or money on preventive measures at the same level as the better-off, the insurace system seems to promote only the use of the most expensive kinds of health treatments, driving up the cost (premiums) for everyone. If HSAs shift some of the incentives into finding ways to not spend health dollars, i.e. opting for cheaper preventive care, I'm not clear how this could be viewed as a failure, or even really a step down from the current system.

The article the Drum post cites, is troublingly slipshod in its entirety. That people are rational is used as an argument to limit their access to self-governance in health care provisions; one paragraph later, it's our lack of rationality that requires governmental intervention. Adverse selection is, at one point, a major flaw in HSAs. But when it occurs in health insurance usage, it's a symbol of tried-and-true US ideology since sharing burdens of cost among people -- and having those who don't use the service pay for those who do, including shouldering increases as the entirely predictable result occurs and expensive trauma or old-age care makes up the vast majority of spending -- is unquestionably the right thing to do. However, I will leave it to you to read the whole article and decide for yourself.

Markets in Everything: Breast Milk Edition (Updated)

Given the near universal acknowledgement of the relative health benefits of human breast milk over formula, I find opposition to the sale of breast milk to hospitals offensive and repugnant:

A US firm is looking to commercialise breast milk by selling it to hospitals for the treatment of sick babies.

Prolacta Bioscience, a small company just outside Los Angeles, also wants to carry out research to develop breast milk-based therapies....

But the Human Milk Banking Association of North America questioned the "buying and selling" of human milk.

It said introducing the profit motive might pressure women and medical institutions to provide milk to a bank regardless of the needs of their own babies.

Well, I'm not certain the "breast milk as remarkable cure" angle will fly, but that's the marketing... not the science.

Donated breast milk comes from healthy women who pump out more than they use, whether they are weaning their own children, or otherwise. Is it possible a woman will starve her baby to sell her breast milk? Sure, it's possible, but that's not a meaningful, operational standard.

More importantly, I gather that any hospital that uses donated breast milk has nurses, doctors, and other staff who are earning money by feeding and caring for the sick infants. As Alex Tabarrok and others have noted in other contexts, why is it that the donors the only ones not allowed to make money off the deal?

Let's go further with this. Why limit breast milk to sick babies? Why not make human breast milk available to anybody willing to pay the price? Many women currently choose not to breastfeed or cannot breastfeed, and they substitute formula. Other women return to work shortly after giving birth, and choose to pump and store breast milk during the day. Why shouldn't they have the opportunity to purchase what they might consider a healthier and/or easier alternative?

-----

The Markets in Everthing label is stolen from MR, of course.

UPDATE: A little history:

The practice of women sharing breast milk is nothing really new. It's been going on for centuries -- dating back to the era of wet nurses. What is new is a phenomenon in which women, often perfect strangers, exchange breast milk through the Internet, in mommy chatrooms, and even through mainstream sites like Craig's List and eBay.

Now, you need a prescription to buy breast milk from a bank (at $3.25 an oz.)!

In 2003, one Canadian family spent C$700 a week on breast milk. They claim that donors are sometimes paid in the US, unlike Canada, so regulated milk is easier to come by, but I cannot verify this. But "black market" unregulated, untested, risky breast milk is always available:

When supply can't meet demand, a black market emerges. Websites and chat rooms freely exchange tips on buying and selling breast milk.

"When you get milk informally... the donor isn't screened and so it comes down to how well the family knows that donor. And obviously, if it's a complete stranger, then you know absolutely nothing about them. You may be placing your child at some risk," Jones says.

Here's one forum on which many women wanted to know how they could go about entering the market on the supplier side. The motives of several are clear -- they want money so than can stay home longer:

I am among the many women looking to sell my breast milk. As another women said on the board, I am bearly making enough money and would love a way to make extra money so I can stay at home longer with my baby. I agree with that all the way. Maybe in the future when I am a little better off I will look into donating because it is for a wonderful cause but for now I am looking to sell.

Posters ignored warnings that selling breastmilk is illegal in many states, and that the board was not to be used for marketing purposes.

In addition, one woman in Salt Lake advertised in a newspaper classified section, only to get too many prank calls. The asking price: $1 an oz.

