Gender Health Care Sex

TWIS : I believe life begins at conception

“Well, I believe life begins at conception.”

You don’t. It might seem convenient or fashionable in your circle to say that, but it’s important to think that through. And the place that idea inevitably takes us is a bleak vision of government surveillance and control. You see, for every person born in the US, two fertilized eggs died. That means induced abortion (the kind we always holler about) is about 9% of the unborn deaths in the country. But where’s the outrage over the other 91%? Where’s the campaign to raise research dollars to stop failed implantation and spontaneous abortion? If  SIDS were killing two-thirds of babies, you can bet we’d hardly talk about anything else. And why aren’t we prosecuting for manslaughter those parents who fail to maximize their zygote’s chances. If you really believed life begins  at conception, you ought to favor the following policies.

Mandatory birth control. Unprotected sex, because it has such deadly consequences for zygotes, would need to be carefully controlled. This is especially true of married couples who are by far the most likely to be having unprotected sex. Couples would need to undergo an examination to determine they have maximized implantation chances before they are allowed to pursue pregnancy. Forgetting to take your birth control is now a prosecutable offense.

Lots more money for the NIH. Great research is being done to improve implantation rates for in vitro fertilization (IVF). Most of this research is funded by the NIH or NSF. However, one Party in particular is determined to keep those budgets low. We should expand research related to infertility by 10X at least. (As a bonus, we just might improve the lives of the post-natal!)

Mandatory tubal ligation at 35. Beyond 35, implantation rates begin to drop. In IVF clinics, it’s been found that 45% of (in vitro) fertilized eggs successfully implant for women under 35. As women age, that rate drops quite quickly to about 7% for women over 40. Remember that IVF involves fertilizing up to a dozen egg cells, then selecting the healthiest ones and implanting at the optimal time. Natural implantation rates are liable to be quite a bit lower.

Mandatory transvaginal ultrasounds. As you can imagine, the state of the uterine walls is critical for successful implantation. Women seeking to come off of their (state-mandated) birth control should undergo a transvaginal ultrasound to determine their viability. Women with insufficient uterine walls may be required to lose weight or make other dietary and lifestyle changes in order to pursue pregnancy.

In short,  if life begins at conception, there’s going to be a whole lot more of Uncle Sam in your vagina. Even if the only sex you’re having is with your spouse. And, lest you gentlemen feel left out, there is evidence that your health can have an effect on implantation as well. Get ready to drop those drawers for your state scrotum inspection!

Now, ThisWeekInStupid supports a grown-up discussion of when life begins. But we want it clear at the outset that it won’t just be about slut-shaming unmarried women. If life begins at conception, the choices of all of us are going to need to be severely restricted.

Class Economics Education Elections Health Care Taxation

More questions for 11-year-old Peggy Noonan

Peggy Noonan took pen in hand on the pages of the Wall Street Journal to tell us we should think like 11-year-olds in combating Ebola and impose a travel ban. Peggy doesn’t trust people with degrees in public health or medicine. People with degree in law and business should know how to combat infectious diseases.

That got me thinking about what other policy decisions we could leave up to children. If you have an 11-year-old, please give them this brief survey and mail it to Ms. Noonan.

1. What should we do with foreigners brought here as children?
a. criminalize and shun them (but tax them)
b. hug them

2. Which of these parties do you think will best represent Americans?















3. Do you think giving housing, food, and medical care to poor families:
a. Makes them get less done; or
b. Helps them get more done

4. What should we do with children whose parents don’t provide health insurance?
a. Give them health insurance
b. Not give them health insurance

5. To reduce gun violence does America need
a. More guns
b. Fewer guns

5. Our country has a lot of debt. What shall we do to pay it off?
a. Tax the wealthiest people
b. Take it from old people’s retirement

6. Which is worse?
a. Secretly selling weapons to a militant dictatorship (Iran); or
b. Asking for too much paperwork from charities with “Tea Party” in their name

7. Which do you think is the best use of our money?
a. Bombs
b. Schools

Today’s GOP manages to capture all of the ignorance of children without any of their compassion.

Health Care Immigration Terrorism

We treat (insert hated group here) better than our veterans!

