Thank You, Affordable Care Act!

I've come across quite a few patients now in their early 20s presenting with the first symptoms of what may be a serious chronic illness. Many of these individuals happen to be without health insurance for one reason or another. Thankfully, in Massachusetts, the combination of Mass Health (Medicaid), Commonwealth Care and coverage options for young adults under 26 allows many of these individuals to get much needed care. On the other hand, my patients from neighboring states do not necessarily have access to these luxuries, which is were the Patient Protection Affordable Care Act (PPACA) comes in.

The PPACA has quite a few moving parts, some of which are in place and others not (see here and here). One piece that has gone into effect mandates that health plans that cover children of the enrollee to now cover said children up to the age of 26. For several of my patients, this has allowed them to get access to health care as they bridge to their late 20s and eventually find their own care options. As their doctor, this has been huge: it prevents my patients from deferring care for a serious condition that would most certainly result in large short-term and long-term economic and health consequences.

Interestingly, I'm not sure if too many people know about this aspect of the health care law. I told one self-identified Republican, a young man who would go on to benefit from the extension of parental insurance, about it and he seemed shocked: "For real? You mean, this is President Obama's idea? Wow, he's looking out for us."

I wonder now if much of the resistance to the PPACA has to do with similarly placed ignorance. If that is the case, the Republicans should be credited for obfuscating the national debate around the law in their favor and the Democrats chastised for allowing this to happen.

I'm not saying I'm a PPACA homer or anything. The act certainly has some issues. That said, as a new primary care doctor, I just can't imagine practicing in a time where such options were not available. Really, it's incredible that that time was literally a year or so ago. Imagine holding off treatment for newly diagnosed active and fulminant Crohn's disease because of lack of access: would that happen in a just, advanced society? Thankfully, not anymore.

Preventing HIV and STDs with Cash Transfers - Both Abroad and Here?

So on the heels of my post a few days ago comes a brand new study in The Lancet where women in Malawi randomized to receive unconditional cash transfers were less likely to contract HIV or other STDs than their unpaid counterparts. Here is a very nice summary piece on the study.

The mechanism linking cash transfers to reduced HIV may have something to do with the fact that women with access to such resources need not depend on men for the same. That is, women who are cash strapped or who lack opportunities in the labor market may need to depend on relationships where the partner can support them financially. Financial support, in turn, may reduce their ability to negotiate safe sex practices (this is the so-called "transactional sex").

Cash transfer programs of this nature may not just be useful overseas. A forthcoming article in the Journal of Adolescent Health shows that young African American women in Atlanta who have boyfriends who give them gifts are less likely to use condoms than those without such boyfriends or those with boyfriends who go on to find another source of spending money. The authors conclude that "receiving spending money from a boyfriend is common among adolescent women in populations targeted by pregnancy and sexually transmitted infection prevention interventions, and may undermine interventions' effectiveness." (HT: Paula C for the Atlanta paper).

Aspirations and Investing in Girls

Two great posts in Development Impact (my favorite economics blog right now) on aspirations, expected returns to investments, and the advancement of women. The first reviews evidence on how increased labor market opportunities available to women lead parents to invest more in the daughter's education. The second looks at how recent quotas decreeing that a randomly chosen 1/3 of village governance seats in India be filled by women have led to increased aspirations among girls and their parents, as well as increased investments in the former. In the study they cite, the gender gap in child education (which favors boys at baseline) was decimated when a village headship was randomly assigned to a woman.

The posts, and the articles cited there in, make two powerful points. First, information on opportunities for girls that may be unknown to families (for whom the cost of obtaining such information is high because of, say, lack of access to "plugged in" social networks, media, etc) can be powerful in combating gender bias. Second, proactively breaking down institutional barriers can play an important role, too, something we saw with the Civil Rights Movement here on our shores.

Preventing HIV By Paying People to Maintain Safe Sex Practices

Finding an HIV prevention strategy that works is one of the Holy Grail's of public health policy. Indeed, poor evidence of the epidemic quelling effects of most prevention programs (outside of biomedical interventions such as circumcision) have driven many to accept that treatment may actually be the best preventive device we have.

That may be true, but I do not think that all modes of prevention have been exhausted. One margin where there is some growing evidence is in providing cash transfers for people who maintain a given set of behaviors over a period of time. For example, one could pay people for every month they do not test positive for HIV. Such methods have been tried in the substance abuse world, apparently to good effect. Could it work with HIV/AIDS?