Of course, some women are genetically predisposed to having large amounts of breast milk. One such Norwiegan woman sold hers and bought a car:

�I�m making some money on this as they pay 135 krone per liter,� Lie said to TV 2. �I�ve gotten my driver�s license and bought a car, everything paid by breast milk.�

With the liter price of NOK 135 (USD 19.56), Lie got an income of more than NOK 65,000 (USD 9430) on her breast milk. She has an 11 month old son.

$20 a liter is $20/28.34 = $0.75 an oz, which seems like a bargain. Price dispersion is very large, and I never really thought that we must include production of breast milk in our GDP calculations:

One dollar per liter was the value assigned to milk in the Hatloy & Olshaug article from JHL, in which it was estimated that counting human milk production in Mali would raise the the GDP by 5%.

Well, let's play this game for the US. Breastfeeding women require about 500 calories more a day, but the price of caloric intake is much less than the output value of milk. Let's say the 500 calories cost $5, and a baby drinks 32 oz a day at a risk-adjusted black-market price of $2 an oz. A breastfeeding woman produces about $60 a day in net economic value, excluding the opportunity cost of her time. There
are an average of 35% x 4 million = 1.4 million women breastfeeding daily in the US. (This is from an extremely crude linear extrapolation: given 4 million annual births, 70% breastfed at 0 months, 35% breastfed at 6 months, and 0% breastfed at 12 months, the probability of any 0-1 year old being breast fed is 35%). Multiply 1.4 million times 365 times $60 and you find that American women produce, on net, about $30 billion annually in breast milk.

The Ideal Healthcare System

Don Boudreaux writes that the Canadian healthcare system -- the rules and regulations imposed by the Canadian government on its apparently grateful peons -- is inevitably dysfunctional:

And yet, many Canadians continue to fancy themselves "lucky" to be saddled with such a system for providing their health care....

How on earth can a system that invites consumers to treat a scarce good as if it were free possibly work? Isn�t it inevitable � isn�t it utterly unavoidable � that any such system will suffer dysfunctions and troubles that make consumers worse off rather than better off?

I think this both identifies and ingores the critical point about health care/insurance in modern democracies: this dysfunctional system is exactly what people want.

I am guessing that in the common wisdom of Canadians and Americans, the very archetype of a "good" health "insurance" plan -- and hence an ideal "healthcare system" -- is one in which all the care one wants comes without delay or cost. The essential principles of this ideal are very simple; in terms of the American consumer:

1) the full premia are paid by one's employer or the government

2) there is no co-payment for any office visit

3) there is no co-payment for any prescription medication

4) all pre-existing conditions are covered in full

I'd also suggest the following criteria, but these are not as important as the first four:

5) any doctor -- especially top-notch specialists -- can be seen just by making an appointment, preferably on the same day

6) all surgical, restorative, remediable aspects of dental and vision care
are completely covered

7) whatever the patient asks for -- x-rays, antibiotics, anti-depressants,
repeated toxin screening, appendectomies -- is provided immediately without question

That these criteria are unworkable in reality is irrelevant; the healthcare system in utopia is not subject to the constraints of scarcity or opportunity cost.

Drug Reimportation May Not Be So Easy

The debates over drug reimportation from Canada often leave out much of the "Canada" bit. That is, they simply assume that nothing would change on the part of our Northern Neighbor (well, "our" if you're in the US anyway) should the US government decide to get out of the way of buying pharmaceuticals there. Turns out Canada may have a few things to say about it:

Many Canadian internet pharmacies supplying Americans with cheap prescription drugs would be forced to close under proposed licensing restrictions.

The restrictions were proposed by regulators in the prairie province of Manitoba, where close to half of the roughly 150 Canadian internet and mail-order pharmacies are based.

Of course, this is simply regulation masking itself as benevolence. Since the Canadians are buying drugs from the same companies that are supplying the US, "safety concerns" are limited to preventing that great wave of people faking prescriptions because they are able and anxious to take massive amounts of heart, diabetes, and cholesterol medications once they realize they can get them for a lot less than down in the states. Or maybe Paul Martin hears a Canadian version of the great "sucking sound" and knows its possibly the US vacuuming up all the available medicines should reimportation be allowed to go forward.

