Reducing Disparities

File under: doctrine of unintended consequences.

S.799 - Protecting Our Infants Act of 2015

Whitman's Sampler:

HHS must publish a report that includes: 

• an assessment of existing research on neonatal abstinence syndrome; an evaluation of the causes, and barriers to treatment, of opioid use disorders among women of reproductive age and recommendations on preventing opioid use disorders in these women; 

• an evaluation of, and recommendations on, treatment for pregnant women with opioid use disorders and the effects of prenatal opioid use on infants; and 

• an evaluation of the differences in prenatal opioid use between demographic groups and recommendations on reducing disparities [emphasis added].

A curious approach to legislation. Mandated demographic discrimination. I'm sure this will proceed swimmingly.

Rhetoric in the New Commanding Heights

If you don't get at least a little nervous hearing the word "epidemic," consider the possibility that you conform to one of the following descriptions:

1. You are wealthy and comfortable enough to adequately insulate yourself from a contagious outbreak. You have the foresight and planning to make sure that you can enter self-imposed quarantine lasting 90 days.
2. You are an ignoramus. You don't believe in germ theory, instead subscribing to medieval fancies like vapours or angry spirits or something. Or maybe you think that the marginal benefits of vaccines do not exceed the marginal costs.
3. You have faith in modern medicine. Sure, contagious disease killed off untold hordes of our grubby ancestors, but we've got microscopes now! In the secular West, laboratory analysis has meant the end of a great many of the terrors of our dim past.
4. You have faith in the benevolence of the divine. We are strong in our love of the Lord, and His might shall see us safely to the other side. If this describes you, bless your heart. If it doesn't, I'd wager you probably know someone it does describe.
5. You are weary. You may dimly recall the first time you heard the word "epidemic" applied to obesity, or to smoking, or to trans fats, to to whatever choice-related bugbear happened to catch a scold's eye. Maybe you held a little funeral for the deceased word, scattered its ashes into the ocean. Probably not. But surely you're past lamenting its demise. 

According to the BLS, health care's share of total labor employment is 11.7%, up from 9.5% in 2002. They project that in 2022, it'll be 13.6%. The only rival for that kind of share is "state and local government." Heath care is big business and it appears to be getting bigger. When a sector of human activity repurposes an important bit of language as has happened to "epidemic," alert citizens might be wary of grabs for dominion. 

If it is true that the long conflicts in the culture war are waged with words, with rhetoric, then gaining the higher ground with plastic definitions of scary things is a strategy tailor-made for those that seek dominion over the teeming masses of their fellows.

Smoking isn't particularly euvoluntary. Neither is poor diet, lack of exercise, high fructose corn syrup, or any randomly selected hobgoblin of the medical elite. But if you're making a case for state-sponsored intervention in a non-euvoluntary transaction, just imagine how much easier your task is if you can couch your appeal in the same language used to describe an outbreak of the bubonic plague.

The Worms Play Pinochle On Your Snout

Meet Montgomery County, MD Bill 52-14. Introduced last October, but up for debate in council now, viddy well little brother, the gutty-wuts of the thing. Bill 52-14 will:

viz.

1) Require the posting of notice when a property owner applies a pesticide to an area of lawn more than 100 square feet, consistent with the notice requirements for when a landscaping business treats a lawn with a pesticide;
2) Require the Executive to designate a list of"non-essential" pesticides including:
• all pesticides classified as "Carcinogenic to Humans" or "Likely to Be Carcinogenic to Humans" by the U.S. EPA;
• all pesticides classified by the U.S. EPA as "Restricted Use Products;"
• all pesticides classified as "Class 9" pesticides by the Ontario, Canada, Ministry of the Environment;
• all pesticides classified as "Category 1 Endocrine Disruptors" by the European Commission; and
• any other pesticides which the Executive determines are not critical to pest management in the County.
3) Generally prohibit the application of non-essential pesticides to lawns, with exceptions for noxious weed and invasive species control, agriculture and gardens, and golf courses;
4) Require the Executive to conduct a public outreach and education campaign before and during the implementation of the Bill;
5) Generally prohibit the application of non-essential and neonicotinoid pesticides to
County-owned property; and
6) Require the County to adopt an Integrated Pest Management program.

Detailed background behind these measures can be found in the filler in the link. The basic idea is this: EPA restrictions on pesticide use are insufficient to satisfy clamorous and well-organized Montgomery County constituents, so they are in the midst of petitioning the county for redress of grievances.

