Putting the system on trial (10 March 2010)

This post requires an elaborate chain of references: Mark Thoma links to Daniel Little's notes on John Rawls's lectures on Marx. Rawls is trying to explain why Marx doesn't condemn capitalism as unjust, but instead struggles to establish that it is just on its own terms. In other words, the way production is organized under capitalism generates its own norms of justice that suit and support it. From the notes:

Let's now try out this suggestion on the conception of surplus value. The utopians argued that workers ought to be paid the value of their contribution to the firm. Since they are not, capitalism is unjust. Marx rejects this view. It makes the appropriation of surplus value appear accidental -- as if the capitalists could act differently. Marx required a theory of value which made the appropriation of surplus value a necessary part of the capitalist system. On the theory of value every commodity is exchanged for a strict equivalent.
Marx distinguishes between the product of labor and labor power. The worker is given the value of his labor power, not his product. It is on this ground that he is fairly treated. Thus he is undercutting the Ricardian socialist position by rejecting and replacing the principle of contribution. It is the system itself which brings about surplus value, not the behavior of individuals who violate moral principles. Surplus value is an intrinsic part of the working of the social institutions of capitalism.

What difference does this make? Part of it has to do with Marxism's pretensions to being "scientific" -- but that argument distracts from what seems to be the more relevant point. One of the more frustrating aspects of a Marxist approach is that the "enemy," it turns out, is not actually the greedy people and corporations, the fat cats and running dogs, et al., but instead a nebulous system by which moral responsibility is dispersed. We find ourselves obliged to, in a sense, love the capitalists, but hate capitalism.

This is especially true now, with the broader conception of a middle class. We are all implicated in the capitalist system because we are able to benefit at times from its coherent vision of justice, from its apparently stable institutions, in spite of the systemic inequities. Rawls's analysis shows how, from Marx's point of view, we all end up getting co-opted -- we become justifiably invested in the particular, local rules of the institutions we are affiliated with, even those these institutions mesh at a larger level into the capitalist totality that perpetuates all the exploitation, the immiseration, the hierarchy building, the alienation.

Justice is a distributive notion. The appeal to justice suggests that we can separate the mode of distribution from the mode of production. This is for Marx incorrect. Appeals to justice are thus supposed to be superficial. Moreover, appeal to justice suggests that important social change can be achieved by legislation.

Hence the ideological gridlock that always seems to afflict the left, perpetually torn between impulses for reform and revolution. It seems much more persuasive to rally people to the revolution by saying society is unjust. But once you do, you simultaneously make the case for ameliorist measures that leave the underlying problems in place.

All that being said, Markos Moulitsas is right: Dennis Kucinich is being a "little prick" about health care reform, killing it for a better proposal that will never come.

The Six-Million-Dollar-Man fantasy (4 Feb 2010)

This Fast Company story about prosthesis envy is possibly even more creepy than the classic of the genre, the Atlantic's "A New Way to Be Mad," about voluntary amputees. It begins as though it will be a story about reducing the stigma attached to artificial limbs and then takes off into voluntary body modification and the fantasy of transcending human limitations by becoming bionic, like the Six Million Dollar Man. I have nothing against amputees doing whatever they want to improve their lives, but I admit, and this may be wrong of me, that I find the idea of amputating additional parts of one's body for aesthetic reasons disturbing.

Amputees are now regularly removing healthy tissue to make room for more powerful technology. "I see it every day," he says. "People will get a second amputation -- move their amputation up their leg -- to get the prosthetic equivalent of a hotter car."
Orthopedic surgeons often consider amputation the equivalent of failure, Young says, and reflexively save as much of a damaged, injured, or diseased limb as possible. But in leaving lots of human being, they create a bigger problem: There is little room left for high-performance machinery. Now, the allure of that machinery has become so powerful that amputees are routinely taking the extreme step of paying out-of-pocket for what the industry calls "revisions.".... Herr's suggestion, of course, is that the better prostheses make us perform, and the more glamorous they look, the more beautiful they will make amputees seem, too, even though their sheen, contour, texture, and color have ceased to look human.
"What is the obsession with looking human?" he says. "You think the only beauty is human? Bridges can be beautiful. Cars can be beautiful. Cell phones can be beautiful. They don't look biological. So why do you anticipate 30 years from now that amputees will give a shit about human beauty? They won't. Their limbs will be sculptures."

Herr -- an prosthetics engineer -- is right. I wish Apple would stop designing gadgets and start designing elegant human-body-replacement canisters so I could do away with this hideous flesh husk. I have always aspired to be as beautiful as a phone.

Health-insurance profits (2 Sept 2009)

Tyler Cowen does some cursory research and suggests that health insurers may not be all that profitable. Thus, the implication seems to be, they must not be the villain that would-be reformers sometimes make them out to be. But their profitability is not the crux of the problem; profits may be held down by the effectiveness of competition from other insurers. And it is this competition that then prompts their most egregious practices, such as rescission. It's not the level of their profits, it's the fact that are a for-profit concern that rubs reformers who want a public option, I suspect.

Reputation and rescission (5 Aug 2009)

Economist Bryan Caplan, a health-care reform skeptic, argued that health insurers' concern for their reputation would prevent them from abusive practices like rescission, when coverage is revoked once patents need expensive care. Insurers are so concerned about reputation, he argues, that German insurers defied the Nazis and demanded the right to pay damages to Jews after Kristellnacht. Paul Krugman's skepticism about the almighty power of reputation prompted Caplan to wish for a chart that would expose companies' rescission rates (funny that didn't turn up so easily) and later to elaborate on the wonderful powers of reputation in a competitive free market.