Just because I'm against reimportation doesn't mean I favor more government intervention to prevent it.

Neuroeconomics

Tyler Cowen points to this survery of the current findings in neuroeconomics. Considering how new this field is and the probability that one of the early practitioners will get a Nobel, I'm a little surprised that more aren't chomping at the bit. I can't say that the area is a particular interest to me, but this line of inquiry that Tyler mentions is:

What I would want most: A testable neuroeconomic theory of why risk premia vary over time in securities markets. But that is very far away.

I think I'm reading Tyler's mind( or he mine) since this is almost the exact question I find interesting. Here in Claremont we have Paul Zak who does work in this field and since he's my current Macro prof, I get a lot info about his findings. He was talking about using brain scans to map people's utility curves and the problem of investment decisions popped into my head.

The scenario he tests is this: what game would a person play? In one, there are four outcomes, with two of them the person gets $10 for a total expectation for the game of $5. In the second, there are four outcomes, but in only one is there a payoff of $20 with expected value $5. He has them play the game as he scans their brains. Initially people choose the first, but the payoff in the second is changed until they choose it. With this information, he maps their curves.

My thoughts had to do with international investing and why risk-premiums are different across countries and time. Studies have been done to show that emerging markets offer higher returns, but as history of the late 90's shows, this can be a bumpy ride. So why did investors pump money into these places in the mid-nineties only to flee a few years later? Or, why exactly were Russian bonds near 5% in the last couple of years?

On a side note, like biotech investing mentioned below, neuroeconomics also has barriers to entry not easily overcome. The first one is the need for a mountain of additional knowledge needed to study in this area. The second is that this is an expensive field with high costs to perform experiments. The cost per brain scan is, I think, $200(it maybe more). Unless your individually wealthy or working with somebody who has current funding, it would seem difficult to conduct research in this field. I should mention a third problem, this stuff makes me queasy.

Biotech

For econometrics, we have to do an event study on biotechs to see if there is anything significant when press releases are issued. The first thing that probably popped into your mind is that the prof is fishing for something to write a paper on and you would be right since he said he was. I am somewhat interested myself since I occasionally trade these stocks as well. However, there is a huge problem in doing so, mainly, these companies require a tremendous amount of specialized knowledge outside of a typical cash flow analysis skill set. Thinking about my classmates crunching numbers on data that very few of them actually understand gives me the chuckles. At this point, I'm just talking about the FDA approval process and not about whether a drug or contraption may be usefull. Of course, it's just a class project; economists always understand what they are analyzing and add value above and beyond crunching numbers, right?

The purpose of this post wasn't to mock my class or profession, but to look at how one gets around asymmetrical information barrier to investing in these companies. Rather than looking at the effect of an announcement of a new phase of trials(or whatever people are doing), I decided to look at the effects of financing. Just as people rush into a stock that Warren Buffet has recently purchased, one would expect a strategic partnership with Johnson&Johnson to have similar effects(I'm actually interested in any financing and what happens to a stock once it's announced, closed and different types). Of course, these events are mere signallings that company's prospects are perhaps better than the market was pricing in. Conversely, a simple stock offering from a company that's stock price has floundered in low single digits may signal more of the same. So, the quality of the financier may signal the quality of the company. One would expect it to look some like this; pharmaceutical company > private equity > the monkey from Etrade.

I assume that a mediocre company will always be so. If a new drug from an unfollowed single digit stock company was going to cure cancer, everybody would know it. By this, I don't mean that the Yahoo message boards would be filled with bragging about how this unnoticed company has a miracle drug and the only pople who know it are the posters, but that phase trials are administered by the same people, companies, hospitals and they talk. My brother bounces around from biotech to biotech and he always knows when a competitor lobotomizes one of their patients(this actually did happen). Rarely does one get a complete surprise like Genentech's from a couple of years ago, however there is always hope.

