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Just a smidgen more on US healthcare reform

My previous comment on US healthcare reform, which was actually a comment on the current Australian system, got quite a few eyeballs thanks to John Hempton’s shout-out.  Anyway, I thought I’d highlight a couple of new developments for my little audience.

First, Republican Senator Olympia Snowe (of Maine), who sits on the Senate Finance Committee, has said that she will vote in favour of the suggested bill being proposed by that committee’s chairman, Max Baucus.  That is good for the Democrats as it will provide valuable political cover.  It’s no guarantee that she will vote in favour of whatever the Senate as a whole end up producing, or for whatever the Senate and House then negotiate as the final bill, but it’s still a significant move and the probability of her voting for those later versions has just increased.

Second, we have the fact that the healthcare insurance industry has recently done an about-face, from actively promoting reform to actively fighting against it.  Nate Silver points out why:

Take a look at what’s happened to the share prices of the six largest publicly-traded health insurance companies since Labor Day, which was about the point at which the Democrats appeared to regain their footing — at least up to a point — on health care.

Weighted for market capitalization, these insurance stocks have lost 11 percent of their value since Labor Day, wiping out about $10 billion in value. And that’s understating the case since the major indices have gained 5-8 percent over the same period — the insurance industry stocks are underperforming the market by just shy of 20 percent.

So why have they tanked in the stock market?  Nate suggests two reasons:

Firstly, the individual mandate has been weakened to the point where it’s arguably a tokenish provision. There are good, policy reasons to be worried about this, although the insurance lobby’s reasons for being opposed — they’ll have less guarantee of an incoming phalanx of high-margin customers — are not necessarily the same as the public’s at large. The second factor is that the Baucus bill in certain ways treats the insurers fairly harshly, both taxing them directly as well as levying a surcharge on high-cost insurance plans.

I’d also suggest that the compromise version of the public option (that it be in the bill, but with states able to opt out if they wish [Paul Krugman, Talking Points Memo]) will have scared the insurance companies and investors as well.

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Forever starting

I am a chronic starter.  It seems that every week or two I start something new.  This would be great, if only I then kept doing whatever it is that I start.

One of the things that I start doing on a regular basis is running.  Just about every year, usually about half-way through summer, I start running again.  Every year I keep a careful log of what I do, every year I try not to build up too quickly, every year I become tremendously enthusiastic, every year I dream of completing the London Marathon and every year, without fail, I stop running after a month and a half.

Forever starting running

(Click on the image for a bigger version.  Distances are in kilometres; rates are min/km)

I used to be a runner.  Back in 1992, my final year of high school, I ran four times a week on top of two weekly sessions of soccer training in the winter and cricket in the summer.  In the middle of that year I ran the Gold Coast Half-Marathon in 1:38:37 (4 min 40 sec per kilometre).  Later that year I ran a cross-country 8km in 32 minutes flat.  I was in the Queensland junior orienteering team.

I’ve always thought of myself as a runner (well, okay, a lapsed runner).  I’ve blamed everything I could imagine for my repeated failure to get into a habit again.  Diet.  Running too far.  Running too quickly.  Not enough time to rest between runs.  Too much time between runs.  Not running on the same days of the week.  Insufficient variety in my routes.  Not running with music.  Not running enough with other people.

I generally hold that with exercise (hell, with anything), what propels you forward is novelty in the short term, discipline in the medium term and habit in the long term.  The trick, then, is to find a way to deal with a chronic lack of self-discipline in the medium term when you’ve ruled out options like joining the military to have discipline imposed upon you.

Here’s an email I sent to some of my friends last year (21 Aug 2008):

It’s not that I get bored with the runs when I’m on them – I tend to vary my courses and occasionally run with a club. As far as I can tell, I just get to a point where I can’t be arsed going today, tell myself I’ll go tomorrow, end up only going in three or four days and then repeat the process with the lags becoming longer until I just forget about it altogether. I have tended to get quite tired after the first couple of weeks, which suggests that an inappropriate diet might be the cause, but I’m hesitant to use that as the explanation when the phrase “I’m a lazy bastard” is swimming gently across my forebrain. There’s also the possibility that I rapidly envisage absurdly ambitious goals when I first start and manage to discourage myself before I’ve even built the habit of running.

So. I’m looking for suggestions on how to keep it going this time. I’ve managed nine runs so far and all pretty evenly spaced (see attached). The 5km runs are on the Heath, the 7km runs are with a running club of 80+ people around Hyde Park and Kensington Gardens. Runs on the Heath are infinitely variable. I don’t start back at uni for six weeks and have no work planned, so it’s a perfect opportunity to build up a weekly ritual.

My friend Chris replied (22 Aug 2008) with:

My most successful tactic: grinding down the barriers of participation.

The thing that makes it hard to run is NOT the running. It’s the transition from comfort and inertia to physical discomfort and effort (usually in the dark and cold in England).  You have to look at what you need to achieve: in the first few months you are trying to achieve a HABIT. Nothing else. You’re not trying to achieve physical fitness, training, distance or anything else.

