Anecdotal Evidence on Health Care

June 26, 2009
Posted by Jay Livingston

Opponents of government involvement in health care seem to have two strategies. One is name-calling – “socialism” and “European-style” are two of their favorites. The other is to repeat anecdotes to illustrate the horrors that people in Europe and Canada have suffered – delayed treatment, denial of treatment, and so on. There’s a third strategy – spending huge amounts of money in lobbying legislators directly – but that’s less visible.

The Obama Administration has asked Americans for their own stories about their experiences with the insurance industry. Stories have poured in by the thousands. You can read them here, read them and weep.

Some people report on their experiences with socialized European-style health care, and the US does not come off on the plus side (here, for example). Others compare experiences with private insurance against public plans in this country Again, the private system comes off as inferior.
I’ve blogged before (here and here) about the utter hollowness of the claims that socialized health care will mean that “bureaucrats” rather than doctors will be making decisions. In fact, the bureaucrats are already doing that. And a few of them have contributed their stories to the Obama website. Here’s one from Barbara in Barbara, Deer Island, FL

I worked for United Health Care in small group customer service. If a company was more than 5 days late in their monthly payments, United would "terminate" their coverage. When they were terminated the group administrator from the "termed" company would call me to reinstate their coverage. I would take their phone number, go to my supervisor's office and get a computer disk showing all small groups "loss ratios." If the company I was working with was in the high risk ratio, I was not to reinstate their coverage. This meant people in the hospital or scheduled for surgery would never nave coverage with any company because of pre-existing conditions if their coverage was less than 90 days. Sometimes a new group misses payments in the first few months before they get on a payment schedule. This is how United Would "weed out" the high claims group. Their actions were not illegal, but were IMMORAL!

That term “loss ratio” refers to the ratio of premiums that the insurance company pays out. When your insurance company pays a claim to your doctor or hospital, that’s a loss.

Barbara’s story was amplified recently in Congress. Wendell Potter, a former executive at Cigna, testified before the Commerce Committee.

"They look carefully to see if a sick policyholder may have omitted a minor illness, a pre-existing condition, when applying for coverage, and then they use that as justification to cancel the policy, even if the enrollee has never missed a premium payment."
(Potter’s full testimony, thanks to Ezra Klein, is here.)

Selling (Out) Public Transport

June 26, 2009
Posted by Jay Livingston

Even in my early morning stupor, I couldn’t help noticing the new turnstiles at Penn Station. Where once spotless chrome gleamed, proclaiming the subway’s purity, now speaks the crass voice of commerce: There’s a sale at H&M waiting for you upstairs when you leave the station. You can get something for as little as five bucks. Cheap.



It’s not so different from the ads on the walls, I thought. Besides, it might help to keep the fare from going up too much. At least the MTA isn’t selling naming rights to the subway the way the Port Authority nearly sold the George Washington Bridge to Geico (see my old blog entry here.)

That was then. Yesterday, the MTA announced that the Atlantic Ave. Station in Brooklyn will henceforth also be known as the Barclay’s Bank station. The station is a major hub, with transfers available from at least four different subway lines. For a large British bank, the $200,000 a year is pocket change. Talk about cheap.

Oh well, at least they didn’t sell the name for my station.

Taylorized Eating

June 24, 2009
Posted by Jay Livingston

The 1954 musical The Pajama Game makes fun of “scientific management” and efficiency experts. The comic foil in the show is Hinesy, the time-study man. (See my post of last December on Taylorism.)

In the song “Think of the Time I Save,” Hinesy tells the female workers in the pajama factory of how his personal life is devoted to saving time. He even eats so as to maximize efficiency. The song includes this verse:

At breakfast time, I grab a bowl.
And in the bowl I drop an egg,
And add some juice.
A poor excuse for what I crave.
And then I add some oatmeal too,
And it comes out tasting just like glue,
But think of the time I save.

Parody, right? Could never happen, right? Maybe not, but as Mike at Pragmatic Realists Idealists reports, one fast food chain, BBQ Chicken, is coming close.

Twenty-five Is Not a Random Number

June 21, 2009
Posted by Jay Livingston

Political scientists Bernd Beber and Alexandra Scacco have a simple test for electoral fraud in the Iranian election. Here are the results from Qom

• Ahmadinejad . . . . .422,457
• Karroubi . . . . . . . . . . 2,314
• Mousavi. . . . . . . . . .148,467
• Rezaee. . . . . . . . . . . . 16,297

Which digits are the important ones? The left-most ones, of course – Ahmadinejad’s roughly 420,000 to Mousavi’s 148,000.