I won't belabor the risk assessment or the implied cost-benefit analysis. after all, costs and benefits are subjective things, and who am I to judge on others' behalf whether an imperceptible reduction in the risk of cancer is worth the risk of grub or termite damage? What I do find interesting is that this bill is being pitched (at least on the radio during my morning commute) as a matter of externalities. When Smith seeks to slay the creepy-crawlies in his front lawn, runoff contaminates Jones's yard. Hey-presto, property rights violation!

Of course, this is classic Coase. It's a pairwise conflict, one where the grieved parties are clearly identified, easily organized, and in possession of well-established rights in land use. To strum a chord I've sounded before, lawn runoff conflicts are easily resolved in tort. Would you be willing to imprison your mother for the crime of lawn care?

There's a bit of common law jurisprudence that when applied to speech is called "prior restraint." Prior restraint is ex ante censorship, silencing speech before harm can be demonstrated. The intuition that leads the Supreme Court to roundly reject prior restraint is the same that governs tort law. Damages have to be substantiated (even if the methods to do so are a bit, well, let's be generous and call them "suspect") to be recovered. The precautionary principle is the legal antithesis of the presumption against prior restraint. The PP tells legislatures and regulatory agencies to prohibit activities that pose severe, uncompensated risks to the public. Judging by the public health language in the bill, this is exactly the regulatory principle being invoked by Montgomery County officials. What do you think, dear friends? Is the precautionary principle appropriate here? Why or why not? Should the presumption in the legislature be in favor of allowing private citizens to resolve their own disputes or to intervene ex ante?

Montgomery County residents must think carefully about how to address their noxious pest problem.

The Logic of Prohibition: Migration and Communicable Disease

You may have heard by now that measles is enjoying a renaissance in the Western US. You may have even heard that the disease has shown up on our fair shores thanks to a combination of domestic anti-vaccination sentiment and contaminated foreigners.

If you click through on the link, the CDC findings support these claims. Though, if you listen to the talk radio or Web chatter, you might be forgiven for substituting "obtuse California homeopathy wiggins" for "anti-vaccination" and "border-jumping Mexican" for "diseased foreigner." But the bulk of last year's outbreak occurred among the Amish and the original vector was from the Philippines.

It would be tedious of me to add my voice to the chorus singing "get your kids vaccinated," particularly if the groups that are at the most severe risk (the Amish, eg) are the least likely to heed my sanctimonious advice. So I'll focus my attention on the source of outbreaks: foreigners.

If there must be a government, surely among its core functions is to provide basic public goods. Strict immigration quotas make it next to impossible for otherwise law-abiding, peaceful foreigners to make a new life in the US. So they cross the border dangerously, in the dead of night, often with the assistance of unaccountable misfits. And occasionally, it seems, bearing infectious disease.

Consider an alternative scenario. Lift the quota system entirely. Divert human resources towards controlled points of entry, where migrants can be screened for criminal backgrounds and health. Anyone still attempting to surreptitiously cross the border will have self-identified as a rogue. As it is now, the wheat and the chaff do not self-separate, meaning that every interdiction agent out there is wasting time processing people whose only crime is to violate legislated, arbitrary quotas. Relieve them of this burden so that they can work on catching actual dangerous people. And consider that it's probably more cost-effective to inoculate previously unvaccinated migrants right there on the border than to treat scores of American citizens after an outbreak has already erupted.

Even assuming "keep 'em all out with a big wall and machine guns" is a valid moral position to adopt, it might be that the costs of this policy are prohibitively high and the unintended consequences too grave to accept. Ending immigration quotas could well help curb threats to public health and safety.

Sounds pretty euvoluntary to me.

Drugs and Negligence

It's okay to jail people for life on a 3-strikes charge for carrying around recreational drugs.

People who refuse to vaccinate their offspring against communicable disease walk free.

Something is askew in the moral intuitions underpinning popular jurisprudence.

At the very least, anti-vaxxers should be liable in tort (negligence, perhaps). At the most, drug "offenders" should be open to prosecution for selling adulterated goods (or maybe to minors).

In the twinkling of twilight, I try to tell myself that the US is not class- or race-conscious. These are the lies I whisper to help me fall asleep under the merry dance of the stars.

Nosocomial Infection and Choice Architecture

Hospital-borne illness is troubling, and in more than one regard. On the one hand, hospitals are where sick people go, so they are magnets for disease vectors. On the other hand, antibiotics suffer from a particularly tragic tragedy of the commons, leading to drug-resistant strains of bacteria. On yet another hand, even low-cost preventive measures like scrupulously hand washing by health care professionals or annual flu vaccines run the risk of being overlooked by harried, hurried personnel who spend their 12-hour or more shifts running from crisis to crisis. If you've got to deal with four codes in one night, you might well forget to scrub under your fingernails each time. On the (what are we up to here, fourth?) hand, hospitals have no requirement, and no organizational incentive to track nosocomial (hospital-borne) infection statistics. This means that even well-meaning researchers who would be interested in investigating the impact of interventions lack even the basic data to accomplish what should be rather easy analysis.

