Map of life expectancy at birth from Global Education Project.

Friday, June 30, 2017

Common Sense

The various affluent countries around the world have somewhat different ways of organizing and financing their universal health care systems, but they all cover everybody, and they spend about half as much or less than we do. Right now the British system happens to be under strain because the conservative government is underfunding it. Vote Labor back in and they'll put in enough money to fix it.

But I want to talk about rationing. It just seems bizarre to me that people argue against universal health care schemes on the grounds that they require "rationing" or denying some services to some people on the grounds of cost. Yes, that is necessary, because resources are finite and taxpayers only want to reach into their pockets to a certain depth. Ergo, you don't spend a million dollars on the small chance that it will extend the life of a horribly sick person by a week. You have to draw the line somewhere.

But obviously, that already happens right here in the U.S.A., but in a worse way. Lots of people, even with the ACA but mostly because of states that didn't accept the Medicaid expansion, don't have insurance and can't get health care and yes, they die. That's the current reality. And, before the ACA, insurance policies typically had annual and lifetime limits. Insurers also won't pay for many treatments they consider too expensive, and they found ways to kick expensive people off of their policies. The whole pre-existing conditions thing means that if you need insurance, they won't sell it to you. That's rationing, but of a particularly arbitrary and cruel kind.

Whether a very expensive treatment that doesn't do a whole lot of good should be offered to people ought to be a decision that is democratically accountable. That's what they have in Britain. These decisions are made by a body called the National Institute for Clinical and Health Excellence (called NICE) through a transparent, open process. If people object to a given outcome -- and occasionally they do, although the process is generally accepted and supported -- they can complain to their MP. Parliament oversees the National Health Service and NICE, and they can guide policy. Which you can't do with your insurance company.

Update: There was interest in how we can get to universal health care in the U.S., given the institutional obstacles to implementing a single payer system here. Scott Lemieux discusses the possibilities. He isn't totally explicit, but he seems to endorse a Swiss type system, which is sort of ACA on steroids. 

Update #2, Baby Killers: I believe somebody suggested that the case of Charlie Gard proves that single payer systems are evil. Actually it's largely irrelevant to this discussion. This is an English baby with a mitochondrial disorder who is more or less already dead but is being kept on life support. The hospital wanted to turn off his ventilator but the parents went to court to stop it. Meanwhile they were crowdfunding a couple of million dollars to fly him to the U.S. for an "experimental" (actually quack) treatment. The British court said no, the treatment is useless, and it is in the best interest of the baby to turn off the machinery. The European high court has now agreed. So this is comparable to Terry Schiavo and it has nothing to do with the National Health Service or what kind of insurance the family has. There is, however, tangential relevance: spread that $2 million around properly, and you could save a hundred children's lives -- say African kids dying of diarrheal disease, by getting clean water supply to their villages. Think about it.

Wednesday, June 28, 2017

Ideological Blinders

Here's Eduardo Porter in the NYT giving an overview of why universal coverage is worth it from the societal perspective. It shouldn't take wonkery to establish that, but apparently it does.

If you will look up at my banner, you will see that I have already known for some time that health care in the U.S. of A. is too expensive. You don't actually need to tell me that. Funny thing though -- it's a lot less expensive in all those communist totalitarian dungeons in Europe and the Great White North that provide universal coverage to everybody. In fact, the U.S. government spends as much on health care as the British government, but the British government covers everybody and they live longer! Same with Canada! Same with Norway! And the people don't feel oppressed. In fact Norway is the happiest country on earth. Yet it has -- wait for it -- socialized medicine. That's right, you pay your taxes, and the government pays for your health care. Done.

The hospitals don't post their prices, as far as I know, because there is a single payer and the single payer negotiates a single price. Which is lower than the price here. As a consumer of health care, you can't comparison shop they way you might for, say, thermal underwear because:

a) You don't know what you actually need, you need an expert, a doctor, to tell you.

b) You have no way of comparing quality.

c) You might have an urgent need that doesn't give you the luxury of comparing prices at 3 different hospitals. In fact, if you live in a rural area, there might only be 1 hospital. And you might be unconscious!

I must also point out that whether or not you can afford the health care you need is not only a function of whether you had the entrepreneurial spirit, talent and drive to become as rich as Ayn Rand; it is also a function of the pure luck of whether you are hit by a cosmic ray that causes a gene mutation that gives you cancer, or hit by a bus, or born with a genetic predisposition for diabetes, or any of an infinite number of possible misfortunes. The Free Market does not allocate these misfortunes by an invisible hand, rather shit happens.