When we wanted a new house built, we gave 10% of the purchase price to the builder upfront. The builder gave us a contract almost devoid of legal remedies - practically everything was at the builder's "sole and absolute discretion." A few months later, we moved into our house. 99% of the details were exactly right, and they fixed the rest for free. Why would the builder treat us so well? Altruism? Ha. Legal remedies? Ha. Even repeat business is a stretch. What are the odds we'll ever ask them to build a second house for us? The only answer that makes sense is reputation.

Caplan sneers at altruism, but is altruism so different from the professionalism we expect from doctors when we assume they are not keeping us sick to bleed more money out of us in office visits and so on? Altruism, human decency, professional dignity all matter in many of our exchanges, even though it is hard to find a place for them in a formula-driven rationalistic economic analysis of how capitalism functions. In fact (as the film The Corporation depicts) the firm may function to disperse that altruism and mitigate motives other than profit. Responsibility is spread throughout the corporation so no one has to feel particularly guilty about its cutthroat doings -- as when sick patients have their coverage yanked from underneath them. Individuals within the firm can focus on their responsibilities to the hierarchy rather than to customers or society without feeling like unreasonable monsters. (Proprietors of small businesses have to face more of the brunt of the moral consequences of their practices, which makes it harder for them to fend of behemoths like Wal-Mart.) Damage to a brand's reputation can be combated by the same forces that might publicize it, and a corporation is usually going to have more resources for this than those it has wronged.

Arnold Kling, Caplan's co-blogger at EconLog, raises another problem with the reputation idea as it pertains to health care. "Reputation matters when exit matters. That is, if people will switch suppliers based on word of mouth, then reputation will be important." But under the current system we don't do that. And most people don't have a problem with their insurers until they need to actually use the coverage, at which point it will be too late to switch.

UPDATE: Tyler Cowen makes another good point.

Reputation affects market practices, but possibly reputation is part of the problem. It's relative reputation which matters. The operative reputational incentive is not always: provide a better product to get more customers. Sometimes the reputational incentive is: customers tolerate bad treatment, because established reputations suggest they will receive equally bad treatment elsewhere.

This seems to imply the cycle of relative reputation can push all competitors downward.

The intractable health-care market (29 July 2009)

I haven't written much about the health-care-reform debate because it tends to make me irrationally angry. I'm about to lose my health coverage, and it gives me the general feeling that the society in which I live doesn't really care if I die a preventable death, and that seems like a sucky society to live in. The current American system seems to enshrine the worst aspects of this country's prevailing ideology -- that we regard the idea of collective well-being as a empty notion, and that it's okay for people to suffer as long as the "free market" says it must be so. Right now, professional standards among doctors -- basically their pride in their profession -- is all that stands between sick people and their remorseless exploitation, and as economist Kenneth Arrow notes in this interview at The Atlantic's site, they are "eroding."

Some doctors understand that they shouldn't abuse the system. But you still see problems in the way doctors behave towards patients. They goof off. Sometimes it's too much work. Some things are difficult and risky to diagnose.

No system will ever remove the inevitability of human error and individual immorality, but certainly we can arrange for a system in which these undesirable behaviors aren't encouraged. Arrow suggests that the free-floating free-market ideology churned out of the University of Chicago economics department is partly responsible for the current cultural climate, in which profit is seen as the only ethics:

I think there has been a general drift around the country towards the idea that greed is good. Look at Wall Street. All of these industries involve a professional element in which information is flowing. You're supposed to be constrained to be honest about it. I don't really know why. But there is now more of an emphasis on popularization, which does improve efficiency but can also lead to an erosion of professional standards. There was this idea that professional standards were a mask for monopoly power--a Chicago theory, which I believe came from George Stigler. I don't know if they were that influential, but they seemed to be saying a lot of things that people were taking up in practice. I'm not totally sure why these professional standards changed, but it's more than medical reasons.

Rather than having patients pay for the treatment and resolution of an illness, the American system instead nickels and dimes customers with a bewildering variety of charges for tests, consultations, transportation of samples, X-rays, test analyses, and so on. Having your blood tested for a vitamin deficiency can result in six or seven different bills from a variety of medical-service providers. Insurers are supposed to manage this process so that it doesn't trouble or confuse the patient, who has his or her health to worry about. But instead this patchwork system has become a chaotic blizzard of invoices that incentivizes doctors to overprescribe and insurance companies to try to deny payment and care. Both are given economic reasons to keep patients ignorant, even as some like Ronald Bailey in this Reason article, argue that customers (i.e. sick people) must be forced to contain health-care costs, implying that it is their fault that spending has gotten out of hand. In the face of all the confusing billing, customers have failed to be "cost conscious" about health care. But it is impossible to know without an absurd amount of investigation and scrutiny what one is even being charged for in the health-care realm; that we would perform price comparisons and veto procedures and tests before the fact over our doctor's suggestions is a totally unreasonable notion. The insurance market is also notorious for its confusing contracts and for its misleading paperwork, and for denying coverage customers had been led to expect. That's known as rescission and is just about the worst thing in the medical business. Which is why it shouldn't be a business. Arrow argues that things like nonprofit hospitals and the eschewing of medical advertising signal the medical community's commitment to professional standards and its collective effort to correct the inherent market failures, whereas the recent "emphasis on markets and self-aggrandizement in the context of healthcare" undermines those standards and sends the opposite signals. As a result, patients like me get super-paranoid and even less rational in our medical decision-making, worsening the failures that libertarians and liberals alike complain about. Bailey thinks government intervention and regulation has helped cause this problem and only consumers can fix it by being better watchdogs over what they pay for; he alleges that "competition would provide a strong impetus for medical practitioners to provide consumers with good information about the effectiveness of various treatments and drive innovation." Most liberal analysts believe that patients will always be at an informational disadvantage (not least because being sick renders one vulnerable and incapable of rationally sorting through billing details) and only government intervention can help fix it.