This is, as I see it, troubling. Troubling indeed.

Ideally, it'd be great if hospitals would compete on this margin. Imagine if your HCP would claim: "you've only got a 1 in 50 chance of getting sicker after visiting us! Compare that to the 1 in 25 rate you can expect from our leading competitor!" Well yes. Do imagine that for a moment. Savor it.

This is a situation perfectly tailored for behavioral economics. Medical delivery is loaded to overflowing with cognitive bias and heuristic thinking. Evidence-based practice is standard in modern medicine, but patients are not practitioners and bring occult prejudices to the examination room. Experimenting with what might make both patients and HCPs more compliant with basic best practices might be a very good idea, indeed.

But to do that properly, analysts need good data. Medicine will be all the more euvoluntary for it.

The curious thing for me is that I'm not sure how this cuts for my libertarian-ish priors. The world as she is sees a lot of coercion in medical delivery already. Could this be an instance where a little more might actually help increase overall patient liberty?

Kidnapped at Needlepoint

Medicine is not euvoluntary. If you're sick and you don't get a doctor, the consequences could be severe. Single-payer/single-provider systems like the UK's NHS avoid  the implied rent extraction by fixing prices. Third-party-payer/multiple-provider systems as in the US purportedly rely instead on market competition to keep prices reasonable. Naturally, that isn't exactly what happens. Instead of a reasonable bill for services rendered like you'd get at the dry cleaner's, you get a massive laundry list of meticulously detailed line items, from blood panels to MRI scans to a dose of Advil for your achy breaky knee.

Of course, everyone who's either been a patient long enough, or who works in the medical services industry knows quite well that the first bill you get that you send along to your insurance provider is what negotiators call a highball: an obviously grossly overstated estimate of the actual cost of care. Whatever the reasons for treating a routine hospital stay the same way you would haggle over a rug in Marrakesh, the effect on the patient is the same: "good gravy, look at this crazy medical bill. Thank God I have a good insurance plan to take care of it. Could you even imagine having to pay this out of pocket?"

Of course, no hospital would even think of making a patient pay those ridiculous rates out of pocket.

Unless...

"Against medical advice," aka AMA should be right below "we've had an ebola outbreak in med-surg" as the most terrifying thing you can hear as a patient. If you do anything your loving medical staff disapproves of (including undergoing superfluous tests, seeking a second opinion, or refusing medication you've deemed too risky to justify the alleged benefits), you will be acting against medical advice. And if you go AMA, your insurance company is no longer obliged to pick up the tab. That absurdist comedy of a bill you get at the end of a couple days' inpatient care is all yours, baby.

So here's my question for all my great friends out there: is this exploitation? Do hospitals and insurance companies effectively conspire to over-provide zero (or negative)-product care using the threat of AMA as a bludgeon in case patients do not cooperate? And if they do, are they morally justified in doing so? Why or why not?

And if they are not justified in doing so, what moral intuitions steer the median voter away from their ordinary skepticism of big business for health care provision, and instead towards beefing up the entire apparatus via Medicare, the AMA, the ACA, et al? Can the care ethic alone do all the heavy moral lifting here?

I think I'll devote the rest of the week at EE to exploring different possibilities for health care delivery in very broad strokes. Medicine is not euvoluntary, but some systems may be more not euvoluntary than others.

[Update] My old [AS] confederate Cepheus84 informs me that in his professional experience in the medical billing industry, it is (unruly) patients more often than service providers that end up rattling the AMA saber. This is consistent with the frequent tales told by Mrs. Spivonomist about some of the more desperate drug-seeking behavior she encounters at work. AMA, it seems, is a double-edged sword, as the hassle of dealing with an investigation is often more costly than just signing a prescription for some percocet. It's an information asymmetry problem, and patients who've learned how to game the system have an advantage.

Is Contraception Euvoluntary?

The SCOTUS case on crafting emporium Hobby Lobby's owners' discomfort at being forced to provide contraception coverage for employees has revealed some interesting moral intuitions. A parade of blogs, tweets, and status updates have informed me of the inviolable rights of each party, of the immoral coercion imposed (again, by each party), and of the nasty overreach of the [company owners|government (pick one)].

Here's where I'm confused, and perhaps you can help me. I don't know for sure if contraception is a public good.