In a great new NBER working paper, Damien de Walque, William H. Dow, Carol Medlin, and Rose Nathan argue that the answer is a resounding yes (ungated version here). From the abstract:

[W]e discuss the use of sexual-behavior incentives in the Tanzanian RESPECT trial. There, participants who tested negative for sexually transmitted infections are eligible for outcome-based cash rewards. The trial was well-received in the communities, with high enrollment rates and over 90% of participants viewing the incentives favorably. After one year, 57% of enrollees in the “low-value” reward arm stated that the cash rewards “very much” motivated sexual behavioral change, rising to 79% in the “high-value” reward arm. Despite its controversial nature, we argue for further testing of such incentive-based approaches to encouraging reductions in risky sexual behavior.

The abstract undersells some of the evidence they cite in the paper, so I would go ahead and read the entire thing. While people may somehow find it reprehensible to pay people to do the right thing, there is already a great precedent in education and yearly doctor visits (i.e., conditional cash transfers for those things are all the rage in the Americas) as well as (as mentioned above) with getting people to stop using illicit/recreational drugs.

200 Images Every Physician Should Know

As part of their 200th anniversary celebrations, the New England Journal of Medicine has collected 200 of its most striking (and sometimes clinically relevant) images from their "Images in Clinical Medicine" series. These are pretty awesome - especially if you are busy intern trying to sneak in time to read, but don't have either that or the will to work through dense review articles. Think of these as flash cards for residents (or for all doctors in general!). Good stuff (HT: Paula C).

Internal M&M

Like the last two Mornings, The Intern parked his Laptop on Wheels at the Nursing Station and went into a nearby room to see Mr. B. And like the last two Mornings, Mr. B was there, lying in his hospital bed. The Intern looked him over. Some increased bruising on his right arm, maybe some increased bleeding in his gumline. The rest of him looked the same, save an IV sticking out from a long bone in his lower left leg. The Intern lifted the diaphragm of his stethoscope onto Mr. B's chest and heard nothing. This was a New Morning, and this was a New Finding. The Intern had expected it. A silence - really, a vacuum - had replaced once robust heart sounds.

Earlier That Morning, The Intern woke up, weary and maybe even a little defeated, after a Call Day that marched into the night. Like every Morning he reflexively checked his e-mail, and saw the Night Resident's message that Mr. B's heart stopped some time before daybreak. They couldn't resuscitate him. There was the jolt of shock and sadness, of course, but, for that one tiny slice of The Intern's cortex, a perverse affirmation, as well.

The Previous Morning, Mr. B greeted The Intern as always. "Hey doc, what's going on? How are you?" The Intern dutifully listened to his heart, his lungs, examined his eyes, mouth, fingernails and felt his abdomen. He felt for enlarged lymph nodes. Everything was fine like always, despite The Numbers telling him otherwise. Very low platelets, very high this, very low that. More Data forthcoming. Biopsy results pending. The difference between Mr. B in person, on exam, and Mr. B on The Computer was always jarring and troubling to The Intern. Something viscerally troubled him more on this day, however. He came to check in on Mr. B every two hours or so.

And so for the first part of Yesterday, Mr. B was just like he was on admission - well-appearing, kind, deferential, interested in talking about his family, and speaking seriously about an incipient scandal in college football. But later in the day, he seemed uncomfortable. "I don't know what's going on doc...I just don't feel right," he told The Intern. He pointed to his abdomen, just below his rib cage - "it hurts here. I’m sorry to keep bothering you." The Intern examined him, drew some Labs, looked over a Scan and then reassured him. "First of all, don’t apologize. I’m here to Take Care of you. And what’s going on, it's probably your pancreas. I'm going to give you some fluids, some pain medications. We’ll get an ultrasound. Don't eat anything, OK? Well, maybe you can have that milkshake over there. I'll turn a blind eye to that." A lame joke, a smile.

But The Intern was disturbed. Mr. B could not articulate what was wrong with him and The Intern knew him to be an articulate man. The Intern pushed what he recognized as an ominous feeling to the recesses of his brain, so that it occupied only a tiny slice of cortex, and pushed his Laptop on Wheels forward to see another patient who was very ill. He did, however, return to see Mr. B a few more times, and was reassured when he seemed a bit better. At eleven that night, The Intern saw Mr. B one final time before going home. "I'm great doc, thanks for everything! Go get some sleep!"

As he looked down at Mr. B on This Morning, The Intern's mind skipped through a slide set of images and thoughts, as if they were set to a random shuffle. He remembered, with some shame, how three days ago he was annoyed to be paged about a new admission late in the day, only to feel some form of joy when he connected with Mr. B during that first conversation. He thought about how Mr. B told him about the first time he met his wife, when she thought he was "some married jerk flirting with her," only to realize later that he was single and legit - "we've been together ever since." He wondered whether Mr. B's pancreatitis, chest pain and low platelets were all tied together by one of two catastrophic diseases, based on a discussion he had with The Consultants and The Attending the other day. He remembered what Mr. B said about his children, how they weren't wealthy but were doing jobs that they really liked and that that's what he’d always wanted for them. The Intern knew he'd tell his children the same thing someday.