At his NYT blog, Paul Krugman summed up the essential problems facing market-driven health care (and why the American system so badly needs reforming), drawing on this classic paper (pdf) by Arrow. Krugman's post is worth reading in its entirety, but the gist is this: For-profit insurers "try to deny as many claims as possible, and ... avoid covering people who are actually likely to need care. Both of these strategies use a lot of resources, which is why private insurance has much higher administrative costs than single-payer systems. And since there’s a widespread sense that our fellow citizens should get the care we need -- not everyone agrees, but most do -- this means that private insurance basically spends a lot of money on socially destructive activities." Achieving cost-effective treatment can't be entrusted to for-profit entities, because they will always put profit ahead of your health, defeating the ultimate purpose of medical care in a society. The state has a better chance of organizing workable health-insurance pools without concentrating energy on innovating new ways to deny care to maximize profit.

This is the point at which conservatives complain of rationing -- the government is going to decide who gets what care. This is meant to distract us from the de facto as rationing already in place through unaffordable prices. The current arrangement suggests that we as a society believe the poor should just go get sick and die. Reform efforts are aimed at present a different face of our society, one currently suppressed, in which we collectively face the mortality risk we all share, the thread that unites us all, no matter what other circumstance we may have been born into.

Health insurance and personal responsibility (20 June 2009)

Conor Friedersdorf -- currently blogging for the Atlantic's ideas blog -- made an interesting point about this WSJ op-ed about grocery chain Safeway's health-care plan. In the op-ed, Safeway's CEO touted how his company's health-careplan emphasized personal responsibility as a means to control costs:

Safeway's plan capitalizes on two key insights gained in 2005. The first is that 70% of all health-care costs are the direct result of behavior. The second insight, which is well understood by the providers of health care, is that 74% of all costs are confined to four chronic conditions (cardiovascular disease, cancer, diabetes and obesity). Furthermore, 80% of cardiovascular disease and diabetes is preventable, 60% of cancers are preventable, and more than 90% of obesity is preventable.
As much as we would like to take credit for being a health-care innovator, Safeway has done nothing more than borrow from the well-tested automobile insurance model. For decades, driving behavior has been correlated with accident risk and has therefore translated into premium differences among drivers. Stated somewhat differently, the auto-insurance industry has long recognized the role of personal responsibility. As a result, bad behaviors (like speeding, tickets for failure to follow the rules of the road, and frequency of accidents) are considered when establishing insurance premiums. Bad driver premiums are not subsidized by the good driver premiums.

This seems like an expression of a classic conservative position: In the last analysis, individuals can shape their living conditions in a meaningful way and consequently can be held responsible for their own suffering. Charging high-risk people ("fair risk pricing") more for their insurance seems to make good common sense; they should have their insurance coverage supply a sort of moral hazard. Probably no one says to themselves, "Fuck quitting smoking. If I get lung cancer, my insurance will pay for it," but they may not take the sort of precautions to prevent illness because nothing in the structure of their lives provides a incentive counterbalance to the immediate pleasures (such as they are) of smoking, drinking, eating poorly, getting a tattoo, etc. (It's worth noting that currently, in some private plans, certain sorts of preventive care are regarded as elective care and thus are not always covered.) It seems obvious to build an insurance system that rewards healthy behavior in patients and penalizes known unhealthy behaviors.

Friedersdorf says as much, but also points out the downfall of such a plan -- where do you draw the line on what sort of behaviors insurance companies should be permitted to police? Isn't monitoring for "unhealthy" behavior a wedge for introducing Minority Report-style total surveillance? With a note of libertarian alarm, Friedersdorf writes, "Smoking today. Alcohol, downhill skiing, and premarital sex tomorrow? Pricing unhealthy habits means testing for them in ways intrusive enough to reliably detect them. What are your vices? Do you want your employer or your government determining which vices cost you money?" Or do you even want that data, for that matter, cataloged somewhere, becoming an albatross around you worse than a credit report? Instead of prison-inspired panopticism, perhaps the Foucaldian nightmare that awaits us is a medicalized one, along the lines of The Birth of the Clinic. The state derives new power and leverage from its control of the social definition of health.

Of all the arguments against nationalized health-care, this seems to me the strongest: that once taxpayers are footing the bill for the avoidable health risks other citizens take on, it's only a matter of time those taxpayers demand further regulation of those risk-taking individuals' behavior. And whether or not something constitutes a health risk is open to a lot of interpretation (think of the nebulous studies that lead science writers to proclaim the health risks or benefits of caffeine, red wine, etc., etc.) -- it could become a site of ideological struggle, with healthfulness being used as a pretense to prescribe certain standard, predictable ways of life. After all, insurers' main concern is risk that can't be anticipated and controlled. The social pressure toward conformity could become even stronger than it already is now. It's a wonder old-school conservatives -- who want nothing more than to prescribe a "traditional" lifestyle -- aren't more in favor of state-supplied health care.

Perhaps the future of health care will involve private insurers undercutting the cost of the state-offered plan, and a mandate that all individuals be covered. (That's part of what makes the auto-insurance market work.) If you want to pay extra for privacy, you can opt for the national plan. If you are comfortable having your health data monitored to save a few dollars, a private insurer could offer that.

Medical waste (18 June 2009)

The Obama administration, thankfully, is making a serious push to reform the absurdly inefficient U.S. health care system, which is currently and pointlessly tied to employment status. And private insurers have every incentive not to insure individuals who may perhaps have the effrontery to become sick in the future, leaving those who get laid off doubly screwed over. In America, private nsurance appears like a racket whereby the companies collect premiums and then seek to deny coverage when the opportunity arises. If you don't already hate health insurers, read these posts about recission and see what you think. Recission is when insurance companies respond to a customer needing health-care services by trumping up some error they made in filing paperwork as fraud, which then justifies the insurers in denying claims and dropping their coverage. And when questioned about the practice in Congress, the CEOs of several health insurers refused to consent to limiting the practice to, in the Los Angeles Times's words, "only policyholders who intentionally lie or commit fraud to obtain coverage."