Let me be more clear here. Recall that a public good is one where the end user can't stop others from enjoying the benefits of its consumption. If Art paints a mural on Betty's building, Carl gets to enjoy it without paying for the privilege. In the case of contraception, if Betty is on the Pill, she and Art can make the beast with two backs to their heart's content and Carl won't have to worry about his tax money going towards the upkeep of the fruits of that union.

True, it's not a public good in the classic sense. Any spillover costs from an unwanted pregnancy exist only because of legislation, but let's ignore that for the moment and take the legislation as given. The thing that confuses me is that if contraception (or indeed, any form of health care) is a public good, why on earth should the costs redound to someone's employer? How in the nine hells are these two things even remotely related? Well, okay, given today's podcast, maybe there are some industries where it's salient, but arts and crafts? Nope.

Look folks, I'm not all that convinced that health care is a public good, but if you want to make the claim that it is, stop pussyfooting around the issue already and make it well and truly public. Go single payer or go home. This weird chimera fails to serve the public interest, it throttles euvoluntary exchange, and it wastes the court's resources. Shame shame and treble shame.

You Gonna Eat That?

I assume this is a goof, but if the remarks from the SF Health Department are legitimate, it's a goof that has officials flustered.

It's an app that allows strangers to finish your lunch for when you can't cram the whole thing down your facehole yourself. My initial thought (beyond "this is a silly joke") is "f-ing nasty, man", but you know, different strokes and all. If someone wants to risk, I don't know, mononucleosis or something for a lukewarm, sloppy Reuben, that's their business. Caveat comedor.

What do you think? Public health hazard? Price discrimination? Recycling? What's the right analytical approach? Is LeftoverSwap euvoluntary?

Medicine is not Euvoluntary: Juvenile Lung Transplant Edition

A federal judge in Philadelphia has ordered HHS head Kathleen Turner Sebelius to reverse her decision that a 10-year old girl be ineligible for a lung transplant from a donor above the age of 12.

The economics of the case are trivial (no market, no prices, so weird allocation decisions are the norm), so let's instead consider some of the moral intuitions that lead to the existence of an organization like HHS.

1. Conventional ownership/exchange
   For what I assume are mostly Rawlsian and Arielian reasons, folks object to spot transactions for vital organs. Roth-style matching algorithms seem to strike a balance between the nice thick market we'd like to see and the callous, mercenary sale of the components of life we'd like to avoid. But in the sense of plain jane alienability, we're pretty far from owning our own organs. This leaves open the extremely relevant question of who does? If it's some nebulous "society", or even "medical science", we're still left with a concrete puzzle of just who it is will make final allocation decisions. Is vesting a DC appointee or an elected official this responsibility a priori superior to the natural arrangement where my guts and lights are my own?
   
2. Regret
   Tissue rejection might be a reason to regret a transplant, but it's more likely that families will regret having to queue for organs, particularly when viable organs are available. One of the troubles here is that unlike markets for toilet paper (where you can buy as little as half a dozen squares in some places in the world), the unit under sale is more or less fixed. If the price of a kidney is $10,000, a patient can't just say, "well, I've only got two grand, so give me a fifth of a kidney." Renal systems don't work that way. I wonder if there might be something to Paine's aphorism here: "what we obtain too cheap we esteem too lightly" when we consider high-income patients. I apocryphally recall conversations with friends who claim that markets in organs would subsidize intemperate consumption by rich folks. Why bother taking care of yourself when you can just buy a new liver when your old one wears out? To the extent that this might be empirically true, it offends any reasonable sense of fairness.
   
3. Externalities
   None that I can think of.
   
4. Coercion
   Institutional coercion is what replaces market allocation, so there's that, I suppose. Is this morally preferable? Consequentially preferable?
   
5. BATNA disparity
   We tend to dislike debt issued under conditions of duress. Duress from crappy BATNA means that lenders can don a usurer's cap and pile on punitive interest rates. Or so it seems from third parties' perspective. Never mind I guess that organ transplants imply a somewhat stronger default risk. At any rate, it's a matter of perception: people on transplant waiting lists are desperate in an absolute sense and disparate in a relative sense. Voters and medical elites alike can adopt clinical detachment and prescribe a suite of organizational treatments. Who better to be an object of paternalism than the sick? And who better to be the paternalist than... a beltway bureaucrat in a nation of over 300 million people? Right?

I have a hunch that the ACA is going to turn out to be a hideous chimera that eats itself and within a decade or two we'll have EU-style single payer here in the US. Ask the Ollie Williamson question: is the ACA a crowbar to pry out a class of entrenched interests? Is it nothing more than a flurry-sheaf meant to overcome a transitional gains trap?