So we need to at least start by acknowledging some simple, indisputable truths. That does not seem to be within the philosophy of some people.

Monday, June 26, 2017

Where I'm at

I'm in New Orleans for the Academy Health Annual Research Meeting. Academy Health is the weirdly named health services research society. I had a poster presentation this morning, now I'm just going to be hanging out and listening to people, mostly.

If anything exciting comes up I'll let you know. But for now I'll just say that health services research is especially wonky and boring and weird in this country because of our irrational, fragmented, wasteful, incoherent health care system. We have such an inefficient and ineffective system because of freedom, unlike those totalitarian dungeons in Europe where they spend half as much, get better results, and cover everybody. But that's slavery, which we won't allow to happen here.

Thursday, June 22, 2017

Is a fourth grade education a requirement to be a reporter?

Apparently not. An Ecuadorian couple claimed that they live without food or water, from the "universe's energy." Numerous newspapers and highly recognized web outlets published this as unquestioned fact, including Yahoo, The Sun, The New York Post, The Independent, The Daily Mail, Metro and many others. (This story appears on CNN, so admittedly there's a bit of a pot and kettle thing going on here.)

The excuse is that it was too hard to go to Ecuador to fact check. This is a really wicked problem. Many people do not believe the news in the corporate media, which means for example that they do not believe that Russia interfered in the recent U.S. election. It is hard to explain why they should believe that and not believe this. I knew that the Bush administration's claims about "weapons of mass destruction™" in Iraq were bullshit, and I argued for that extensively on this very blog; but the New York Times was enthusiastically promoting it.

So no, you can't believe everything you read in the paper or see on TV, but you need to apply critical thinking. Not everybody is good at that, unfortunately, and once they have built up a coherent alternative reality it is very, very hard to extract them from it. In order to have a  workable consensual reality, we need a smart, knowledgeable press corps with critical thinking skills that we can depend on. We do not have that. 

The result may well be catastrophe for human civilization.
ahoo, The Sun, The New York Post, The Independent, The Daily Mail, Metro - See more at:
Yahoo, The Sun, The New York Post, The Independent, The Daily Mail, Metro - See more at:
Yahoo, The Sun, The New York Post, The Independent, The Daily Mail, Metro - See more at:
the universe's energy

Tuesday, June 20, 2017

Weather Report

Here's the current forecast for Phoenix. This is pretty much applicable to the entire southwest.

Patchy blowing dust after 5pm. Mostly sunny and hot, with a high near 120. East southeast wind around 5 mph becoming calm.
Patchy blowing dust before 8pm. Mostly clear, with a low around 93. Breezy, with a northeast wind 5 to 15 mph becoming southeast in the evening. Winds could gust as high as 20 mph.
Sunny and hot, with a high near 116. East wind 5 to 10 mph becoming west in the afternoon.
Wednesday Night
Mostly clear, with a low around 89. Breezy, with a west wind 10 to 15 mph becoming light and variable after midnight.
Sunny and hot, with a high near 114. Breezy, with a southeast wind 5 to 10 mph becoming west 10 to 15 mph in the afternoon. Winds could gust as high as 20 mph.
Thursday Night
Mostly clear, with a low around 87. Breezy, with a west wind 10 to 15 mph becoming southeast 5 to 10 mph after midnight. Winds could gust as high as 20 mph.
Sunny and hot, with a high near 113. South southeast wind 5 to 10 mph becoming west in the afternoon.
Friday Night
Mostly clear, with a low around 88. West wind 5 to 10 mph becoming east southeast after midnight.
Sunny and hot, with a high near 115. Light and variable wind becoming west 5 to 10 mph in the afternoon.
Saturday Night
Mostly clear, with a low around 89. West wind 5 to 10 mph becoming southeast after midnight.
Sunny and hot, with a high near 114. Southeast wind 5 to 10 mph becoming west southwest in the afternoon.
Sunday Night
Mostly clear, with a low around 89. West wind 5 to 10 mph becoming southeast after midnight.
Mostly sunny and hot, with a high near 112. Southeast wind 5 to 10 mph becoming west southwest in the afternoon. 
The region would be uninhabitable without air conditioning. And it's just going to get worse.  Note those overnight lows barely dipping below 90. With the jet stream getting loopier, these sorts of blocking patterns will become more frequent. It's here folks. It's for real.

