Archive for August, 2013
This post is going to wander a bit. But I want to share a few observations and questions about the future of the US that seem to me to be absent from a lot of the current political discussions and blame games.
- The US dominates the list of the top universities in the world. You can be skeptical about the rankings, how they are made and what this all means, but in almost any list you see the US is at the top. In the link above, 35 of the top 50 are from the US and 52 of the top 100 are from the US. Typically science and technology is what dominates the rankings and if you look at the top US institutions, they are also at the top of the NIH and NSF rankings in total research dollars. While a lot of esoteric stuff happens in research universities a lot it eventually ends up translated to things that have economic value and make a difference in people’s lives. Government funding for R&D is under threat and tuition is higher than ever. Are these good long term trends that bode well for future economic growth?
- The US was an early investor in universal education and shortly after the Civil War there was free primary education in every state and a very high rate of literacy. Early emphasis on literacy for religious reasons has also been credited for the economic success of both Protestants and also Jews. The idea is that an educated population creates the human capital needed for societies to thrive economically. Other things have to be in place as well, but you can only do so much with an uneducated population. We can bash the schools, we can bash the teachers, we can spend more money, we can spend less money, but does anyone have any idea about what policies actually work and how they might get implemented?
- One issue in the US and perhaps the rest of the developed world is that as a result of globalization and labor saving technology there is no such thing as a middle skill high wage job anymore. Some of what happened in the US in the 1950s when there were plenty of high wage jobs in manufacturing probably also reflected that fact that most of the rest of the world’s industrial capacity had been destroyed or degraded by World War II. So, some of what has happened is also about the rest of the world simply catching up. There are a lot of arguments about how unions or management blew it, and what policies could have been in place to change things. However, maybe the blame game misses the big picture. Isn’t the real question, what do we do next to make a new wave of middle class jobs accessible to more people?
- A lot of people are concerned about the rising income gap and gaps in economic opportunity. This concern is made worse perhaps by the loss of middle skill high wage jobs. To fix this aren’t we going to have to do more than simply change the tax code? The wars in Iraq and Afghanistan are projected to cost between 4-6 trillion dollars and what have we gained? Are we more or less secure than when they started? Could this money have been better spent on things like rebuilding roads and bridges in the U.S.?
- The US is lurching toward the next big set of budget show downs and the prospects for a collection of policies that stimulate growth in the short term and tame the deficit in the long term look unlikely. Every time I read about this nonsense I think about how Ronald Reagan and Tip O’Neill negotiated to restructure Social Security and the Tax Code. If Reagan, an icon to conservatives, could negotiate with a New Deal liberal like Tip O’Neill; why can’t the current crop of “leaders” find some common ground?
I am sure I could come up with 50 more questions that we might all ponder, but for some reason I keep coming back to these five. Who knows what the “right” answers are, but it seems to me you can’t get to the right answer if you don’t ask reasonable questions.
One topic I’ve posted on several times relates to the use of taxes, insurance premiums and other “nanny state” approaches to shape behavioral health. The basic idea is most of what ails a given population is driven by behavior and that focusing on individual choice or medical care after people are sick only gets you so far. Thus public policies that encourage better choices related to things like diet/obesity, smoking, drinking and physical activity are essential. In other words, make healthy choices more attractive, easier, and less costly in comparison to unhealthy choices. Here is an update on a few things related to this general topic.
Mayor Bloomberg’s third term as mayor is coming to a close and the New York Times is running a series of articles reviewing his legacy. He has been a champion of using public policy to shape behavioral health. While Mayor Bloomberg gets mixed reviews from the citizens of New York on many topics, his efforts to reduce trans fats at restaurants, post calorie counts, reduce smoking , and promote physical activity have all gained high marks…….mostly in retrospect.
These policies were not particularly popular when they were first discussed and implemented and yapping about the so-called nanny state was and is common. However these policies have become much more popular and perhaps show that Mayor Bloomberg (for all his billions) is someone who “cares”. These findings should also give politicians and regulators the confidence that even if unpopular when implemented, such policies will likely become more popular with time. Can you imagine the outcry many places if smoking bans were reversed? It is interesting to note that the one unpopular policy is his effort to restrict the size of sugary drinks. Is that because it is his latest effort, or is regulating what people eat and drink going to be more difficult than things like smoking bans?
Penn State Health Insurance Plan
Another interesting news report comes from Penn State where there appears to be significant (or at least high visibility) push back on efforts to link health-care premiums to the behavior of employees.