Cool Blog Posts: Kiwi Coercion

Very cool post from my favorite anglophone country, New Zealand here. Under discussion, marginal increases in coercion for including contraception in women on the dole.

It's been a while since I've been to NZ, but I do remember it fondly. In some ways, the Kiwis are more open to voluntary exchanges that we here in the States tend to restrict.

I think if I had to pick a NZ city to live in, it'd be a toss-up between Dunedin and Christchurch. I think Dunedin would end up losing as I imagine driving would be hellish in the winter months.

Things that are painless (and bring on many changes)

Flare-ups over the contraception coverage portion of the Affordable Care Act and its intersection with the beliefs, doctrines and practices of the Catholic Church are back in the news. Gripes on all fronts of late have gotten me to think more about a rather grim subject close to my research interests: suicide. Specifically, physician-assisted suicide. 

NYT: Why Kidney Sales Should Be Legal

Guest op-ed by Excerpt:

On Thursday, I will donate one of my kidneys to someone I’ve never met. Most people think this sounds like an over-the-top personal sacrifice. But the procedure is safe and relatively painless. I will spend three days in the hospital and return to work within a month. I am 21, but even for someone decades older, the risk of death during surgery is about 1 in 3,000. My remaining kidney will grow to take up the slack of the one that has been removed, so I’ll be able do everything I can do now. And I’ll have given someone, on average, 10 more years of life, years free of the painful and debilitating burden of dialysis.

If kidney donation is this easy, why do the stereotypes about heroic sacrifice persist? Part of the problem is history: before modern medical advances, organ donation used to be quite painful and dangerous. But organ donation advocates also deserve some of the blame. In a misguided attempt to make the families of brain-dead patients consent to the posthumous donation of their organs, advocates treat donors like saints. But deifying donors only serves to make not donating seem normal. When I first told some friends and family that I wanted to donate a kidney, they assumed I’d gone off my rocker. They saw it as a crazy act of self-sacrifice, rather than what it is — one of the many ways a reasonably altruistic person can help others.

This is a serious problem, because there aren’t nearly enough saints in the country to tackle the growing waiting list for a kidney. More than 34,000 people joined the waiting list in 2010; fewer than 17,000 received one. Thousands of people die waiting each year.

This is a tragedy, but it doesn’t have to be this way. The people waiting for kidneys aren’t dying because of kidney failure; they’re dying because of our failure — without Congress’s misguided effort to ban organ sales, they would have been able to get the kidneys they desperately needed.

It has been illegal to compensate kidney donors in any way since 1984. The fear behind the law — that a rich tycoon could take advantage of someone desperately poor and persuade that person to sell an organ for a pittance — is understandable. But the truth is that the victims of the current ban are disproportionately African-American and poor. When wealthy white people find their way onto the kidney waiting list, they are much more likely to get off it early by finding a donor among their friends and family (or, as Steve Jobs did for a liver transplant in 2009, by traveling to a region with a shorter list). Worst of all, the ban encourages an international black market, where desperate people do end up selling their organs, without protection, fair compensation or proper medical care.

A well-regulated legal market for kidneys would not have any of these problems. It could ensure that donors were compensated fairly — most experts say somewhere in the ballpark of $50,000 would make sense. Only the government or a chosen nonprofit would be allowed to purchase the kidneys, and they would allocate them on the basis of need rather than wealth, the same way that posthumously donated organs are currently distributed. The kidneys would be paid for by whoever covers the patient, whether that is their insurance company or Medicare. Ideally, so many donors would come forward that no patient would be left on the waiting list.

Corporate Wellness

Are corporate "wellness" programs coercive?

A view, with some background.

The Heinz Dilemma

The Heinz dilemma

"A woman was near death from a special kind of cancer. There was one drug that the doctors thought might save her. It was a form of radium that a druggist in the same town had recently discovered. The drug was expensive to make, but the druggist was charging ten times what the drug cost him to produce. He paid $200 for the radium and charged $2,000 for a small dose of the drug. The sick woman's husband, Heinz, went to everyone he knew to borrow the money, but he could only get together about $1,000 which is half of what it cost. He told the druggist that his wife was dying and asked him to sell it cheaper or let him pay later. But the druggist said: "No, I discovered the drug and I'm going to make money from it." So Heinz got desperate and broke into the man's store to steal the drug for his wife.

Should Heinz have broken into the store to steal the drug for his wife? Why or why not?"

Kohlberg, Lawrence (1981). Essays on Moral Development, Vol. I: The Philosophy of Moral Development. San Francisco, CA: Harper & Row (For the "Stages of Moral Development, see here)

If you say that the theft is legitimate, it must be because you believe the transaction the druggist proposed was NOT euvoluntary.