As any sane person would point out in response to this, the U.S. needs a public option -- an insurance plan offered by the state that doesn't seek to profit at the expense of the sick, one that is reasonably affordable and doesn't rule people out entirely based on the risk they represent. Of course, in order for such a program not to explode the budget, health care costs would need to be brought under control. On that point, Atul Gawande's recent article in the New Yorker about wasteful Medicare spending in McAllen, Texas, offers a lot to consider. It turns out that doctors' overprescription of expensive tests leads to worse outcomes for patients.

. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.
To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.

Gawande shows how hospitals and physicians, caught up in a for-profit medical world, have metrics that show them only whether they are making money, not whether their practices are making their community any healthier.

Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How is Lawrence Gelman or Gilda Romero to know whether all that is essential, let alone the best possible treatment for the patient? It isn’t what they are responsible or accountable for.

This dynamic, along with a prevalent ideology that holds that what markets provide for is best, leads some doctors to conclude that maximizing profits is in some way guaranteeing that the appropriate amount of health care being administered. To do anything else would be socialistic "rationing."

David Leonhardt, writing in the New York Times, punctures that conservative talking point: "The noise about rationing is not really a courageous stand against less medical care. It’s a utopian stand against better medical care." He notes that we are always already rationing (nobody gets their medical care without sacrificing something, even if it's only a couple bucks), only we don't call it that when richer people reap its benefits.

The high cost of care means that some employers can’t afford to offer health insurance and still pay a competitive wage. Those high costs mean that individuals can’t buy insurance on their own.
The uninsured still receive some health care, obviously. But they get less care, and worse care, than they need. The Institute of Medicine has estimated that 18,000 people died in 2000 because they lacked insurance. By 2006, the number had risen to 22,000, according to the Urban Institute.
The final form of rationing is ... the failure to provide certain types of care, even to people with health insurance. Doctors are generally not paid to do the blocking and tackling of medicine: collaboration, probing conversations with patients, small steps that avoid medical errors. Many doctors still do such things, out of professional pride. But the full medical system doesn’t do nearly enough.

Professional pride is a thin thread from which to hang the health of a country, particularly one as enamored with "rational self-interest" as the U.S. is. And the AMA -- which boos Obama and decries the public option because it might deprive them of the opportunity of bilking insurance companies -- does not give me much faith in the "professional pride" of doctors, though as one doctor notes here, the AMA is losing membership quickly. (It not represents less than a quarter of practicing physicians.) Clearly, the legal and social framework should be changed to align incentives with that professional pride, to make it easy for doctors to do the right things, help patients and overall healthfulness, rather than make it easy for them to rationalize doing the wrong thing and buy an extra Lexus or two. Gawande recommends that communities adopt a Mayo Clinic model in which doctors are paid a salary, rather than charging per visit and procedure, and work together to determine the course of a particular patient's care, serving as a check on one another for unnecessary tests and such. I suspect the AMA does not concur.

Rebranding disease (11 Dec 2008)

At the Mind Hacks blog, Vaughan Bell links to a study whose name is self-explanatory: "The Role of Medical Language in Changing Public Perceptions of Illness." Medical language, it seems, is deployed to make humdrum conditions more exploitable in the market. Conditions like baldness can be rebranded with medical jargon that has the effect of making the condition seem more acute, more unhealthful. We take diseases more seriously if they sound complicated and Latinish. Patent-medicine hawkers and nostrum makers have of course taken advantage of this for years—using obfuscation and crypto-erudition to cause alarm and insecurity—so it's no surprise to see the efficacy of the tactics confirmed in research. And of course, one of the triumphs of modern advertising was the invention of "halitosis" -- the semantic means of medicalizing bad breath.

Capitalism thrives by fostering new needs; luckily, new worries also qualify. In 1936, Printer's Ink, an advertising trade journal, began to keep a list of diseases invented through marketing. It makes good business sense to hit people where they are most vulnerable and potentially most ignorant. Jargonizing health discourse has the neat effect of seeming to educate consumers while actually confusing them and making them more manipulable. (Perhaps all jargon serves this function.) It's subtraction through addition.

Bell sums up the larger ramifications of the research well:

Pharmaceutical companies often promote the benefits of their product, but they also regularly attempt to change our understanding of the problem itself, so the use of their medication seems the most sensible option.
However, there are many other players in the public discussion of illness and certain ideas about causes, symptoms and treatments are often pushed by people because it fits in with other agendas they have.
This is particularly relevant for scientific theories and it is no accident that many of the most significant public medical debates in recent years have been over the acceptance of certain explanations - such as the role of the MMR vaccine in autism, the role of neurotransmitters in mental illness, the role of genetics in obesity.
There is no explanation of illness independent of culture and an understanding of how popular ideas influence our personal medical beliefs is an essential part of understanding medicine itself.

In an article from Stay Free, Carrie McLaren drew the requisite conclusions about the commercial persuasion industry's effect on that "culture" and those "popular ideas."

when it comes to advertising, the more symptoms–and the more noticeable, painful, and embarrasing the symptoms–the better, because the easier it is to sell to consumers; that is, the more likely the illness will be self-diagnosed. And drugs for self-diagnosed ills–allergies, weight-reduction rather than cholesterol or blood pressure–are those seeing the greatest boost from commercials. Eskimos may have 14 words for snow, but we’ve now got just as many for allergy symptoms. In the same way that the availability of a drug such as Prozac can define an illness, televisibility now figures in.... It is, in other words, eerily fitting for drugs to be sold as consumer products, for products–whether cookies, diet drinks, or cigarettes–have long been sold as drugs, as magical cures.... Consuming, in other words, is our placebo.