He remembered how Mr. B kept talking about his family and his good fortune to have them in his life. He talked more about them Yesterday and The Intern wondered then if Mr. B somehow knew Yesterday itself that he would not see them ever again. He wondered if articulate people being unable to find words for their unease and distress was a poor prognostic sign.

And then he asked himself whether he could have done something differently. Whether he could have thought more about the medical mystery that was Mr. B instead of spending time running around writing for Eucerin cream and Imodium or rushing through tasks in order to go home at a reasonable hour. He wondered if Large Academic Hospital's Cadillac of a Differential Diagnosis distracted him from the few more obvious possibilities, the ones that may have mattered to fixate on. He wondered if he could have simply done better by knowing more and thinking faster. He wished that tiny slice of cortex that told him to be afraid did so more loudly and forcefully.

It was then that The Intern noticed The Tag on Mr. B's left big toe. He didn't bother to read what was written on it; he knew it served to identify, perhaps to differentiate Mr. B from others in The Morgue. The Intern looked elsewhere, with his gaze stopping at Mr. B's right hand, which lay there palm up, fingers open. The Intern thought he must have died like this, keeping his hand that way as if to ask to touch another person one last time before his exit. The Intern reached down and closed his fingers, rotated the hand inward. Mr. B's fingers were cold in a way that The Intern had never experienced. The Floor Nurse stared at The Intern, worried and puzzled. The Intern looked up at her, adjusted his Mask of Professionalism, and then left, rolling his Laptop on Wheels, Progress Notes in hand, ready to see his next patient and scribble down The Plan before Attending Rounds started.

A Senior Resident told him that every Resident has a Patient that dies like this and that it is part of the Doctor Experience. “You’ll be fine.” But The Intern knew that the questions, regrets, self-doubts, memories, and sorrows would all come back later. In a wave that would sweep him into a darker place. As if reflexively, he suddenly thought of the people he felt lucky to have in his own life, and reached into his pocket for his phone.

Does Discrimination Make You Sick? And How?

Interesting new paper, forthcoming in the Journal of Health Economics, that uses 9/11 as a quasi-experimental source of variation to try and get at the causal effect of discrimination (here, against Muslims in the UK) on health outcomes. It also goes a bit further than this and tries to get at some of the mechanisms. The findings are, sadly, along the lines of what I expected:

The attitudes of the general British population towards Muslims changed post 2001, and this change led to a significant increase in Anti-Muslim discrimination. We use this exogenous attitude change to estimate the causal impact of increased discrimination on a range of objective and subjective health outcomes. The difference-in-differences estimates indicate that discrimination worsens blood pressure, cholesterol, BMI and self-assessed general health. Thus, discrimination is a potentially important determinant of the large racial and ethnic health gaps observed in many countries. We also investigate the pathways through which discrimination impacts upon health, and find that discrimination has a negative effect on employment, perceived social support, and health-producing behaviours. Crucially, our results hold for different control groups and model specifications.

So in addition to the deadweight loss of underutilizing potentially talented men and women, as well as increasing social unrest and the potential political costs that might have, we can now add health to the slew of negative impacts from discrimination.

In a later post, I'll go over a paper that Sonia Bhalotra and I are working on that looks at how discrimination can prevent children who have better childhoods into tapping into that wellspring as adults.

Public Health and Health Care Reform

As the fate of the Affordable Care Act (ACA) hangs in the balance, the Obama administration has had to make some compromises in order to keep the bill afloat. One of these is cutting #3.5 billion from the $15 billion Prevention and Public Health Fund. The fund exists given increasing recognition that a majority of chronic disease we see now are likely secondary to what are public health issues (changing diets, limited opportunities to exercise, pollution, etc).

The usual justification for public health is that, in the long-run, it prevents disease and thereby lowers health care costs. I think this is fundamentally correct. However, it's a tired argument, especially in the context of four-year political cycles (why wait on cost savings that will take a long time to materialize if they don't confer any immediate electoral benefit?) and a natural fixation over observable events (it's hard to appreciate things that don't happen, but seeing someone catheterize an occluding blood vessel to the heart is real and amazing; doing something about that raises political visibility).