But Beber and Scacco were interested in the right-most digits, the ones that we might throw out and round to zero. Here’s why:

When people try to make up numbers that appear to be random, they show certain preferences. Try it yourself. Think of any random number from 0 to 100. I’ll wait. Got your number? O.K. Chances are it’s an odd number that does not end in 5. More than likely, it does end in 7.*

In an honest vote count, about 10% of the final digits should be fives, and 10% should be sevens. If five is underrepresented, and if seven is overrepresented, someone is trying to make up numbers and have them seem random.

Beber and Scacco looked at the 116 results (four candidates x 29 provinces) and . . .

The numbers look suspicious. We find too many 7s and not enough 5s in the last digit. We expect each digit (0, 1, 2, and so on) to appear at the end of 10 percent of the vote counts. But in Iran's provincial results, the digit 7 appears 17 percent of the time, and only 4 percent of the results end in the number 5. Two such departures from the average – a spike of 17 percent or more in one digit and a drop to 4 percent or less in another – are extremely unlikely. Fewer than four in a hundred non-fraudulent elections would produce such numbers.

In a second test, Beber and Scacco also looked at the last two digits.

Psychologists have also found that humans have trouble generating non-adjacent digits (such as 64 or 17, as opposed to 23) as frequently as one would expect in a sequence of random numbers.

Sure enough, the totals had fewer non-adjacent pairs than would be expected, especially in the province totals for Ahmadinejad. The two tests provide a fairly persuasive case for what most people think anyway – that the vote totals reported by the Iranian government were fabricated.

Beber and Scacco report their research in the Washington Post here.

*Street magician David Blaine uses this same tendency in one of his mind reading tricks. A lot of people pick 37.

Hat tip to Joshua Tucker at The Monkey Cage, which has links to the electoral data.

States' Rights, and Wrongs

June 19, 2009
Posted by Jay Livingston

The Supreme Court decision in Osborne yesterday allows a state to prevent a convicted person from re-examining evidence using modern DNA testing, even though such testing might prove innocence.

That’s bad enough – especially for people who have been wrongfully convicted and who might be exonerated. But my guess is that the conservative majority has bigger things in mind – rolling back incorporation.

Incorporation is the theory that the Warren Court used to prevent states from violating individual rights. The language of the Bill of Rights clearly protects people against actions by the federal government. “Congress shall make no law . . . ” But it says nothing specifically about what state governments may do. The Fourteenth Amendment, like the other two Civil War amendments imposes limitations on the states. No slavery, no denial of the vote. The Fourteenth requires states to follow “due process” in criminal cases.

The trouble was that what state courts considered due process varied widely. In Mississippi, beating defendants till they confessed and then using that confession to convict them was not a violation of due process.

Beginning in the 1960s, the Court handed down some landmark decisions saying basically that certain due process rights which already existed at the federal level (a free lawyer, the exclusion of illegally seized evidence, etc.) were incorporated on the states via the due process clause of the Fourteenth Amendment.

The conservatives seem to want to restrict these protections and return the definition of due process to the states. As Chief Justice Roberts wrote in his opinion.

This approach would take the development of rules and procedures in this area out of the hands of legislatures and state courts shaping policy in a focused manner and turn it over to federal courts applying the broad parameters of the Due Process Clause. There is no reason to constitutionalize the issue in this way.

“No reason to constitutionalize.” There is a reason, actually – making sure that a state is not locking up (or executing) an innocent person. But that’s a small price to pay for taking one small step in rolling back the constitutionalizing protections of the Court’s more liberal period. Of course, when it comes to state practices the conservatives don’t like (restricting guns, allowing abortions and assisted suicide, counting Democratic votes), I doubt that we’ll hear much from them about the evils of constitutionalizing and incorporation.

None of the legal blogs have mentioned incorporation (at least not the two I looked at). So what I’m saying is either so wrong or so obvious that it isn’t worth noting.

Folkways and Laws

June 17, 2009
Posted by Jay Livingston

Stateways cannot change folkways. Or can they?

Henry at Crooked Timber, who has apparently spent some time in the pubs of Ireland, says he never expected the Irish to obey the new anti-smoking law. But they did. Henry’s explanation is not that he underestimated the power of the law but that he overestimated the strength of the norms:

prevailing norms (that Irish people can smoke in pubs to their hearts’ content, and that others will just have to put up with it) were much more fragile than they appeared to be

In France too, and Italy, many people were sure that smokers would ignore new restrictions on indoor smoking, but the bans in those countries have been surprisingly effective.

The crucial point is not that social scientists misread the norms but that the smokers on the ground did. It’s a case of “pluralistic ignorance,” a phrase coined by Floyd Allport in the early 20th century to describe this misreading. Most people have doubts about the norm (in this case, the norm that smoking is O.K.), but each thinks that others support it, so each person publicly states support for the norm and keeps his doubts to himself, which only leads everyone to further misread just how weak the norm really is.