This is what makes consumerism so tenacious -- it makes us feel better without fulfilling any of its promises. It's essentially a means for circulating promises; the products themselves are, in a sense, by-products -- just props for the healing daydreams.

"Nocebos" and WebMD disease (26 Nov 2008)

One of my hypotheses is that consumer behavior is anchored in the placebo effect, and advertising serves the vital function of supplying the mind with material to work with, just enough to make belief plausible enough to achieve desirable effects. We just have to grant ads the authority we give to actual experts, like doctors. It seems as though we do this readily, without much profound consideration of what should constitute actual expertise. (I'm supposed to buy a certain kind of tea because Dodgers manager Joe Torre drinks it.) We are basically culpable in our being seduced by ads; we're not somehow tricked into belief against our will. It's beneficial to believe, because it promises us placebo magic. Skepticism can turn out to be a costly failure of imagination, especially when we just need to imagine we can feel better to actually achieve it.

Consumerism supplies imaginary solutions to problems that marketing has convinced us to reconceptualize as purchasing decisions. Making the choice to buy masks whatever underlying problem spurred the "retail therapy" in the first place. Whether or not the good has any actual demonstrable effect on anything -- whether or not we even use it -- is beside the point. An example: I downloaded a bunch of Genesis albums the other day, but I can assure you that I will never listen to most of them. But there was still something satisfying about filling a hole in my music collection, even if that hole wasn't actually a problem. It wasn't like I was suffering for want of hearing Trespass. But acquiring things is a simple way of making myself feel like I have taken some sort of action. Marketing, I guess, functions by making sure I am always aware of that sweet simplicity.

Anyway, I've seen a few articles lately that explore the dark side of the placebo effect, where the benefits of belief turn into liabilities. Last week, the WSJ reported on "nocebos":

Research has shown that expecting to feel ill can bring illness on in some instances, particularly when stress is involved. The technical term is the "nocebo effect," and it's placebo's evil twin. "It's not a psychiatric disorder -- it's the way the mind works," says Arthur Barsky, director of Psychiatric Research at Brigham and Women's Hospital in Boston.
Nocebos can even be fatal. In one classic example, women in the multi-decade Framingham Heart study who thought they were at risk for heart attacks were 3.7 times as likely to die of coronary conditions as women who didn't have such fears -- regardless of whether they smoked or had other risk factors.
Research deliberately causing nocebos has been limited (after all, it's kind of cruel). But in one 1960s test, when hospital patients were given sugar water and told it would make them vomit, 80% of them did.

This is a scary look at what the socially distributed notion of authority can accomplish. Even internal movements of our consciousness, which seem to be generated from within, are apparently easily shaped, once we commit ourselves to participation and belief. Back up would-be authority figures with institutional heft, and they can basically create your reality, down to the level of nausea you feel.

Doctors may unwittingly foster placebo or nocebo effects by how enthusiastically or warily they discuss medication. "Physician communication with patients is the closest thing to magic. It gets communicated in incredibly subtle ways—a flash in the eye, a smile, a spring in the step," says Daniel Moerman, an emeritus professor of anthropology at the University of Michigan-Dearborn.

The authority figure -- the social relation -- is what counts. Often, apparently, the medicine is just the trace of that.

I'm tempted to get sidetracked into a consideration of whether such induced feelings are "authentic" or not, though I suppose death is about as authentic an effect as can be achieved. But it's probably irrelevant to the degree that all "symptoms" are in some way "induced" by something. If we attempt to ignore or downplay the "induced" aspects of consciousness, what would be left to be real? The article makes clear how when you ask someone for symptoms, they generally will supply them.

"People's expectations play a very important role in how they react to all medications," says Richard Kradin, a physician and psychoanalyst at Massachusetts General Hospital in Boston, and author of "The Placebo Response and the Power of Unconscious Healing." He notes that about 25% of patients who get completely inert placebos in clinical trials complain of side effects -- typically headaches, drowsiness and dizziness.

If the stage is set for us to be self-aware in that way, our minds will make something happen. This has led me to be against biofeedback. The more I know about what is happening with my body, the more I think is wrong with me and the worse I feel. Is there a way to have no expectations at all? Is there a way to achieve total health ignorance? Would preventive care prevent me from feeling good?

The NYT followed with this article on research Microsoft carried out that suggests, to the surprise of absolutely no one, "that self-diagnosis by search engine frequently leads Web searchers to conclude the worst about what ails them."

Such findings evoke the debate about whether the internet can create and propagate new mental illnesses by making the very concepts behind them more prevalent and accessible. (This Atlantic story, which I am always looking for excuses to link to, explores that question.)

Condition branding (or manufacturing depression) (19 Nov 2007)

In the New York Review of Books, Frederick Crews (the Hawthorne scholar?) looks at three books that argue that depression has been fomented by the pharmaceutical industry, which stands to benefit directly from any increase in depression diagnoses. If you have ever seen the film Johnny Mnemonic -- if any of those 12 people are reading -- this will sound familiar:

Most of us naively regard mental disturbances, like physical ones, as timeless realities that our doctors address according to up-to-date research, employing medicines whose appropriateness and safety have been tested and approved by a benignly vigilant government. Here, however, we catch a glimpse of a different world in which convictions, perceived needs, and choices regarding health care are manufactured along with the products that will match them.
The corporate giants popularly known as Big Pharma spend annually, worldwide, some $25 billion on marketing, and they employ more Washington lobbyists than there are legislators. Their power, in relation to all of the forces that might oppose their will, is so disproportionately huge that they can dictate how they are to be (lightly) regulated, shape much of the medical research agenda, spin the findings in their favor, conceal incriminating data, co-opt their potential critics, and insidiously colonize both our doctors' minds and our own.