How does one get access to this information which is known to only a few? You have to rely on analysts, even dare I say, brokerage analysts. Last spring, the biotech analyst from Pipar Jaffray actually made me money by conveying information which was known within that circle mentioned above. He added value in two important ways to my decision making process. One was that the drugs prospects were poor(btw, the company was Genta). The second was that the company had done a poor job in analyzing/gathering its data which would lead to a rejection. With such specialized knowledge needed to make investment decisions in this industry, it appears that investing here is a hard go. It is always worth it to figure out what the smart money is doing and, here, the magnitude in difference between smart and dumb could be huge.

I will add another rule on investing. I listen to a lot of conference calls and the Q&A is mostly typically populated with analysts, but if an "investor" ever manages to get in a question, run! One more thing, I don't really invest, but trade options and these positions are often riskless(flys) in these type of stocks. The Genta mentioned above wasn't which add a few bucks to the P&L.

Proposition 72 Barely Defeated

FYI, Proposition 72 on the California ballot--the requirement that non-small businesses provide their employees wide ranging health care plans, and pay for a large share of the costs--has been defeated 50.9% to 49.1%.

Do you want to eat more? Here's how!

The November 2004 Issue of Harvard Health Letter ($) asks "Why do we eat so much?" The answers: we eat too slowly, with too many people, with people who are too important to us, our food is too visible and accessible, we have too many choices, and stock up on prepackaged goodies. There was also this gem :

Plate, bowl, and cup size are important... In one experiment, researchers had people eat soup from bowls that were secretly connected to a hose that added more soup while they ate. They ate over 75% more from these "bottom-less bowls" than from normal bowls.

So now you know how you can cram even more food into you.

Also note that women eat 13% more when they're with men than when with women.

No Drug Reimportation? I know...Blame Canada!!

(Of course, now I have the song going through my head.)

Realizing the potential hollowing out of the Canadian drug market if the US is allowed to start ordering prescription drugs en masse, some Canadian pharmacies are going to start rejecting bulk orders.

Why politicians think a country of 31 million people that has price controls on pharmaceuticals has enough excess drugs just sitting around that the US can start shopping like Paris Hilton on a bender is beyond me. I'd consider this a smart move on the part of these pharmacies. On the other hand, of course, this just means that those pharmacies that will sell to the US are going to be able to demand higher prices. If enough places adopt the no sales policy (to swing once again the other direction), the prices for those drugs that are available may rise to near-US levels, eroding the benefit. (Does anyone know if the price controls in Canada apply to international sales? I couldn't find anything in a quick search.)

For more on the reactions to the greater outcry for reimportation, see this excellent NYT piece.

More than one side to every story...

I'm not the only one posting on the vaccine shortage. Russ Roberts has some great stuff in posts here and here. (While the good Professor obviously does a far better job than I, I would like to note that he too suggests the mess may have something to do with the way government buys vaccines).

This is all from the US perspective, however. What I also find interesting is looking at the issue from another side. What about Canada? They have a far more socialized health care system than we do, but it appears they have a small surplus they'd be willing to sell.

How can that be? To be honest, I'm not entirely sure. If I had the time, I'd look into their department of health and see how they go about purchasing to provide some comparison to the US method.

One thing I will note, however, is that the company that is poised to provide the extra vaccines is a domestic Canadian company. While I admit to drawing inference from a very thin source, might it be possible that the domestic company is financed largely by the Canadian government (cough --PEOPLE-- cough)? The US has no company that is producing flu vaccine, and looks to international producers for its supply. If this is, in fact, the case for Canada, then the cost of the vaccine is largely irrelevant for the production level, since the company may never have to worry about covering costs. Should that be true, it doesn't invalidate the claim that government purchasing is at the heart of the US vaccine shortage. Since the US is using its position as a near monopsonist to change prices, the private company is induced to produce less because of falling margins. A state-owned company doesn't have as much to worry about if funding from the government is available. (All else equal, of course, since there are plenty of cases where a state enterprise can fail even with the possibility of loan guarantee, bailout, whathaveyou.)