So looking at it as habit training, the best thing you can do is work on the habit above all else. It doesn’t matter a toad’s cloaca whether you go out and run 12k or 400 metres, if you stop a fortnight later. And as you know, stopping is never a decision to stop running. It’s a decision to take tonight off and go tomorrow instead. Then tomorrow. Then tomorrow…

The only way to succeed is to form the habit above all else, and the only workable way to form the habit is to make the habit easy.  So, change your goal. It’s not to go for a run, it’s to put your tights on and step outside the door. Make THAT what you do 3 times/week (or better, every Tues, Thurs and Sunday, since “3/week” gives you wiggle room).

So 3 times a week you will put your shoes and silver bodysuit on, and walk to the gate. What happens then is purely a matter of how you’re feeling at the time. Until you are standing at the gate, you are not planning anything else.

Pound down the delta between what you are doing now (vegging in a warm lounge room) and what you will be doing in 10 minutes (standing outside your door). Smash the crap out of that delta, because that’s your only enemy.

Which is eminently sensible advice, but as you’ll see above in the image, I stopped running two weeks later.  There was something missing.

Another friend, Anthony, also suggested last year that I

drop down a lot of cash on an event, such as Noosa Tri, which gives [you] some financial and pride incentives not to look like a fat unfit bastard on the day.

Again, excellent advice, but unless I have a basic belief that even with no training at all I can still cough and wheeze my way around the course, there’s a fair chance that if it’s all seeming a bit too hard I’ll just give up and call the cash gone.  However, it does lead into the classic economist’s way of solving any problem:  financial incentives.  In January 2008, Ian Ayres, Jordan Goldberg and Dean Karlan (two of them economists) lauched stickK.com.  It’s a site that will let you set up a contract on yourself (e.g. to lose weight).  If you don’t meet the terms of the contract, you forfeit money.

I think it’s a neat idea, but it’s never really sat well with me.  If your money is potentially going to a charity that you hate, then that’s just stupid.  If it’s going to a charity that you like, then your incentives are all screwed up.  So instead, I’ve decided on a different idea:

As soon as I finish writing this post, I’m going to go to the bank and withdraw £520.  I will then divide it across eight envelopes and give them all to a good friend, Dimitri, with strict instructions to return the money back to me piecemeal as he is satisfied that I have gone for a run.  The amounts returned will be increasing over time, so the first run will get me £30 back, the second £40 and so on up to the eighth run being worth £100.  There will be a time limit of three weeks on my claiming the money back and a limit of no more than four runs being claimed per week. Here are the benefits, as I see them:

  • Dimitri is a good friend and I trust him not to run off with my money.
  • If I don’t meet the requirements, I also trust Dimitri to not turn Good Bloke and give me the money back anyway.
  • He is pretty fit at the moment, having just competed in the London Triathlon, and is training regularly himself.
  • It’ll be up to Dimitri to judge whether he believes me when I say I went for a run.
  • The total amount of money is large enough that I will really want to get it back.
  • The incentive is increasing over time, so I won’t be tempted to just go for a couple of runs and call it quits.
  • The overall time limit combined with the restriction of no more than four runs per week will make sure that I don’t put it off and that I don’t end up hurting myself.
  • Possibly most importantly of all, it extends the period of novelty well into the period that would otherwise be solely governed by (a lack of) discipline.

Eight more runs will take me to 20 in total.  If it goes well and Dimitri is willing, I might then repeat the process.  After that, I should hopefully have been running for long enough that I can get myself out the door without the financial incentive.

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A description of Australia’s healthcare system

John Hempton has gotten to it before I did and written it far better than I would have anyway.  Have a read.  Although I agree that Australia’s system is much, much better than America’s current system or any of their proposed frameworks, I would add three negative comments about Australia’s system:

  • Medicare payments to GPs for a consultation by a patient are determined centrally (at the federal level) and have not increased with inflation.  At first that meant that GPs shortened each consultation to fit more people in per day, but in the long run served, I believe, to reduce the supply of GPs and as a result pushed people with minor ailments to hospital emergency rooms.
  • I don’t know if it is better or worse than other countries, but the administrative overhead in the state government health departments is surprisingly large, even to me.  I am led to believe that adminstrators and middle-managers exceed more than 50% of the staff of Queensland Health (and that does not include admin staff on the wards).
  • The federal-state funding arrangement in Australia is a real problem.  I don’t know whether the best policy is to put all health care in federal hands or to grant the states more revenue-raising posibilities, but something does need to happen.
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Enquiring minds want to know …

Are obese people more likely to break their bones when they fall over because of their extra weight?

I can imagine that their bones are stronger than healthy-weighted people, but are they sufficiently stronger to make up for the extra pressure in a fall (as opposed to just walking around)?

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Fat = lower wages on average?

