Hobbesian conclusions of NRC panel

In Leviathon, Thomas Hobbes famously conjectured that life in the state of nature, with every man against every other, is "nasty, brutish, and short." A scientific report by a panel of the National Research Council, U.S. Health in International Perspective: Shorter Lives, Poorer Health, has concluded much the same thing about life in the U.S. in the 21st century.

From the report summary (bold from the original)

The panel was struck by the gravity of its findings. For many years, Americans have been dying at younger ages than people in almost all other high-income countries ... This disadvantage has been getting worse for three decades, especially among women. Not only are their lives shorter, but Americans also have a longstanding pattern of poorer health that is strikingly consistent and pervasive over the life course -- at birth, during childhood and adolescence, for young and middle-aged adults, and for older adults.

In almost every category you could imagine--infant health, injuries and homicides, sexually transmitted diseases, drug abuse, diabetes, heart disease--Americans suffered worse outcomes than most other developed countries, leading to especially high odds of dying before age 50.

Even worse, the reasons for these disparities are as unnecessary as they are tragic. The panel cited gaps in our health system (especially the lack of insurance), poor health behaviors (especially over-eating and drug abuse), accidents, violence (especially the availability of firearms), poverty, social immobility, and physical environments that discourage natural exercise. As the NRC panel states, "The tragedy is not that the United States is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary."

Many of these gaps are addressable, but one party seems determined to widen, rather than close, nearly every addressable one. That party's fiercely professed "respect for life" is belied by a host of policies that promote death.

Did something other than sight-see in Denmark

I was lucky to spend today attending a workshop on “Health, Work and the Workplace” at the Aarhus School of Business (academic economists use an odd definition of "lucky").

Besides the opportunity to interact with lots of researchers with similar interests, there was an opportunity to hear about some fantastic data that are available to Danish researchers. In particular, social scientists are Aarhus University have access to survey data sets with personal identifiers that can be linked to social registry data on jobs, social insurance, and even health care utilization.

The conference featured several studies that linked survey data on perceptions of work conditions, such as exposure to physical and health hazards, workplace policies, work schedules, job satisfaction, supervisor practices, and the like, with more objective information on earnings and job turnover as well as long-term information on these outcomes. Several papers showed how bad work conditions and practices were associated with worse health outcomes for employees. Another paper showed how some of those policies hurt companies by increasing turnover. Although the emphasis was on how health worked through and was affected by these workplace conditions, it’s easy to imagine lots of additional research that could be done.

All of the research focused on outcomes in developed economies in Europe and the U.S. These countries all feature relatively strong protections for workers’ health. In the case of the European countries, workers also had fairly uniform access to quality health care. Despite these protections and supports, there was still consistent evidence throughout many of the papers that certain types of working conditions, such as holding a job with high physical demands, being exposed to job insecurity, and even having to work for a “toxic” boss, takes its toll on people’s physical and psychological health.

At this point, the research seems best poised to help us refine our understanding of how health and work outcomes are determined, borrowing insights from two related fields. It is also likely to help us understand the possible consequences of work intensification at jobs as employers downsize, “rightsize,” and shift more risks to workers. These policies may have immediate benefits for employers’ bottom lines, but the research at the conference suggests that they may be costly in the long run. Worse, these costs may be external to firms and may appear years after firms take certain actions, giving the firms few incentives to mitigate them.

We already know that economic outcomes for many workers have deteriorated over the last decade and especially through the Great Recession. Regrettably, the results from the workshop suggest an additional mechanism by which workers may have been made worse off by employer restructuring.

Applying Bayes' theorem to breast cancer screening

Bayes' theorem gives the formula that statisticians use for calculating conditional probabilities.

Suppose that you have two events A and B that have joint probabilities. From Bayes' theorem, the probability that A occurs given that B has occurred, Prob(A|B) is

Prob(A|B) = Prob(B|A)*Prob(A)/Prob(B)

where Prob(B|A) is the probability that B occurs given A, Prob(A) is the unconditiional probability of A occurring, and Prob(B) is the unconditional probability of B occurring.

Let's apply this to cancer screening. According to the American Cancer Society, the unconditional probability that a woman who is age 40 develops breast cancer by the time she is 50 is 1.44 percent.