UPDATE: I stand corrected. Thanks to Tom North for pointing out that ID Biomedical is a public company in Canada. I tried looking for their ticker, but came up empty. Chalk it up to being too ignorant of Canada to make the search effective. I will admit, however, to being skeptical that this means that the company isn't otherwise guaranteed by the government, or that the cost structure for the company is radically different because of the more socialized system. I say that because in an environment where the end product is tightly controlled, and the product is (as almost everyone has mentioned elsewhere) tough to make and realizes thin returns, it's interesting that a publicly traded company can afford to exist where companies across the world failed. I'll have to look into it more. Hey, I'll be the first to admit it when I get it wrong...

Quick Pointer

For more on the health insurance issue, Arnold Kling has an interesting column up at Tech Central Station.

Rather than initiating the poor into the wonderful world of insurance company rules and claims-filing procedures, Fogel suggests that we would do more good by directly providing them with prenatal and postnatal care, health care education and mentoring, child health screening in public schools, and neighborhood public health clinics.

As I mentioned in the comments below, my reading of current health care issues would make me think that Fogel's right by saying that the poor under-utilize certain kinds of health care: preventative care, most notably. The later -- drastically higher -- cost of catastrophic health care is shifted towards other consumers then.

Just more reasons that I'm not sure the real issue facing the country is health care insurance per se, but rather the cost of health care provision.

Do the uninsured subsidize the insured?

Did you ever play with one of those liquid-filled balloon-like toys that, when you squeeze one end the other end extends, usually displaying a picture of a snake of some sort? The impression was supposed to be that the snake was inching along at the effort you expend on one end, since the whole contraption was wrapped in on itself. I remember being fascinated with the mechanics of it when I was young. There seemed to be change and progress, despite the clear lack of introducing new liquid or removing the old. I'm no expert, but something about the issue of health insurance in this country strikes me as similar to this old toy.

Case in point, this (to me) odd editorial from the USA Today: Uninsured billed unfairly.

According to the article, the uninsured are facing higher prices for their health care than the insured, since hospitals charge insurers less, and face a cap on the price they can charge to medicare patients. The article sounds almost incredulous that hospitals are attempting to recoup their cost of operation in places like care for the uninsured. Rather than be shocked at the behavior, I'm personally shocked at the surprise this seems to have aroused in the op/ed writers. Though, I suppose I shouldn't be since they've brazenly declared their poor reasoning from the outset:

Scott Ferguson, a retired artist without health insurance, was billed $66,900 for treatment of a heart condition at St. Anthony Central Hospital in Denver last December. If he had had insurance, his attorneys claim, the tab would have been about $10,000. Last month, he joined a lawsuit that accuses St. Anthony and other non-profit hospitals of reneging on promises to provide charity care in exchange for their tax-exempt status.

Well, yes, the bill for the insured would be lower, as that's the very point of having insurance. Pooling risk makes it possible for the insured to recoup some of what they've previously spent on the insurance. Sure, Mr. Ferguson has a higher bill, but he also hasn't had to face a couple hundred dollars a month in insurance costs. The act of having the insurance should, by definition, make the payments lower. How this shows anything aside from poor logic, I have no idea. Rather, it's this that makes me the most alarmed:

Ferguson's experience highlights the double whammy against uninsured patients who aren't poor enough to qualify for Medicaid. Not only do they have to pay their own medical expenses, but they often are victims of price-gouging by hospitals that offset the lower fees they charge insurers, which have the clout to demand deep discounts.

Worse, many hospitals employ strong-arm collection tactics that include garnishing wages, seizing homes and seeking arrest warrants. The financial impact can be severe. Medical bills are the second-leading cause of personal bankruptcy, a 2003 Harvard University study found. The unfair disparity in hospital fees is just one price society pays for a health care system that leaves 44 million without insurance and few with protections from exorbitant charges that have little relation to actual costs.

I suppose it's my fault for being surprised, since I had always assumed that people simply understood the relationship between prices and costs. It's not obtuse economic theory. Every day, in almost every part of the globe, people are assembling goods and seeking to sell them. It's a truly rare individual who isn't attempting to at least recoup the cost of production in the price of the good. After all, if they keep taking less than the thing cost to produce, they will soon have no money with which to produce more.