No one beats Republicans for hyperbole. And I mean no one. Hyperbole in the right-leaning media makes Joseph Goebbels look “fair and balanced.” Right-wing hyperbole has done more damage to America than the Rosenbergs, child pornography, McCarthyism, and The Bachelor combined.

I kid. But they do tend to get ahead of themselves. And so, of course, when it came to light that military veterans at VA hospitals were put on a secret waiting list for treatments to hide the dire situation from oversight, the right fired up the ol’ hyperbolic comparison engine and got to work, producing ideas like these:



Not to spoil the surprise, but Michelle thinks undocumented aliens have a much better time than veterans.

I’ll address both of these momentarily. First, I think it can be debated whether care in the VA is in any degree worse than at conventional hospitals. A recent RAND study showed better-than-average care at VA hospitals. For a variety of chronic and non-chronic conditions, VA patients received the AMA recommended treatments more often than at conventional hospitals. Two studies of patient mortality by the National Institute of Health revealed VA hospitals to be on par with or slightly better than non-VA hospitals. A synthesis of several studies by VA researchers concluded that VA hospitals perform better on process-of-care metrics and equally on risk-adjusted mortality than non-VA hospitals.

Now, I think Michelle and (gulp) Louie Gohmert have a point in that we do a great disservice to our American servicemen and servicewomen in sending them to war all to often. We need to be much more careful in counting the real costs of our wars. I’m proud of our nation for leading the way in treating the mental and emotional scars of war and I hope we continue to resource research and treatment of PTSD and other combat related mental illness.

Come for the employment exploitation; stay for the medical neglect

But Michelle, Louie, come on. Before we get to the illegally incarcerated terror suspects, let’s talk about the plight of illegal aliens. They pay taxes but don’t vote or collect Social Security. They are, overall, less likely to commit crimes, but more likely to be the victims of crime. They have little recourse to authorities in disputes with employers and so work in poorer conditions for lower wages. They also use health care resources at a much lower rate. Although immigrants (documented and undocumented) make up 10.7% of the US population, they use just 8% of health care dollars. Of course, immigrants do tend to be younger and therefore healthier, on average, accounting for some of this. But Nadereh Pourat, director of research at the UCLA Center for Health Policy Research, found that illegal immigrants are less likely to go to the doctor, even if they have health insurance for fear of deportation. According to Steve Camarota, director of the moderately anti-immigrant, Center for Immigration Studies, the United States spends about $4 billion per year on health care for illegal immigrants, or about one-fourth of the federal subsidies of crop insurance given to wealthy farmers last year. Since many undocumented immigrants are agricultural laborers, ThisWeekInStupid thinks we should just call that even.

The biggest contributor to poor health care outcomes for undocumented immigrants is that almost half are uninsured. Since they are more likely to be uninsured, health care for immigrants comes more often in free community health clinics and emergency rooms where wait times are much longer and outcomes are significantly worse. Chronic conditions, like the ones that kill most Americans–diabetes, heart disease, etc.–are likely to go completely untreated until problems are very severe. In 2009, Dr. John Z. Ayanian of the National Academies’ Institute of Medicine testified before Congress, summarizing several hundred studies of health outcomes for the uninsured thusly:

Uninsured Americans frequently delay or forgo doctors’ visits, prescription medications, and other effective treatments, even when they have serious disease or life-threatening conditions. … Because uninsured adults seek health care less often than insured adults, they are often unaware of health problems such as high blood pressure, high cholesterol, or early-stage cancer. Uninsured adults are also much less likely to receive vaccinations, cancer screening services such as mammography and colonoscopy, and other effective preventive services.

The result of this lack of access, noted Dr. Ayanian, is that working-age adults are 25% more likely to die prematurely than their insured counterparts.

Now, undocumented immigrants have committed a crime. That’s undeniable. But it’s important to remember that the things they’re doing–working, paying rent in Tuscon, going to the hospital, sending their children to school–are completely legal for you not because you do them differently or because you do less harm or more good than they do, but rather because of where you were born. Some are content to give this fact a “them’s the breaks” shrug and continue on their ungrateful, entitled way. That, in the opinion of ThisWeekInStupid, is quintessentially un-American.