Friday, June 16, 2017

Breathing is Fundamental

The new BMJ has a lot to say about air pollution, starting with this editorial. Everything they say about the UK applies to the US, if not more so. Nowadays the most important source of exposure to polluted air in the industrialized countries is motor vehicle exhaust. Two components, ultrafine particles and oxides of nitrogen, cause the most damage to human health. Ultrafine particles are less than 2.5 microns in diameter -- microscopic, invisible, and odorless. They are in highest concentration near highways, which also happens to be where the nearby residents are likely to be low income people. A favorite place to site low income housing is next to highways.

As the BMJ editorial says, air pollution is the world's fourth leading cause of death. We had mass hysteria over the Ebola outbreak that killed fewer than 12,000 people in West Africa and precisely nobody in the United States; while almost nobody seems to care about air pollution to which about 40,000 annual deaths are attributable in the UK and something like 200,000 in the U.S. Now, this is a little bit misleading in that everybody dies. Attributing these deaths to air pollution means that they are accelerated, the person dies earlier than they would have if they hadn't been exposed. So the years of life lost is not as great as, say, motor vehicle crashes that affect many young people. Still, it's a way of looking at the problem that gives us a sense of its magnitude.

There is also disability associated with air pollution and it has deleterious effects on fetuses and children's development. As the linked essays states, "Although we are familiar with the effects of summer and winter pollution episodes on asthma, pneumonia in older people, strokes, and heart attacks, the wider effects of air pollution are less known. Chronic exposure impairs lung growth of the fetus and throughout childhood, increasing the risk of developing asthma and contributing to impaired cognition, type 2 diabetes, various cancers, and skin ageing and even serving as a risk factor for obesity."

Since the same exhaust pipes and smokestacks that spew out these toxins also spew CO2, which is changing the climate and destroying the oceans, we probably ought to do something about it. Instead, we are now furiously "de-regulating," because the Koch brothers want to continue to murder you for profit and the president works for them. 

Wednesday, June 14, 2017

Democracy in Action

This is actually quite bizarre. Mitch McConnell isn't just concealing the specifics of the Senate health care bill from the public and from Democrats; he's concealing it from his own members:

While there have been thrice-weekly meetings on the legislation to repeal and replace the 2010 health care law, those have mostly focused on broad policy. And while complete legislative text has not yet been drafted, leadership has begun initial conversations with the nonpartisan Congressional Budget Office on several proposals. But GOP senators say they do not know what those are. "While I haven't seen the language, I am hoping that it stays within the confines of what we've discussed within the caucus," Sen. Joni Ernst of Iowa told Roll Call.
Evidently they're committed to voting for it anyway, because they don't actually care what it does. Well, if it's anything like the House bill, one thing it will do is cause sick old people in nursing homes to be tossed out into the snow to die. The state of public discourse in this country is so debased that most voters literally do not know that the bulk of Medicaid spending goes to disabled and elderly people, and particularly for long-term care. And they have to spend all their money first and become destitute before it kicks in. This applies to lots of formerly middle class people whose savings don't outlast the ravages of age.

By the way, I am arguing public policy here. If you happen to notice an implication that conservatives are horrible people, that occurred to you on your own, I didn't say it.

Monday, June 05, 2017

Intelligence test

Republican congress returns to DC with repeal of the Affordable Care Act still on their agenda. They may not get it done, we'll see. Below please see a representation of the key accomplishment of the ACA. Can you spot the supersecret mysterious reason why Republicans don't like it?

Sunday, June 04, 2017

The Greatest Story Ever Told

The Energy Expansions of Evolution, by Olivia P. Judson, in Nature Ecology.

Do read it -- you'll enjoy it and you'll learn something. Then read my commentary.

This is the story, in part, of how Gaia got her cloak of green; and subsequent major developments. It also helps us to think about the so-called Fermi paradox -- why don't we see any evidence of extraterrestrial technological civilizations, when there's no particular reason to think we're unique or special? Finally, it's just a story of awesome grandeur that should make us focus very, very hard on overcoming the present crisis facing humanity. We are incredibly lucky to find ourselves on such an unlikely planet, let's not kick it away.

Life is believed to have appeared on earth some time before 3.7 billion years ago. But for a long time, it didn't amount to much. Extraterrestrial visitors to our we rock likely wouldn't even have noticed the microscopic  self-replicating polymers encased in oily bubbles, that were probably found only near deep-sea geothermal vents and possibly some other isolated locations. Our old idea of life originating in shallow, sun-lit tidal pools is probably wrong, because the earliest life couldn't exploit sunlight as an energy source. The sun warmed the rock and water, which radiated the heat back into space. In between, it didn't do anything.