In Johnny Mnemonic, Keanu Reeves had to rescue the world from some pharmaceutically manufactured chronic disease that would make the world entirely dependent on an evil drug company's ministrations. (I think it also involved the perilous downloading of information into Keanu's overloaded brain.) The filmmakers probably didn't have SSRIs in mind then, but the analogy would have been apt: Citing one of the books, Crews notes the SSRIs "horrific withdrawal symptoms, such as dizziness, anxiety, nightmares, nausea, and constant agitation, that were frightening some users out of ever terminating their regimen—an especially bitter outcome in view of the manufacturers' promise of enhancing self-sufficiency and peace of mind. The key proclaimed advantage of the new serotonin drugs over the early tranquilizers, freedom from dependency, was simply false."

That loss of individual autonomy in the face of marketing campaigns and the slipperiness of diagnosing mental illness on the basis of a movable feast of symptoms is the part of premise of the books Crews looks at: Big Pharma uses advertising to transform what may once have been considered character traits into pathologies that one should treat with medication, promoting the sense that individual idiosyncrasy is a kind of disability that needs to be corrected, so we can all conform to the same master personality, the sort of synthetic pseudo-humans we see impersonated on television, people who are always happy, never hostile or self-sabotaging, never wracked by doubt, never anything but eager to cooperate and behave how society expects. Turning idiosyncrasies into mental health problems is known as "condition branding" -- the industry treats the name of a disease as a brand and promulgates it with the same marketing techniques that a company would use for toothpaste or laundry detergent, a process that has brought us social anxiety and restless legs syndrome and, these books argue, the depression epidemic.

Such a thesis is certain to offend lots of people who are debilitated by depression and may potentially see this line of argument as an attack on their right to feel better. For them, Crews has this rejoinder:

This isn't to say that people who experience infrequent minor depression without long-term dysfunction aren't sick enough to deserve treatment. Of course they are. But as all three of the books under consideration here attest, the pharmaceutical companies haven't so much answered a need as turbocharged it. And because self-reporting is the only means by which nonpsychotic mental ailments come to notice, a wave of induced panic may wildly inflate the epidemiological numbers, which will then drive the funding of public health campaigns to combat the chosen affliction.

The books are not simply denying the severity of a particular illness; instead they offer a subtler attack on individual autonomy, implying that people can be talked into feeling sick by advertising and other devious promotional campaigns. The premise of these books would seem to imply that people don't really know what to make of what they are feeling, and it's our inclination to turn to social norms for guidance. In our commercial, consumerist society, of course, those norms are bought and sold, and they hinge on solutions that permit for shopping and consuming objects with magic-seeming properties of transformation -- like, say, Prozac. Crews calls such drugs political sedatives, since any relief they seem to provide also serves to dissuade us from wondering whether commercial imperatives dictated their prescription.

But, as Crews explains, this is an old story, and it goes back to the imperatives that underlie the whole ediface of a consumer society, which hinges on an building an insecure populace that can be counted on to seek comfort in goods. Advertising is the art of creating dissatisfaction, and preying on personal vulnerabilities is an especially efficient way of accomplishing that end. The process is perhaps at its most extreme when the goods being advertised as medicines, and the dissatisfaction is elevated to the level of a disease that one ignores only at one's personal peril. The tendency of marketing to drift toward this maximalist approach is one reason sensible countries ban pharmaceutical advertising directed at consumers rather than theoretically disinterested medical professionals.

The American Health Care Money-go-round (15 April 2007)

Ezra Klein linked to the chart below, a graphic representation of the money flow through the American health-care system. As his commenters point out, this is a streamlined portrait, and the reality is actually much more complicated.

This makes it clear how many entrenched parties would need to be "disintermediated" before any progress could be made toward a simplified system, which would not only save American tax dollars but would remove the disincentive from seeking medical care that's created by the complexity and confusion. Of course, the confusion may be a feature rather than a bug, meant to accomplish precisely that (just as voting registration is sometimes made more complex to keep the wrong sort of people from voting). It heaps shame on those who need medical attention but can't afford it, as if being sick in the first place wasn't already troubling enough. Instead we built into the health-care system assumptions that (a) health insurance is necessary to use as bait to keep people productive and working institutionalized sorts of jobs (ie insurance is a management tool, not a social service) and (b) people must be assumed to be abusing the health-care system (for who knows what perverse reason) and should be treated with suspicion.

Perhaps the burdensome health-care system is just a reflection at the institutional level of the fundamental conflict that haunts health-care provision -- a patient comes in with a selfish investment in the unique severity and significance of his symptoms, and the system must gently remind him that there are scads of people who are just as sick, and there is nothing special about his mortality. Does the American system mystify that conflict and lessen its sting? Would a more transparent payment system, organized more clearly for society's benefit, remind us all too much just how minute we and our medical problems are when compared with society as a whole?

Health care in America (2 Feb 2007)

Though the Bush plan for health-care reform (an attempt to shift the tax subsidy for health insurance from employers to individuals) was pronounced dead on arrival, it did prompt some lucid analysis of the many problems with the American system, which is largely the product of an accident. Post WWII wage controls encouraged the end-around provision of benefits to lure workers. Health benefits became a standard part of the package and have remained so, even though it makes little sense and discourages people from self-employment or quitting bad jobs. In my 20s, I was told countless times that I needed to get a "real job": This was not a job that made me feel fulfilled or socially useful; this was a job that gave me health benefits. And the lack of benefits is the bane of the freelance existence -- it becomes prohibitively expensive to insure yourself, especially if you have even the slightest whiff of a preexisting condition. When you don't want a corporate job, or work nine to five (what Jim Kirkland would call the dork schedule or the family nerd hours) this inconvenient arrangement can seem conspiratorial -- that you are being forced to sell out and play the bourgeois game if you want any kind of assurance that you won't be bankrupted by medical bills. But in truth, corporations would probably like nothing more than to get out of the insurance business, which saddles them with overhead costs and phalanxes of HR staff that might then become superfluous.