The Posh Life of a Terror Suspect

And now for Guantanamo. Picking on Louie Gohmert is no fun. But he was retweeting this story by J.D. Gordon of Fox News. As proof of his claim that we’re nicer to Gitmo terror “suspects” than to veterans, he cited the idea that the ratio of prisoners in Gitmo to physicians is higher than the ratio of veterans to VA physicians in the US. Now, this idea was quickly debunked since the doctors in that tally also treat the soldiers on the base. For many reasons, it’s awfully stupid to declare detainees at Guantanamo Bay have it easy.

Since 2002, 779 men have been detained at Guantanamo Bay. Eight have died. Six were reported by the military as suicides. In comparison with the Phoenix VA, who are currently treating 123,000 patients, that means you are 8 times more likely to die as a healthy 26-year-old sent to Gitmo than as a veteran on a secret waiting list at the Phoenix VA Hospital.

The majority of detainees at Guantanamo Bay have not been charged with any crime. Some are under 18 years old. All are neither judicial prisoners, nor prisoners of war, leaving them with uncertain legal protections. Forty-six prisoners are currently designated for open-ended detention since they are too dangerous for release, but the government has insufficient evidence to try them.

Allegations of torture at Guantanamo Bay, which are many and from varied sources, are difficult to verify. The International Committee of the Red Cross reported in 2004 that prisoners were subjected to humiliating acts, solitary confinement, temperature extremes, stress positions, sleep deprivation and beatings that were “tantamount to torture.” They additionally reported that at least some of the time of these Guantanamo Bay physicians was spent preparing prisoners for “enhanced interrogation” or supervising the same. The New York Times reported the statement of an FBI agent that prisoners at Guantanamo Bay were sometimes left shackled in the fetal position, in their own urine and feces for 18-24 hours. In 2004, an American soldier posing as a prisoner during a training exercise was beaten enough to cause traumatic brain injury and seizures. It turns out even soldiers at Gitmo are treated worse than veterans at the VA.

You’ve probably heard that several dozen inmates at Guantanamo Bay have staged a hunger strike, on-going now for several years. These prisoners have been force fed to keep them alive. Although the video-recordings of force feeding detainees are not available, the actor Mos Def volunteered to be force fed for the camera. I have great respect for Mos Def as an actor, but I think you’ll agree this is legitimately a horrible experience. No one would blame you for not playing the video below, especially if your children are looking over your shoulder.

Take a moment to let this fact sink in: Fox News thinks we should be treating Guantanamo detainees worse.

Now, ThisWeekInStupid is not a pacifist site. We believe a great country often needs defending. But, if there were a nation less than 100 miles from the United States that captured and held young men, charged them with no crime, tortured them and gave no timeline for ever releasing them, wouldn’t our great nation be inclined to intervene? Even at the cost of American lives? I love and revere my nation and am forever grateful for what it’s given me, but I am ashamed we haven’t managed to halt this situation even on our own soil perpetrated by our own soldiers.

So, it’s clear that veterans in Phoenix and likely other hospitals were (and continue to be) treated shamefully, to be sure. But, let’s not lose our heads.



Health Care

Health Savings Accounts Will Solve Our Health Care Spending Woes

HSAs solve a problem, but not the problem.

Republicans are enthusiastic! From many of them I’ve heard about Health Saving Accounts. It’s not that hard to control health care costs, they say. Just reconnect health care consumers to their spending. Most recently, Dr. Ben Carson weighed in, even suggesting that the government simply fund people’s HSA to the tune of $2000 per person. I’m told that support for HSAs is an important plank in the (possibly mythical) “Republican healthcare plan.”

What’s an HSA?

An HSA is a pre-tax account into which you and/or your employer can put money reserved exclusively for health care costs. It might work like this: In lieu of traditional health insurance for minor medical expenses, your employer might provide you with an HSA to which she contributes. You could also put money into your account yourself. The first health care costs incurred that year would be paid out of your HSA. Once the HSA is exhausted, you, the employee, are responsible for paying medical bills directly. An HSA is usually coupled with a major medical insurance plan with a high deductible so that beyond several thousand dollars in medical bills, a traditional insurance plan kicks in.