About 3.7 billion years ago, organisms emerged that could exploit the energy of sunlight. But they didn't split CO2 and water to make hydrocarbons and emit oxygen. The early forms of photosynthesis were less efficient and required access to existing organic carbon. So one-celled organisms became more numerous, but no major transformation resulted. (They probably emitted methane, which helped warm the planet.)

Then, about 2.4 billion years ago, oxygen began to build up in the earth's atmosphere. This was because a group of organisms called cyanobacteria had evolved oxygenic photosynthesis. Actually they had  evolved a few hundred million years earlier; it took a while for the oxygen build up to get going. But cyanobacteria could now inhabit a far wider array of niches and create far greater biomass. A consequence was that it was now possible for other organisms to make a living just by eating others, but another unlikely event had to occur before that became a major industry.

Then an unlikely event occurred. An organism called an archaeon acquired a bacterium as an endosymbiont. The bacterium was very efficient at converting oxygen and nutrients into ATP, the cellular fuel. The resulting organism, called a eukaryotic cell, could grow big and complex, and they started making a living by engulfing and digesting smaller cells. Then, one of them acquired as a second endosymbiont a cyanobacterium, and the plant cell was born.

Because of the way they reproduce, eukaryotes could form complex multicellular organisms. We started to see big things that could move around and seek food. They even started eating each other. This happened around 575 million years ago. As Judson tells us:

[W]ith animals would soon come a powerful new force of nature: the acquisition of energy through the active hunting and eating of other life forms, especially, other animals. This would produce a radical shift that, within a mere 40 million years, transformed the Earth. Before this epoch, ecosystems were microbial. The advent of widespread flesh-eating launched the Phanerozoic, triggering an enormous increase in organism size85, a new tempo of macroevolutionary change86,87, new kinds of ecosystems86,​87,​88, and an increased impact of life on the fabric of the planet87.
The collective term for these critters is metazoa. A million years ago or so, one of the metazoans started to deliberately set fires in order to cook its food and perhaps ward off predators. Then it started to use fire to extract metals from ores, and shape them into highly effective tools. Then it discovered abundant fuel in the ground that could be used to power machinery -- you know the rest.

If you really think about it, this chain of events seems quite unlikely. Maybe it isn't really and it would happen sooner or later on any properly situated planet. Who really knows? But we shouldn't be surprised if it is very rare in the universe. We really need to start appreciating it.

Thursday, June 01, 2017

Bad Science

This is not really news -- there have been less rigorous critiques before -- but this research letter in NEJM has gotten people's attention. In 1980, Jane Porter and Hershel Jick of Boston University published a one paragraph letter in the Journal. They said they had reviewed the medical records of 11,882 hospitalized patients who received opioids, and found evidence of addiction in the files of only four of them.

Note that these are hospitalized people who presumably receive only a short-term course of opioids; and that there is no reason to think that subsequent addiction or opioid use disorder would wind up in the records of that particular hospital, where most of the people will very likely not be seen again once they make their way into the world.

Nevertheless, this single letter to the editor -- not peer reviewed, not even really research -- was cited 608 times. Most of the citations were used to support the proposition that prescribing opioids for chronic, long-term pain, was not dangerous. More than 80% of the citations did not even say that the patients were hospitalized. The authors of the new letter give some examples, e.g. "The medical evidence overwhelmingly indicates that properly administered opioid therapy rarely if ever results in 'accidental addiction' or 'opioid abuse.'" This assertion is based on the single citation of the 1980 letter.

What they don't tell us is that this all happened in the context of heavy promotion of the long-acting opioid OxyContin by Purdue Pharmaceuticals, which was spending lots of money to promulgate these claims. They turned out to be false, and the result is the epidemic we face today.

So yes, science can be corrupted, by money as in this case, and in other ways. I spend a lot of time on this blog complaining about it. The good news is that the truth comes out in the end, but sometimes it takes too long. I should also make it clear that some scientific findings are simply not in doubt. Climate science is not corrupted by money -- on the contrary, the big money has been trying to corrupt it, and failing, for decades. So don't draw the wrong conclusions. But we need to keep our critical thinking faculties sharp.

Update:  I should have noted that the state of Ohio is suing Purdue and four other drug companies for causing the opioid epidemic.