The opponents of the plan cite privacy and other concerns. It will be interesting to see what happens as more and more organizations and perhaps governments start to charge different rates for health insurance based on behavioral risk factors that are at least under some control or perhaps a lot of control by any individual policy holders. There’s some evidence that these policies work to get people to change behavior, but will it be acceptable and how much political pushback will there be?
Gallup Poll Data
The chart below from the Gallup Organization tracks responses of the general public to questions about higher insurance premiums for smokers and people who are overweight. The link also shows how opinion varies by political affiliation, smoking status, and self-reported obesity/overweight. While there is significant support for adjusting premiums, there are plenty of people who oppose this strategy even for smoking.
It is hard for me to think that we are going to make the country much healthier without a bigger effort to change unhealthy behaviors. Insurance premiums are going to be part of the mix and it will be interesting to see if they become widely adopted and how long it takes. My bet is that they will become widely adopted and it might not take as long as people think. The current smoking restrictions and seat belt laws would have seemed inconceivable 20-30 years ago.
Today’s post is short. There was a report last week of a successful vaccine for malaria. The vaccine in its current form will present logistical challenges for wide spread use, but this is a start and my guess is that clever people in the biotech industry and various academic and government labs will figure something out. Currently there are about 7 billion people on Earth and about 60 million deaths per year. About 660,000 of these deaths are due to malaria, with about 86% of the deaths in kids less than 5. There are about 200 million clinical episodes per year, and the disease caused by infection with a protozoan (a type of parasitic microorganism) that is transmitted by mosquitos. About half of the world’s population is at risk. The map below shows the history of malaria eradication (pesticide, draining swamps etc.) since the middle 1800s. The dark blue areas are at risk as of 2010. There is also concern that this at risk zone might spread with global warming. Here is a link an excellent CDC site with facts on malaria.
I started medical school in 1982, and if the preliminary success of the vaccine reported last week can be scaled up, it will be the biggest breakthrough since I started. The topic of vaccines also highlights the key role of prevention for both communicable and non-communicable diseases like diabetes, heart disease, obesity and many forms of cancers. The fact that much of the word once at risk for malaria is no longer at risk also shows the role of the environment, behavior, and public policy in preventing diseases of all types.
Alex Rodriguez (A-Rod) was suspended for 200 games by major league baseball based on “non-analytic” evidence of doping, most recently as part of the “Biogenesis” scandal in south Florida. He was one of 13 players suspended and his suspension is the longest doping suspension in major league history. Like Lance Armstrong he “passed” any number of drug tests. That having been said, there was a terrific article a couple of weeks ago in the Economist about “game theory” and doping in sports. The idea is that the athletes are in a game with each other. If testing and enforcement are lax, then (depending on the rewards for a superior performance) the risk of getting beat by a doper is greater than the risk of getting caught.
The Bud Selig Game
The athletes are also in a game with the authorities. More importantly the authorities are in a game with the fans. Incredible performances increase fan interest and so a cynic might argue that the owners want the appearance of compliance more than a truly clean game. This charge has been leveled at Baseball Commissioner Bud Selig who has been accused of turning a blind eye during the Mark McGuire, Sammy Sosa, and Barry Bonds homerun derby era after the 1994-95 baseball strike. One argument about the Lance Armstrong case is that the cycling authorities knew what was going on but were more than happy to have Lance win year after to year to “grow” the interest in their sport in the U.S. which was a relatively untapped market compared to Europe.
The Yankee Game
The Yankees signed A-Rod to a huge long term contract. To what extent are they more than happy to see him more or less go away so they can “head in a different direction”?
The Other Games
Here are some other games that are being played:
- As I have pointed out numerous times, testing is beatable on many levels. Who are the authorities trying to fool?
- Testing in U.S. professional sports is generally less rigorous than WADA based testing used in the Olympics, and WADA based testing is still beatable.
- There is a lack of transparency. Post who was tested how often but after the tests were performed. Then post the results. This would increase confidence among athletes about “unilateral disarmament” and also let everyone see if any stars were in fact being protected. It would also essentially crowd source scrutiny of high normal values, and I bet there are plenty.
- What about unregulated anti-aging clinics that sell all sorts of hormone based potions to all sorts of people? When Jane or Joe six-pack can essentially get drive through hormone treatment to buff themselves up, why not ballplayers?
Suspend Bud Selig?
A-Rod (like Lance Armstrong) is not a person I want to defend. However, he is just one dishonest cog in the machinery of denial. If he deserves to be suspended then so does Bud Selig for either turning a blind eye or never looking very hard in the first place. Does anyone really believe that the hard-nosed billionaire owners did not know what was going on? Are they cracking down now because they finally woke up or because their checkbooks are talking?
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