Why should health care be any different? If a hospital costs a certain amount to run, then, through the prices charged to all those who use its services, it will need to cover that cost in order to keep running. Telling a hospital that it can only charge certain amounts to certain people, it's only natural that the gap between the price charged and the cost incurred must be covered somewhere else. You can squeeze the balloon in one place, but that just means the liquid will rush to someplace else; it doesn't just leave.

And notice the odd reasoning in the second paragraph above. Insurers, according to this piece, are able to demand massive discounts in the prices they face; but the problem is that too few people are uninsured. Extending insurance coverage would, by extension, mean that everyone takes advantage of the discounts offered to insurers, right? What happens, then, to the gap that isn't being covered? The hospital hasn't gotten cheaper to run. The cost of provision of care hasn't become more efficient. Instead, every consumer (the insurer) is simply paying less. Either hospitals will close, or someone else will have to pick up the tab: if it's not the person needing health care, and its not the insurer, then who? The only likely candidate I can think of is the government. Which means, ultimately, the people. So not only would we all pay for insurance, but we'd also end up paying for the subsidization of hospitals. After all, in this article and my example, there has been no change in the cost of health care provision.

Unless something can poke a hole in the balloon -- that is, reduce the growing costs of health care provision -- the extension of insurance strikes me as just squeezing one end and calling it progress.

Youth Smokers Should Quit by 30

This New York Times article describes academic evidence that lifetime tobacco smokers live an average 10 years fewer than nonsmokers; it also contains the following, to me shocking, paragraphs:

The study also found, however, that kicking the cigarette habit has equally dramatic effects. He found, for instance, that someone who stops smoking by age 30 has the same average life expectancy as a nonsmoker, and that someone who stops at 50 will lose four, rather than 10, years of life....

Doll and Peto said that while the harm of smoking is dramatic, so is the benefit from quitting. According to their findings, a person who stops smoking at 60 will have a life expectancy three years longer than someone who continues; a 40-year-old will have a life expectancy nine years longer; and a 30-year-old will have a life expectancy no different from that of a nonsmoker.

We've known that not every cigarette is harmful--each butt certainly does NOT take 11 minutes off your life.

To me, what this means is that the only longevity justification for preventing a youth from smoking is that the youth may not stop smoking in his 30s. Otherwise intervention must be justified on financial grounds, or (perhaps specious) quality of health grounds.

Hence, there are two plausible government policies, if you think government should get involved in private--not "public"--health matters: 1) stop kids from smoking, and 2) stop adults in their late 20's and early 30's from smoking. It seems to me that we don't know whether 1, 2, or a mix is the more effective or cost-effective method of aggregate life extension.

In fact, cost-benefit guidelines suggest that we try to keep as much benefit and eliminate as much cost as possible. We should focus government funds on reducing smoking where the marginal costs start to outweigh the marginal benefits. This means, if it were administratively possible, don't tax tabacco for teens, but ramp up the taxes prohibitively for those over 30, and target anti-smoking campaigns to that demographic. And who cares of tobacco companies target teens through Joe Camel adverts if kids can smoke without permanent harm, should they quit by 30?

Note: I don't smoke. Frankly, I don't see why I should. However, this article doesn't tell me why I shouldn't, at least for a few years, until I hit 30.

California HealthCare

Daniel Weintraub, of the Sacramento Bee, talks about health care in his column today and notes that trend of doctors opting out of the insurance networks is continuing:

Dr. Marcy Zwelling-Aamot is sick of being told how to care for her patients. So the Los Alamitos physician - and president of the Los Angeles County Medical Society - says that as of July 1, she will no longer be working with health insurance companies.

"I am divesting myself of every insurance contract," said Zwelling-Aamot, an internist. "I can offer better care less expensively to my patients. I have a list, a waiting list, and I haven't even started advertising yet."

Zwelling-Aamot hopes she is on the leading edge of a wave of the future, which would really be a return to the past. She envisions an era when doctors and patients once again deal directly with one another, without the reams of paperwork, authorizations, second-guessing and billing nightmares that come with the current system.

All well and good, over on the previous site, we have talked about this trend before. Weintraub then brings up an unfortunate little bill standing in the way of market forces in California, SB 2.

But Zwelling-Aamot's dream of bureaucracy-free medical care is clouded by one thing: SB 2, the proposal heading for the November ballot that would require California companies with more than 50 employees to provide health insurance to their workers.