How an HSA worksAn employer once offered this to my family. We paid a portion of our premium and got $2000 at the beginning of each year added to our HSA. From this account, we paid the full cost of all our medical expenses–doctor visits, medications, etc.. No copays or cost-sharing. Your HSA pays it all. If expenses got high enough, this account would run dry. After that point, we would pay all expenses out of pocket. To protect us on the high side, the plan included a major medical policy which would begin to cover expenses beyond about $4500, just like a standard insurance policy with a high deductible. You might think this was some scheme by my ruthless employer to cheat us out of health care, but my engineer co-workers and I all agreed. There was no scenario in which this plan would cost employees more than the old plan. If you go to the doctor once for $250, you pay less than the old plan. If you get cancer and rack up $600,000 in bills, you still pay less than the old plan. And for every point in between those two, the new plan was still less expensive for employees.

Market-based savings

So why did my employer make this change? The idea is that employees will pay attention to the cost of their health care and that alone will reduce costs. And it worked, at least on a personal level. We started asking, “How much does that cost?” and “Could we give it another day before seeing the doctor?” We didn’t have any major expenses while under that plan, but if we did, I think I would have asked “Is that the cheapest MRI, or just the closest?” This is where the GOP puts their faith. Unsurprisingly, they count on shrewd consumers in the free market and the responses of equally clever suppliers to bring prices down and quality up. So, is your blowhard Republican roommate right?

But not where we need it most

Unfortunately not. HSAs are effective at controlling costs for small medical bills, but America’s problem is at the other end. We’re spending over half of our health care dollars on just 5% of patients. Those people have long exhausted any reasonable HSA. Meanwhile, the bottom 50% of spenders, those still spending money out of their HSA, account for just 3% of all health care spending. Probably HSAs will affect almost none of the top 20% of health care spenders which account for 80% of health care spending. This graph, borrowed from NIH, shows this effect quite clearly. On the lower axis is the percentile rank according to health care spending. The vertical axis is the  fraction of health care dollars spent on everyone below that percentile rank. So, when we see that the 40th percentile has the value of 1.4%, we know we spend 1.4% of our health care dollars on the healthiest 40% of patients. The steepness of this curve indicates that the spending addressed by HSAs is a very small portion of total spending.

Most of our health care dollars treat just a few patients.

Health care is classically, almost pathologically, unsuited to a free market. Demand is inelastic. Information is asymmetric. And the numbers are so far beyond people’s experience, that we have great trouble assessing risk and valuing the different health care products. This problem just gets worse for more expensive treatments and, as shown in the graph above, that’s where the problem is. Even if HSAs dramatically reduced costs for the 80% of us whose costs fall under their major medical deductible, we’d still go bankrupt unless we find a way to control costs for that top 20% who’ve exhausted their HSA and have no personal incentive to control costs.

So, even without asking whether convincing people to postpone their colonoscopy or shop for the cheapest throat culture is really a net savings, we can conclude that HSAs are ignoring most of the problem. That doesn’t mean HSAs are a bad idea, but they are, at best, window dressing for anything aspiring to be called a “health care plan.”

#BecauseMath Economics Health Care

The Market Will Set the Right Price for Health Care

I don’t suppose the interweb needs another discussion of the failings of market forces in health care markets. And yet the idea persists that setting the price of health care should be left to the unregulated market and that this will lead to maximum efficiency. The omnipotence of the market is a comforting concept.

Demand-side troubles

But the market for anti-retroviral drugs bears little resemblance to golf clubs or top sirloin. At risk of sounding condescending, a typical demand curve looks like this


As the price of a good or service rises, the quantity demanded shrinks. Lots of people will buy a pair of basketball shoes for $6. A few would pay $140.