Suppose that we had a screening test for breast cancer that gave a positive result 100 percent of the time that breast cancer is present. That is, let's assume that the test never generates a false negative. However, let's also assume that there is a small chance, say 5 percent, of false positives.

From these figures, the probability of a randomly screened 40-year-old woman receiving a "positive" result is

Prob(Pos. test) = Prob(Pos. test|Cancer)*Prob(Cancer) + Prob(Pos. test|No cancer)*Prob(No cancer)
= 1.0*.0144 + .05*(1-.0144) = .0637

And the probability that a woman with a positive test has cancer is
Prob(Cancer|Pos. test) = Prob(Pos. test|Cancer) * Prob(Cancer) / Prob (Pos. test)
= 1.0 * .0144 / .0637 = .226

In this case, a positive test means that the woman has only a one-in-four chance of actually having cancer. She is much less likely to have cancer than to not have it.

The test provides information. Without the test, the woman would have only known about a 1-in-70 chance.

However, because of the very low underlying rate of cancer, the test yields many more false positives than true positives (three times as many). Many, many more women without cancer are tested and subject to false positives.

Suppose that the same test is used for a 50 year old woman. According to the American Cancer Society, the woman would have a 2.39 percent chance of developing cancer over the next ten years. The probability that she has cancer given a positive result from our hypothetical test is 33 percent. So, the rate of false positives drops from one in four to one in three.

To be clear, these examples are not arguments for doing away with testing. However, they do show some of the limitations associated with even a very good test and some of the excess costs associated with routine testing.

Cost benefit in cancer screening

The U.S. Preventive Services Task Force has issued a stunning recommendation. It recommends against routine screening mammographies for women 40-49 years old with no other risk factors for breast cancer and recommends only biennial mammographies for women 50-74 years old. It also recommends against teaching women how to self-examine.

The recommendations reverse those made by the same group in 2002.

The task force reviewed evidence from numerous studies in making its recommendation.

It concluded that there is a benefit to regular screening mammographies; the evidence demonstrates that they reduce cancer mortality among women aged 40 and over. The benefits increase with age. So, the task force's recommendation will likely contribute to a higher death rate.

However, the task force cited new evidence that the mortality benefits were exceedingly small. For every 1,903 women aged 40-49 who were given the opportunity for annual screening, only one cancer death would be avoided. For women aged 50-59, the ratio was 1,339 to one. The new evidence was largely responsible for the change in recommendations.

The task force balanced this small but undeniable benefit against "moderate" costs and harms from screening.

The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman's lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman's life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.

The task force found no benefit from self-exams but some of the same harms as mammographies.

An interesting thought experiment is to consider how the recommendations might change yet again if a less expensive but more accurate screening technology is developed (the recommendations do compare film, digital, and MRI screenings). A technology that reduced the screening costs and led to more true positives and fewer false positives could well tip the balance back in favor of additional screenings.

With the current technology, however, the "rational" approach is to cut back on screeings.

Sickening employment policies

The New York Times reports this morning on how the spread of H1N1 and other illnesses is assisted by crummy sick leave policies.

Public health experts worried about the spread of the H1N1 flu are raising concerns that workers who deal with the public, like waiters and child care employees, are jeopardizing others by reporting to work sick because they do not get paid for days they miss for illness.

Firms clearly face a dilemma with these policies. On the one hand, sick leave helps to curb the spread of illnesses among employees, possibly raising output (or at least reducing losses associated with illness). On the other hand, sick leave promotes absenteeism (e.g., people calling in "well"). Economists call this "moral hazard," which in this case translates loosely as "if you offer it, they will cough."

An underlying problem is that firms cannot completely observe employees' health. It's difficult for a firm to determine whether an employee really is sick, and requiring employees to submit independent documentation of an illness is costly and impractical.

There is also a good possibility that firms and employees undervalue this benefit. A contagious disease is a classic example of a negative externality--a economic harm whose costs aren't fully borne by the immediate parties. Workers fail to consider the harm that they are causing their coworkers and others by showing up sick; firms fail to consider the harm that their sick employees may be causing customers, commuters, and others.

As an estimated 39 percent of workers lack sick leave, there's some evidence that sick leave is under-provided.

Even when sick leave is available, firms sometimes discourage its use. The Times article describes the policies of, who else, Walmart.