Attribution theory has a related explanation. When we see someone behave in a certain way, we are quick to attribute a whole set of motives and characteristics to the person. If someone is smoking, it must be because he wants to. He is a smoker. On top of that, if we see nonsmokers in a pub where there is smoking, and they are not objecting, we conclude that they have no objections. In both cases, we are using our observations of behavior to make simplistic assumptions about what’s in the minds of the people we observe.

If we thought about it for a couple of seconds, we’d realize that most people who smoke feel at least ambivalent about smoking. They’d like to quit and have probably tried to more than once. A ban on smoking indoors gives them one more external push to do what they want to do anyway.

Something similar happened when New York City passed a “pooper scooper” law thirty years ago. By the late 1970s in New York City, dog droppings in the public areas of the city – the parks, streets, and sidewalks – had reached a level that many people found disgusting. It was a shitty version of the tragedy of the commons. Each individual acted out of self-interest (walking away was more pleasant than scooping up the poop) with a result that made the city less pleasant for all.

Many people thought the new law would have no effect. They were applying a rational, economic analysis. True, there was a fine for not cleaning up. But the city had much heavier fines for running red lights, and still many New York drivers continued to treat stop lights more as a suggestion than as a command. Besides, it was very unlikely that a cop would be around at the precise moment a dog owner walked away leaving the incriminating evidence. The law was all but unenforceable. How could anyone seriously expect New Yorkers, of all people, to cooperate?


But much to the surprise of most people, including New Yorkers themselves, the law worked. Dog owners did clean up, even though they could easily have gotten away with violating the new law. But why? Here’s my guess: Even before the new law, dog owners had probably thought that cleaning up after their dogs was the right thing to do, but since everyone else was leaving the stuff on the sidewalk, nobody wanted to be the only schmuck in New York to be picking up dog shit. In the same way that the no-smoking laws worked because smokers wanted to quit, the dog law in New York worked because dog owners really did agree that they should be cleaning up after their dogs. But prior to the law, none of them would speak or act on that idea.

So it looks as though stateways can indeed change folkways, at least when the folks want to change.

Oceane Tide Rising and Falling

June 12, 2009
Posted by Jay Livingston

In the previous post on names, I said that the rapid rise and fall of Oceane in France paralleled the career of Madison in the US. But Madison is still hanging in there, still in the top 5, having descended only one or two places in the rankings. A better example might be Hannah (though Oceane doesn’t have Hannah’s history), or Ashley in the late 20th century.

(Click on the graph to see a larger version.)

Still, both these American names were less volatile than Oceane in France. In a single decade (1991-2000) the number of Oceanes increased by a factor of six. Six years later, it had fallen nearly by half.
(US graphs are from babynamewizard. More data on French names here.)

It's How You Finish

June 11, 2009
Posted by Jay Livingston

Flaneuse at Graphic Sociology reprints a neat graph by Baptiste Coulmont showing trends in the endings of girls' names in France.

(Click on the graph to see a larger version.)

The final “e” has long been characteristic of French female names, though with some variation (the “ette” suffix is so 1930s). The most remarkable trend in recent decades is the rise of the final “a” to the point that it is now more common than the final “e.” The three top names in 2006 (the most recent year I could find data for), were Emma, Lea, and Clara. (I also noted that Oceane has now dropped out of the top ten. Apparently, in terms of fashion cycles, Oceane is to France what Madison is to the US.)

Final letters of boys’ names in the US have also seen a dramatic shift, as documented nearly two years ago by Laura Wattenberg at babynamewizard. The half century from 1906 to 1956 saw little change. D,E, S, N, and Y shared the closing spotlight, probably thanks to David, George, and James/Charles/Thomas, John and several Y names.

Final Letter of Boys' Names 1906

Final Letter of Boys' Names 1956

But by 2006, N had conquered the field and stood pretty much alone.

Final Letter of Boys' Names 2006

It won not by having a single blockbuster – only one of the top ten boys’ names, Ethan, had a final N – but with more of a long-tail effect. Of the names ranked 14th to 27th, nine of the fourteen ended in N. (The list is here).

Dialing, Dollars, and Doctors

June 10, 2009
Posted by Jay Livingston

The only health care costs I was thinking about when I started calling orthopedists today were my own. That’s why my first question was to make sure that the doctor participated in my insurance plan. I was calling only orthopedists listed listed on my plan’s website. But the woman who finally answered the phone of my first choice told me No.

The personal is the political, and I started thinking of all those warnings from conservatives that if the government gets into health care, we won’t be able to choose our own doctors, and we’ll be subject to incompetent government bureaucracy. It took only one phone call to discover that under what I have now, I can’t choose my own doctor, and that, at least when it comes to keeping their website information current, the insurance company bureaucracy isn’t exactly a paragon of competence.