But this doesn’t often work for medical services. I recently had my appendix removed. I’m told a typical appendectomy costs $25,000–a lot of money no matter who you are. But whether it had cost $100 or $100,000, I still would have bought exactly one appendectomy. The demand curve for appendectomies looks more like this:

Quantity demanded is unaffected by price
Quantity demanded is unaffected by price

There is, perhaps, some fall in demand. A 96-year-old might decline a quarter million dollar appendectomy. In some cases, there may be more than one treatment for an ailment so that one good or service may be substituted for another. But, in general, demand for health care services, especially the very expensive, life-saving treatments, tends to be highly inelastic. The quantity demanded is affected very little by the price. So, can providers of health care charge whatever they like?

Supply-side salvation?

Not necessarily. There may be some help on the supply side of this market. But, one reason markets are so effective and robust is the interplay of supply and demand. Without both working properly, the market can misallocate. When the supply side of the equation breaks down, for example in the case of a monopoly, we know that even with a healthy demand side, we’ll run into inefficiencies. So, we already have cause to worry. A truly effective market needs both a healthy demand side and supply side.

Switching to the supply side of things, if the price of a good is very high, more people will be willing to supply it. A supplier that overcharges will find herself undercut by a competitor willing to supply the good at a lower price. So, even with highly inelastic demand curves, there’s an equilibrium price at the point where the supply and demand curves meet.

The market sets the price where the supply and deamnd curves meet.
The market sets the price where the supply and deamnd curves meet.

So, it all might work out just fine, as long as actors can’t manipulate the supply curve. Unfortunately, two of the easiest ways to do that are both, of necessity, highly active in health care markets. The first is patents. A patent grants a single company the exclusive right to produce a product for a certain period. A supplier with a patent cannot be undercut by a cheaper competitor. When you are the only supplier of a lifesaving procedure, the market will not place any limit on the price (although public opinion or your own morality might). For this reason, it’s more useful to think about the supply curve for health care research than for particular treatments. If the payout for developing a new drug is very high, more people will be willing to do research toward that end. So, even where patents are applied, there is a functioning supply side curve at work. But in such a market, price signals can take longer to move through the market. When I need medication today, it’s slim comfort to know that the exorbitant price I pay for patent-protected drugs is providing the impetus for a robust market for drug research.

Another common way to move a supply curve is through licensing. Most people who treat you in the hospital are licensed, some of them very licensed, which is wonderful. It comforts me immensely that the person holding the scalpel has undergone years of training and scrutiny. But, the effect of this is to reduce the supply of doctors, nurses and other medical professionals. The FDA’s approval processes provide the same type of scrutiny for medications, equipment and treatments, with the same effect.

I wouldn’t have it any other way, of course, but the effect of this licensing is to shift the supply curve downward, increasing the price of goods. The further the supply is reduced, the higher the price. The inelasticity of the demand curve (and also the supply curve) multiplies this effect.

As the supply is reduced, the price increases.
As the supply is reduced, the price increases.

You can see how influence of these licensing processes could be very lucrative for suppliers. Doctors, for the most part, do important work for sincerely good reasons, but putting the AMA in charge of licensing doctors is a lot like asking the fox to guard the hen house. The tendency of almost everyone is to highly value their own work and the incentive for doctors is to limit the supply of doctors, raising their own salaries. Similarly, if pharmaceutical or medical supply companies can delay or scuttle approval for competing drugs and equipment, they also stand to make lots of money.

I’m not for a minute suggesting we do away with licensing of doctors or patents for drugs. Health care markets can’t be effective without these things. But, perhaps it’s a good idea to think hard about the markets for health care rather than blithely assuming the miraculous market will allocate everything just right. Without some advocates for consumers of health care, rising, inelastic demand will push prices out of reach and make life-saving care an unaffordable luxury.

Health Care Media

Obamacare is killing this pastor

Sometimes these posts write themselves. Since I started this blog, I’ve been exposing myself to more right wing news sources. Occasionally, it really feels like cheating. Today, Fox News tweeted this


This Iowa pastor has cancer. His old insurance plan refused to cover his treatments due to a pre-existing condition. As a result, he has $50,000 in medical debt. He went to and found a “gold” plan that would cover he and his wife for $800 per month. But, because he signed up on the 18th of February instead of the 15th, his coverage doesn’t start until April 1. Now, who in their right mind thinks this is an Obamacare horror story? Fox. Oh, wait…