So there is some agreement across the political spectrum that employment and health insurance shouldn't be associated. But liberals and conservatives have radically different solutions, as economist Paul Krugman explains well here. Conservatives think the main problem in American health care is economic inefficiency -- no one has any incentive to be careful about what they spend on medical care. The sick, because they are spending the insurance company's money, don't comparison shop and look for bargain treatments; neither patients nor doctors have any incentive to pinch pennies. If the sick had to spend their own money, the theory goes, they'd think twice about having unnecessary tests administered and prescriptions filled. Thus conservatives want people to pay for their own health care, seeing it primarily as a private rather than social issue. Hence they envision a system where people buy their own insurance with their own money and deduct it from their taxes. People would have stripped-down insurance to cover catastrophic scenarios and would pay for the rest with tax-free dollars from an HSA. Having less insurance (forcing people to surrender their overgenerous "gold-plated" health plans) would make health-care "customers" more careful about what they pay for and encourage them to research into how to make the most of what they spend.

Underlying the conservative view is a philosophical position that essentially rejects the idea that society has a collective responsibility for tending to the health of all of its members. Instead, health is a personal matter, your own business. If fate deals you a nasty cancer, this line of thinking implies, that isn't the rest of society's fault, and no one should force your neighbor into helping you pay the costs of your misfortune. It's every person for herself. You can see this perspective throughout Becker and Posner's analysis of Bush's plan. Becker writes

Aside from humanitarian concerns about the wellbeing of others, why should it matter to the rest of us if individuals and families, many of who are young and healthy, do not have health insurance? The main reason usually given is that since all persons must be accepted for treatment by hospital emergency rooms, regardless of whether they have insurance, taxpayers and other hospital patients who do have insurance bear the cost of treating persons without insurance. Due to this "externality", persons without health insurance impose costs on others whenever they use emergency health care facilities.

Becker imagines the only reason we'd give a damn about a stranger's illness is because we don't want it raising costs on our own care. Maybe this is so in the aggregate, when you reach a suitable level of economic abstraction and the utility function seems to explain all. But at a less lofty level, the institutionalized callousness to the sufferings of others would probably be intolerably chilling. The problem of the uninsured doesn't seem to be an abuse of emergency facilities; it's more likely the psychic burden of insecurity weighting down an ever-increasing portion of American society.

Becker concludes somewhat grudgingly that there should ultimately be a subsidy for individuals to get insurance, but Posner can't see any reason society should provide that:

if there were no tax subsidy for health insurance, probably much less would be purchased, which would be fine. People might even be healthier, because diet and other life-style choices are substitutes for medical care and thus for health insurance.
The fact that millions of people have no health insurance does not strike me as a social problem. It is true that they are free riders, but so to a considerable degree are the insured, since their premiums don't vary much or at all with how much health care they obtain. As Becker points out, the quality and conditions of charity medical treatment (such as long queues in emergency rooms) discourage overuse of "free" medical care--it isn't really free, because the nonpecuniary costs are substantial; among those costs are the fear and discomfort associated with medical treatment.

This is classic moral hazard argument -- health insurance gives people an excuse not to take better care of themselves, overcoming the incentive provided by how frightening and uncomfortable seeking medical care can be. (You half expect Posner to suggest hospital visits be made even more unpleasant to provide more incentive for healthful behavior.) He's willing to grant that "most people do not court illness in order to be able to consume subsidized medical care, or demand more medical care than is necessary to treat their illnesses" but still wants to argue that "Whether money is spent by the sick or by the taxpayer is more than a detail, in part because withdrawal of subsidy might induce people to adopt a healthier style of living." But what prevents people from living more healthily isn't the promise of a tax refund or a free trip to the doctor's -- it's more that they lack the routine preventive care that educates them about healthy lifestyles and then lack the financial means to live them. Barbara Ehrenreich's Nickeled and Dimed illustrates how the complications and constraints of poverty -- insecurity, mainly -- induce stress and unhealthy choices. Tyler Cowen has a concise refutation of this view as well: "Our tolerance for anxiety is sufficiently low that I expect the future to bring more and more insurance of many kinds, whether from the private sector or from government. The cost of this insurance, in terms of induced inefficiencies, will be high, but a secure health care situation is one of the things in life that alone can make a difference between happiness and misery." For Posner, though, health is almost a matter of choice: "If people want to spend more of their money on medical care and less on food or housing because they greatly value good health and longevity, that is their free, legitimate, and authentic choice." No one, then, should be forced to be healthy by being remanded to buy insurance, and people who get sick obviously failed to choose to value health over food and shelter.

Posner does address what seems to me the key issue in health care debates: adverse selection. Insurance companies won't cover people who are likely to get sick, and only currently do so because they are lumped in with healthy, employable folks in pools generated by company payrolls. Adverse selection is the main reason liberals, who do regard health as a social problem, will argue for universal, government-supplied programs; everyone is covered, and the risks presented by those unfortunate sickly people are borne collectively by all of us. (But what about those sick people who aren't unfortunate but are instead engaging in risky behavior?) One way of accomplishing this would be to slowly and steadily extend Medicare benefits to more and more people -- an incremental solution along the lines of what Matt Yglesias proposes here and Guy Saperstein proposes in this Alternet essay. Posner argues precisely the opposite, that Medicare ideally would be abolished.

The best, though politically unattainable, reform would be to abolish Medicare, brutal as the suggestion sounds. Then people would purchase catastrophic or other medical insurance for their old age, or depend like the young on charity. If it were thought "unfair" to make elderly people of limited means pay for their entire costs of health care, there could be a subsidy, but it should be means-tested, unlike Medicare. Why taxpayers should pay the medical expenses of affluent oldsters, of whom there are a great number, is an abiding mystery, at least from an ethical as distinct from a political standpoint.