Enter Nicholas Stine and Dave Chokshi, both physicians at the Brigham and Women's Hospital. They have a nice perspective piece in this week's New England Journal of Medicine that makes a fresh case for public health expenditures. In particular, they cleverly frame the value of public health in terms of immediate cost savings and current cost-control objectives in health care. Some of the more interesting points:

-We are now interested in paying for good quality health services rather than health services in general. There is also a push to think more about population management? Which means we need to be able to measure things we've never measured before on a larger scale. Public health organizations have the know-how and capacity to do population surveillance which can be helpful in this regard. Why not outsource the data gathering and analysis aspects for both quality, capacity and population based outcome measures to the pros? In this way, spending on public health will have spillovers to the medical care.

-More generally, we can use public health departments help organize IT. It is now very difficult for smaller practices or hospitals to afford good IT. Outsourcing this to a larger organzation that could perhaps manage IT for many different providers could be really useful in cutting costs for individual firms both in the short and long-run.

-In the same way we are paying for good health care, why not introduce financial incentives for good public health, so as to glean gains from it in the shorter run?

This is a great piece because it takes the public health versus medicine issue and illustrates how the two are complementary. The new angle is that the complementarities can lead to cost-savings sooner than we'd expect, and can help augment and empower current initiatives on the medical care side to improve quality and cut costs. Even their title is beautiful: I'm sure that "Opportunity in Austerity" is what every politician wants to hear now!

Random Links: Read "Short White Coat," the Value of a Good Kindergarten Experience, and Why Drop Out?

My co-intern in the primary care program, Ishani Ganguli, is an incredibly thoughtful individual who writes really well. She has a blog (a real blog, one with a consistently large readership that is fronted by the Boston Globe) that discusses various aspects of health care and medical education through the eyes of a resident. Worth checking out, especially her latest post on teamwork in health care.

-There's a great book, now a classic, by Robert Fulgham called "All I Really Need to Know I Learned in Kindergarten." Now some new research from some big shot economists on the value of a good kindergarten experience:

In Project STAR, 11,571 students in Tennessee and their teachers were randomly assigned to classrooms within their schools from kindergarten to third grade. This paper evaluates the long-term impacts of STAR by linking the experimental data to administrative records. We first demonstrate that kindergarten test scores are highly correlated with outcomes such as earnings at age 27, college attendance, home ownership, and retirement savings. We then document four sets of experimental impacts. First, students in small classes are significantly more likely to attend college and exhibit improvements on other outcomes. Class size does not have a significant effect on earnings at age 27, but this effect is imprecisely estimated. Second, students who had a more experienced teacher in kindergarten have higher earnings. Third, an analysis of variance reveals significant classroom effects on earnings. Students who were randomly assigned to higher quality classrooms in grades K-3 – as measured by classmates' end-of-class test scores – have higher earnings, college attendance rates, and other outcomes. Finally, the effects of class quality fade out on test scores in later grades but gains in non-cognitive measures persist.

-In related news, there's a great recent NYT Op-Ed on the cost of high school dropouts to the US economy (thanks James Hudspeth!). The authors (both well known economists) mention the following:

Studies show that the typical high school graduate will obtain higher employment and earnings — an astonishing 50 percent to 100 percent increase in lifetime income — and will be less likely to draw on public money for health care and welfare and less likely to be involved in the criminal justice system.

So a good economics question: if high school completion is so valuable, why would anyone drop out? Is it because of ability (low ability kids are forced out), time preference (the value of now exceeds the returns of income later?), or a lack of information about the returns to high school? There are other explanations. But if we assume that people make choices based on marginal returns, it seems bizarre that so many would drop out and leave that kind of money on the table, right? Thoughts?

Partisan Professors and Race

Great new paper in the latest issue of the American Economic Journal: Applied Economics about the political orientation of your professor and the grade you may receive in her/his class:

We study grading outcomes associated with professors in an elite university in the United States who were identified—using voter registration records from the county where the university is located—as either Republicans or Democrats. The evidence suggests that student grades are linked to the political orientation of professors. Relative to their Democratic colleagues, Republican professors are associated with a less egalitarian distribution of grades and with lower grades awarded to black students relative to whites.


The paper is by Bar and Zussman and their models look at variations in grades within the same student taking courses in the same department, so it controls for selection into majors and, to some extent, classes. The most interesting part of this paper is the race angle. One may think that it has something to do with the fact the demographics of Republican professors, not so much their ideological preferences. Not so: even controlling for gender, age and race of the professor doesn't change the results.

So how to interpret this? I'm sure that many would argue that Republican professors harbor some subtle, perhaps subconscious, prejudices against black students (this guy would agree). This is entirely possible, but I think the study needs to be interpreted with some caution. First, the sample size of Republican professors is small (only 5.3% are). Secondly, its unclear where the grade variation is coming from. Do students - black or white - perform worse in Republican-professor taught classes (they don't like the take on the material, they may be too ticked off with partisan politics to focus on assignments, etc)? The study can't distinguish this explanation from the racist-professor one.