The idea sounds good at first. So good that it was enthusiastically supported by the California Medical Association, the state's largest professional physician group and the parent of Zwelling-Aamot's county medical society.

But Zwelling-Aamot and a number of prominent CMA members fear that the measure, if approved by voters this fall, will bring the downfall of quality health care in California by putting still more distance between doctors and their patients.

"The politicians say that people are uninsured and we need to cover them," Zwelling-Aamot says. "But coverage doesn't mean care."

The proposal would require any employer of more than 50 people to provide coverage or else pay a fee into a state fund that would buy insurance for their workers. Companies with more than 200 employees would also have to provide care for dependents of their workers. A government board would establish the minimum benefits required, and set the level of the fee charged to companies that cannot or will not provide coverage.

This is supposed to increase access to care for those who don't have it now. But as Zwelling-Aamot and others point out, it might not do a very good job of that and in the meantime could wreck health care for everyone who has coverage today.

"This just perpetuates a failing system," said Dr. James Knight, a San Diego urologist and president of that county's medical society. "It doesn't do anything to address the problem that we're seeing, and actually will perpetuate it. There are many physicians who believe this is very dangerous legislation."

With costs climbing fast, due in large part to an aging population and expensive new technology, many businesses will find it difficult to keep up with rising premiums, Knight believes. Instead, companies will, in increasing numbers, opt out of the system and pay the fee, shifting their workers to the government-run system.

"Employers are going to pay the fee and the government is going to buy the lowest common denominator," Knight says. "We are going to build a bureaucracy that is going to run health care for probably 80 percent of the population."

And the health care the government provides will probably look a lot like Medi-Cal, the bare-bones program that now provides care for the poor. Benefits will be limited, and patients will have a hard time finding doctors who want to be part of that system. If costs continue to climb, pressure will build on the government to cap doctors' fees. But that would only lead to still more shortages of doctors willing to participate.

"It's going to be the worst kind of insurance out there," says Dr. Thomas LaGrelius, a Torrance family care specialist and a consultant to independent doctors who are part of preferred-provider organizations. "We are going to move in the wrong direction."

Perhaps the greatest insult of all is that the proposal requires workers to pay up to 20 percent of the cost of this care, which could lead many employers who pay for all or most of the insurance now to instead bill their workers at the level established by the government as the standard.

"Many people will get less insurance and they will be forced to pay more," says Zwelling-Aamot, "and they will have less control than they do now."

Weintraub kind of muddies it by making it appear that this needs to be defeated in November when it is already law. The decision in November is whether to repeal it. That makes me nervous, because it is a lot easier to just make people vote no.

Overall, I think the analysis is dead on. Eventually, companies will abandone marlet rate insurance and go to the government because it will most likely price itself cheaper. Of course, it will provide less coverage, but in the long run for medium and large size companies who alreay provide health insurance, this just another cost of doing business and takes some headaches off of their hands.

Benefits in Risk Pooling Occurs to Fortune 500 Companies

Lots of good stuff in the news today.

A group of Fortune 500 corporations are getting together to offer health insurance to their non-full time workers.

What I find most interesting about the move is that it appears to be a direct reaction to the long-term externalities of an uninsured populace: the shifting of costs from the uninsured to the insured. Long term concerns play as much of a role in evaluating costs as do short run concerns, so this seems only natural. The Christian Science Montior agrees, but responds to the possibility that others may be scratching their heads.

But so what if self-interest is at work? That's how many social problems are solved in a market economy. The big-business alliance would help solve this one by pooling workers, thus offering them lower insurance rates which they couldn't find as individuals. The alliance estimates it could cover as many as 4 million people - 10 percent of the uninsured.

The presence of uninsured does have direct consequences for the insured. But it would seem wrong to believe that the presence of uninsured indicates a complete and continuing market failure that can only be addressed by government intervention.

The Perils of Choice

The topic is not a new subject around T&B: the impact of high levels of choice on the consumer.

This time it's manifested itself in the world of Medicare. Tthe range of discount card options has hit 73, and seniors are saying that it's tough discerning which one is the right one for them.