At Wal-Mart, when employees miss one or more days because of illness or other reasons, they generally get a demerit point. Once employees obtain four points over a six-month period, they begin receiving warnings that can lead to dismissal.

In addition, when Wal-Mart employees call in sick, their first day off is not a paid sick day (although workers can use a vacation day or personal day), but the second and third days are paid.

In this case, Walmart imposes a cost in terms of demerit points and lost personal/vacation leave for sick days, creating a clear disincentive to using those days.

In the end, the choices come down to having employees use too many sick days or too few. This employee's vote would be for too many.

Risks of tanning

A new study indicates that lying in a tanning bed carries the same cancer risk as smoking cigarettes or breathing asbestos.

The International Agency for Research on Cancer (IARC) had previously classified sunbeds as being a "probable" cause of cancer.

However, the agency is now recommending that tanning machines should be moved to "the highest cancer risk category" and be labeled as "carcinogenic to humans".

It followed a review of research which concluded that the risk of melanoma -- the most deadly form of skin cancer -- was increased by 75 per cent in people who started using sunbeds regularly before the age of 30.

The IARC also says there is evidence of a link between eye cancer and the use of sunbeds.

Given the current policy trend of taxing harmful activities to both promote better health and raise revenues, legislators should immediately consider a special tax on tanning beds.

Once that is done, they can also consider taxes on skimpy swim suits and on the sun.

Preview of Republican-style health care reform

The local News & Record has a poignant story about the cold reality of private, go-it-alone health insurance--the kind of "choice" that Republican lawmakers like Sen. Burr are advocating.

In his mid-50s, George Kretchun was finally living the dream: After years of working for someone else, the Reidsville man opened his own catering business.

But when he went looking for health insurance, the dream dimmed.

At his age and with a pre-existing condition, he faced paying more than $25,000 a year in premiums.

Mr. Kretchun's problem was that he developed a liver condition several years ago. As part of a larger risk pool, such as a large employer, Mr. Kretchun's bad health draw would have been balanced by better health draws, making affordable insurance possible. However, as a self-employed person, Mr. Kretchun constituted a pool of exactly one. Insurance companies seeing his pre-existing condition would only offer him unaffordable policies. Mr. Kretchun's experience illustrates a well-known market failure that can arise in the presence of adverse selection.

The Republican plan, which calls for ending end tax subsidies to companies for providing health care and replacing them with individual subsidies, would lead to the further dismantling of employer-provided care. The plan hails itself as providing "choice," but choice in the insurance market is a two-way street--insurers also get to choose how much they will charge each customer based on that customer's health.

Mr. Kretchun was eventually helped through one of those supposedly awful government-established and subsidized programs, Inclusive Health, North Carolina's high-risk health insurance pool. The pool is administered by a non-profit that was established by North Carolina with strict rules regarding how much it can charge and who can be admitted. The plan is targeted toward people who are unhealthy and who lack access to employer-based plans. Because insurance for these folks would be unaffordable to them, the plan is subsidized by the state. Inclusive Health is still much more expensive than the insurance available to currently health people, but it's premiums are nevertheless within reach of most people.

The Republican plan rules out "new government spending." However, individually-affordable high-risk health insurance requires some type of subsidy. The Republicans also criticize "public plans," like Inclusive Health thusly

Patients should be able to choose from a variety of private insurance plans. The federal government would run a health care system—or a public plan option—with the compassion of the IRS, the efficiency of the post office, and the incompetence of Katrina.

Mr. Kretchun had his choice of market-based private insurance plans--the private insurance market failed him. As he put it "I don’t mind if they tell me you’ve got to pay double. But don’t tell me I’m not allowed to get any insurance." His experience shows that government intervention can be compassionate, socially efficient, and competent, "a God-send" in his words.

New "one percent doctrine"

After eight years of Dick Cheney, I was really hoping for a Vice President who would reduce panic rather than add to it.

I'm still looking for the section of the Constitution that says the Vice President's job shall be to convene the Senate and run through the streets yelling "OMIGOD! OMIGOD!"

Swine flu precautions

Besides avoiding someone who coughs while reading Charlotte's Web, the Centers for Disease Control has practical advice on how to avoid Swine Flu and how to care for household members who are sick.