The default assumption is that people who need assistance are somehow freeloaders bilking the system and cheating other people -- eventually the existence of poor people will be acknowledged, but only grudgingly, after the terms of the debate are set to marginalize them or at least cast suspicion on anyone who uses government services. (If these damned poor people were so worried about being healthy, why weren't they working harder to get the money necessary to sustain their health?)

Rather than poor consumer incentives, Krugman suggests that the health-care problem is ultimately one of the difficulty of rationing health care fairly: "Rather than admit that private-sector institutions aren't any good at rationing, conservatives now say that patients should be induced to ration their own care by being forced to pay more out of pocket. And that's where Bush's attack on gold-plating comes from: reduce the tax advantage of employer-based care, and deductibles and co-pays might go up. The trouble is that the big money is in stuff like heart operations - areas where (a) people can't pay out of pocket in any case - they must have insurance or go untreated - and (b) people really aren't sufficiently well-informed to make the decisions." So the question is ultimately a matter of whether expensive health problems and serious illnesses should be covered for everyone or just those who can afford to pay for care themselves (or were lucky enough to get coverage before becoming afflicted). The conservative view seems to be that money is the best way to decide who gets treated and when. (Basic economics -- using price, supply and demand to distribute scarce resources.) If you can afford more health care, you get more of it. If you can't, well, you should have thought of that before you wasted what resources you had on food and housing.

There must be alternatives to that, wherein public health is seen as a public good (as is medical innovation, pharmaceutical R&D etc., which those against government-sponsored care argue will be jeopardized when the profit motive is removed from the health care industry). Not sure how the rationing problem is solved, though.

UPDATE: The folks at Marginal Revolution offer a correction for the misuse of adverse selection, in its strict definition (of which I am guilty). Cowen's post, however, reaches what appears to be a similar conclusion, that how health care should be rationed ends up being an ethical question rather than one of strict economic efficiency.

Fat taxes (18 October 2006)

Everybody's getting in on banning trans fats: New York City, Chicago, Disney, Pepsi, Wendy's. But why impose a ban when you could generate some revenue with a tax?

On his and fellow conservative Richard Posner's blog, (which is totally bizarre from a rhetorical point of view; it seems as though it were written by Spock), Gary Becker, an economist famous for treating human beings as a commodity (human capital), and performing economic analyses on drug addiction (it's rational) and domestic life (it's a factory), mulled over the implications of a tax on fat, which would be a less paternalistic way of ridding the world of trans fats (a.k.a. hyrdogenated oils) that clog arteries and cause obesity. (Some health officials go so far to compare hydrogenated oils to the threat posed by lead paint, but I think I'd feel substantially more comfortable with children eating doughnuts than paint chips.)

Becker is skeptical that the danger outweighs the social pleasure afforded by hamburger sandwiches and french-fried potatoes, and suspects that obesity is more attributable to kids' propensity for such "sedentary activities" as "listening to music on iPods and other devices." Kids spend too much time in front of computers, he suggests, and we wouldn't want to start imposing Pigovian taxes on Internet usage, would we? This seems like a red herring to me -- to find something more appealing to substitute for fat in order to make the argument against social engineering through taxes seem more salient. The same goes for when Becker, evoking the idea that obese citizens may stress the publicly financed health care system and should therefore be taxed to compensate for that (a la one of the rationales for cigarette taxes), shifts the subject to health-care savings accounts and consumer-driven health care, the preferred conservative nostrums for America's health care crisis.

Posner, in his reply to Becker, seems more cogent on the subject. He raises the point that obesity is correlated with poverty, so a fat tax would likely be regressive and would possibly fail to achieve its intended effect.

Indeed, high-caloric "junk food" might conceivably though improbably turn out to be the first real-world example of a "Giffen good," a good the demand for which rises when the price rises because the income effect dominates the substitution effect. A heavy tax on high-caloric food might so reduce the disposable income of the poor that they substituted such food for healthful food, since fatty foods tend to be very cheap and satisfying, and often nutritious as well.

But his main contention is that the rationale for a fat tax relies on the belief that people who eat fatty food are making informed rational choices and revelaing a preference for Ho-Hos and Doritos over broccoli. Posner, somewhat surprisingly, is willing to throw rational choice out the window here:

I don't think the fact that obesity is correlated with poverty is due entirely to the fact that fatty foods tend to be cheap as well as tasty and satisfying. I suspect that many of the people who become obese as a result of what they eat do not understand how, for example, something as innocuous as a soft drink can produce obesity. I also suspect that producers of soft drinks and other fatty foods are ingenious in setting biological traps -- designing foods that trigger intense pleasure reactions caused by brain structures formed in our ancestral environment (the prehistoric environment in which human beings attained approximately their current biological structure), when a taste for fatty foods had significant survival value.

Because of these biological traps, and the imperviousness of poor neighborhoods to nutrition education, Posner is willing to consider a ban of deceptively innocuous products like soft drinks: "And while generally parents know better than government what is good for their children, many parents who permit their children to drink soft drinks do not."

As much as I don't think the government should be telling people what they can and can't eat, it's hard to see the harm in disincentivizing food that makes for fat children. But the problem seems larger than the junk-food industry, which arises in response to generalized time crunch and the devaluation of time spent sharing a meal. I don't think the poor are necessarily ignorant about the ill effects of junk food, but they don't have the time to put into policing these questions or pursuing the frequently labor-intensive alternatives. We have developed a food infrastructure premised on the idea of delivering filling calories quickly to serve the need for convenience rather than nutrition. What may be needed is a proposal that could provide incentives for convenience, which is almost impossible to imagine, seeing how convenience virtually has become the definition of incentive.