Via Steven Levitt, here’s an interesting paper by Roy Wada and Erdal Tekin:  “Body Composition and Wages”

This paper examines the effect of body composition on wages. We develop measures of body composition – body fat (BF) and fat-free mass (FFM) – using data on bioelectrical impedance analysis (BIA) that are available in the National Health and Nutrition Examination Survey III and estimate wage models for respondents in the National Longitudinal Survey of Youth 1979. Our results indicate that increased body fat is unambiguously associated with decreased wages for both males and females. This result is in contrast to the mixed and sometimes inconsistent results from the previous research using body mass index (BMI). We also find new evidence indicating that a higher level of fat-free body mass is consistently associated with increased hourly wages. We present further evidence that these results are not the artifacts of unobserved heterogeneity. Our findings are robust to numerous specification checks and to a large number of alternative BIA prediction equations from which the body composition measures are derived.

Our work addresses an important limitation of the current literature on the economics of obesity. Previous research relied on body weight or BMI for measuring obesity despite the growing agreement in the medical literature that they represent misleading measures of obesity because of their inability to distinguish between body fat and fat-free body mass. Body composition measures used in this paper represent significant improvements over the previously used measures because they allow for the effects of fat and fat free components of body composition to be separately identified. Our work also contributes to the growing literature on the role of non-cognitive characteristics on wage determination.

Looking very briefly through the paper, they don’t seem to be looking at what I would have thought an important factor:  relative obesity.  Wada and Tekin don’t seem to postulate a mechanism for how body fat leads to lower wages on average.  While I’m happy to accept that it may come about because of lower productivity, it also seems reasonable to ask if it’s also partially because of a selection bias by employers.  On that basis, looking at how much fat a person is carrying relative to their community average would seem to be important.

Update:  I’m obviously assuming both causality and direction of causality here, but my comment still holds.  A strong result on my suggested extra regressor would, to me, seem to provide evidence of that causality.

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I swear I’m not a junkie

My wife is American.  This has various benefits for me, but one of the best is the opportunity, at this time of year, to gorge myself stupid.  Last Thursday was Thanksgiving in the U.S., but we decided to have our little shovel-food-down-your-throat-athon on Sunday night with some of my wife’s friends from university.  The turkey was bought on Friday, the giblets removed and discarded (sorry, I just can’t handle them) and we were ready to get started with marinading it.

My wife wanted to follow in her mother’s footsteps by injecting the turkey with red wine.  I’d never heard of this technique before, but a good roast is worth a lot in my book and a turkey is famously difficult to keep moist, so I was keen to try it.  I raided our travel first-aid kit to look for our syringe, but to no avail.  Okay, no worries, it’s off to the chemist we go to get another one.  The coversation, at a Boots, as it happens, went like this:

Us:  Hi.  Do you have any needles?  Syringes?

Them:  Ummm … maybe.  Is it for travelling?

Us:  No.  It’s for a turkey.  We’re going to inject it with wine.

Them:  Ahhh, no.

Us:  Okay, then.  It is for travelling. [Yes, yes, I know.  This wasn’t the most subtle of ploys]

Them:  We’ll need to order them in.  It’ll take two weeks.

Yeah, right.  The implication was pretty clear – hovering in the air, as it were.  They weren’t going to take the slightest risk of selling needles to drug users.  To really slam home the fact that they were looking out for their jobs in a big corporate chain, the conversation finished with:

Us:  Well, do you know where we might be able to find one?

Them:  Perhaps at an independent pharmacy.

… which is exactly what we did.  There’s a wonderful chemist on England’s Lane that just looks Italian (next time you go to Italy, pay attention to the chemists – they’re fantastically unique).  It’s certainly run by an Italian lady and she was fascinated by the idea of injecting wine directly into the meat.  She insisted on my wife spelling out all the recipe details as she promptly sold us a pack of 10 1ml syringes for £2.90.  It was simple, it was easy, it was friendly and it was helpful.  She’ll keep our business from now on.

I got really quite angry from the whole affair.  My wife and I don’t look particularly shabby (I hope).  We were clearly entering the Boots as a couple.  We weren’t shifting around on our feet or trying to speak quietly to avoid undue attention.  None of these seem consistent with how I imagine a drug abuser would present.  It seems perfectly reasonable – to me – to have believed that we were genuine in our request.

But even if we weren’t, I still would have been upset with them.  Yes, the UK operates a needle exchange programme, but any kind of restriction on the sale of needles simply raises their implicit price, which can only encourage drug users to share needles.  If a chain of Chemists can’t be sold on the idea of harm minimisation, we’re in real trouble.

The turkey turned out great, by the way.  We used a Malbec to inject it with, stuffed it with chopped-up apple, prunes and garlic (the bread-based stuffing was being brought by someone else) to sweaten the meat a little, sprinkled quite a lot of rosemary over the skin, roasted it with tin-foil over the top for the first two hours and without the tin-foil for the last hour.  Beautiful.