A public option might be just as good. And who knows – with Obama in office, maybe the music you have to listen to while you’re waiting will be better.

I expected to be put on hold, and I expected the music. But I wasn’t prepared for the ads over the music – a woman’s reassuring voice telling me about all the wonderful kinds of surgery now available. It wasn’t as blatant as those ads on the subway decades ago for Dr. Tush* and his hemorrhoid surgery. The on-hold message didn’t exactly say, “What would it take for me to put you today into this quick and sporty little arthroscopic hand surgery?” There was also the difference that while the straphanger-friendly proctologist was going for volume, the orthopedists were aiming at a smaller customer base but pushing their more expensive products. Still, it was clear that all these practitioners were paying close attention to the bottom line.

Then I remembered that just this morning, Ezra Klein blogging at WaPo had said something along similar lines – less personal, more political and economic.

Reforms to . . . the way doctors are paid would actually do much to change the drivers of health-care spending. . . . Most doctors are paid on a fee-for-service model. Every time they do something to you, they get money for it. That's a subtle incentive toward expensive overtreatment. Conversely, if we paid doctors exactly the same amount overall, but made that money a yearly salary rather than a reward for volume of treatment, doctors would lose an important incentive to provide more health-care services than we actually need.

Ezra also recommends Atul Gawande’s recent New Yorker article, which ought to be required reading for anybody who has anything to do with healthcare.

* Amazingly, I could not find anything about Dr. Tush on the Internet. I’m pretty sure he wound up in prison, but I don’t know whether for medical or financial malfeasance

Well You Needn't

June 7, 2009
Posted by Jay Livingston

The primary school my son went to is moving, and there was a farewell tour of the old building. The walls were covered with the kids’ art and their class projects. I was looking at the classroom doors – guides to trends in names. Gone were Emily and Alexandra and of course Jason.
But this one stopped me in my tracks.


Thelonius!

“There’s Only One Aretha,” I remembered. It was the title of a chapter in Beyond Jennifer and Jason: An Enlightened Guide to Naming Your Baby, by far the best of the books my wife and I consulted back in the late 80s. (The title has since been updated: Beyond Jennifer & Jason, Madison & Montana: What to Name Your Baby Now.)

Don’t name your kid Aretha – that was the gist of the chapter – unless you want to doom her to a lifetime of predictable comments. There are some names that are unique. There’s only one of them, and it’s been taken.

Surely Thelonius must be such a name – even his son goes by T.S. Monk, Jr. But at least on the West Side, maybe it has broken out.

The Dog Corrupted My Homework

June 5, 2009
Posted by Jay Livingston

Inside Higher Ed today reports on a company that sells corrupted files for students to submit in lieu of the paper they haven’t finished. “It will take your professor several hours if not days to notice your file is 'unfortunately' corrupted. Use the time this website just bought you wisely and finish that paper!!!”

A few readers at Ed (Inside Higher Ed and I are on a last name basis) offered ways to defeat such tactics.

I have several reactions..

• Formal rationality and substantive rationality: If you set up a bureaucratized, McDonaldized version of “education,” where forms are more important than substance, you should expect this cat-and-mouse game of students trying not to learn, and teachers trying to catch them.
  
  
• A day in the life. Corrupted-files.com promises students “several hours.” Maybe even a day or two. Will that time really make a difference in quality? Probably not. But students may have complicated lives, and my course is only one of its elements. And suppose that the extra day or two would make a difference in quality . . . .
  
  
• Do you want it Wednesday or do you want it good? It’s a standard line among sitcom writers. TV has to run on schedule, so the answer is usually Wednesday. Which is why TV is so often not good. But my course is not a sitcom (or is it?), and I would much rather have the work be good.
  
  
• WTF? RTF. I ask students to submit papers as Rich Text Format (.rtf) documents. I don’t know if this reduces the possibility for corruption. It does make the paper readable in other formats (like my beloved WordPerfect). And I once heard that a virus can be embedded in a Word document but not in a .rtf document.*

*And please no PowerPoint. As Lord Acton said of the effect of presentation software on thinking, “PowerPoint tends to corrupt. Absolute PowerPoint corrupts absolutely.”

Which Side (of the Newsstand) Are You On?

June 2, 2009
Posted by Jay Livingston

Inflation or deflation – which is the greater cause for concern? Maybe your answer depends on your relation to the means of producing the New York Times – are you a writer or a reader?

On Friday, Paul Krugman wrote:

Suddenly it seems as if everyone is talking about inflation. . . .But does the big inflation scare make any sense? Basically, no . . .. Deflation, not inflation, is the clear and present danger.

When I went to buy the paper Monday to see Krugman’s next column, the newsstand price had risen by 33% – from $1.50 to $2.00. (The increase, equal to the price of New York’s other two dailies, means that the Times price is 300% that of the Daily News or Post.)