I have to admit, I'm not entirely sympathetic to the issue. Complexity of choices is inherent in a great deal of daily life, and building policy based on the perceived cognitive power of those to be affected strikes me as a quick way to devlove the whole issue into a "you don't know enough so let the government decide" sort of argument. (To put it rudely, I don't think we should regulate based on intelligence versus stupidity.)

On top of that, there seems to be a bit of a discrepancy in the story:

When Mildred Fruhling and her husband lost their prescription drug coverage in 2001, they suddenly faced drug bills of $7,000 a year. Mrs. Fruhling, now 76, began scrambling to find discounts on the Internet, by mail order, from Canada and through free samples from her doctors. "It's the only way I can continue to have some ease in my retirement," she said.

Last week, when the federal government rolled out a new discount drug program, Mrs. Fruhling studied her options with the same thoroughness. What she found, she said, was confusion: 73 competing drug discount cards, each providing different savings on different medications, and all subject to change.

Well, if one is able to keep track of deals from multiple websites, the mail, personal contact with physicians, and international comparisons, I'm not entirely sure why turning to a website as a single source of information should be that difficult. Certainly I can understand that government intervention has created a bit of a hydra here, when there are certainly more efficient ways to shift the price of drugs off of seniors to somewhere else, but compared to the adhoc method Mrs. Fruhling and others were resorting to before, isn't this at least a marginal improvement by way of reduced transaction costs?

Thomas Sowell on Price vs. Cost

Sometimes all you can do is link and quote:

The difference between prices and costs is not just a fine distinction made by economists. Prices are what pay for costs -- and if they do not pay enough to cover the costs, then centuries of history in countries around the world show that the supply is going to decline in quantity or quality, or both. In the case of medical care, the supply is a matter of life and death...

When politicians talk about "bringing down the cost of medical care," they are not talking about reducing any of these costs by one cent. They are talking about forcing prices down through one scheme or another.

All the existing efforts to control the rising expenses of medical care -- whether by government, insurance companies, or health maintenance organizations -- are about holding down the amount of money they have to pay out, not about reducing any of the real costs...

For political purposes, what "bringing down the cost of medical care" means is some quick fix that will win votes at the next election, regardless of what the repercussions are thereafter.

Reform=Nationalization

Saw this article over here. In a plan being put together by Australian states premiers that would appearantly put all schools under the control of government bureaucracy and create a new one for national healthcare, they are calling it reform when it really is nationalization. It is unclear from the article if it would include private healthcare in the proposal, it's implied, but I don't want to make that assertion. When they say,

" they want families to be "enrolled" with a selected GP or health clinic for life."

you can't be too encouraged on that front. The main points:

� Replacing COAG with a stronger and more influential Council of the Australian Federation.

� Creating a new public education system which would include not only government schools but also Catholic and independent schools.

� Encouraging greater integration of the health sector with less duplication and more services tailored specifically to meet patients' needs.

� Forming new national bureaucracies to reform and run the health and education sectors.

It is only a working paper of the Australian states premiers, but is worth watching in the run-up to the general election. I somehow doubt this women would be for such a plan:

A WOMAN who was told she'd had a partial miscarriage saved her unborn baby's life by getting a second opinion.

Toowoomba Hospital doctors told Sherri Ann Buchanan on April 28 she had had an incomplete miscarriage and booked her in for a curette the next day to remove the remains of the fetus.

After waiting for about five hours for the surgery, Miss Buchanan, 20, said "it didn't feel right" so she left and sought advice from her GP.

The mother-of-one, who is almost four months pregnant, said her doctor referred her to a private clinic and an ultrasound showed her baby was alive and healthy.

"I couldn't believe it. I just broke down," Miss Buchanan said.

It could be worse, my friend's sister had her baby die in the womb and they didn't notice for six weeks. The amazing thing is they did tests during that time. The fine hospital who did such a thing was Northwestern Memorial in Chicago(the lawsuit was settled some time ago, it damn near killed her). There could be incompetence by both private and public healthcare providers, but it seams that the latter was lacking in resources for the public(which seems implied in the article) hospital the Austrlian women went for her needs.