Madeline in the US?

March 19, 2013
Posted by Jay Livingston
Reposted (with more graphs but no Madeline) at Sociological Images

Readers of Madeline by Ludwig Bemelmans may remember the title character’s emergency appendectomy.  It is, after all, the central plot point.  Madeline is whisked away to a hospital, where she later shows her scar to her housemates. 

Ludwig Bemelmans came to the US at age 16 and became a citizen four years later.  He lived in New York. Yet he set this tale in France. 

And soon after Dr. Cohn
came, he rushed out to the phone,
and he dialed: DANton-ten-six -
"Nurse,” he said, “it’s an appendix!”
Everybody had to cry -
not a single eye was dry.

In a US version of the story, the tears might be caused when the bill comes.*

The Washington Post (here) has provided some data on medical costs showing why there might never be a US version of Madeline. The tab for an appendectomy here runs to $13,000, four times what it costs in France.

(Click on the chart for a larger view.)

No wonder the US spends twice as much as France on health care.  In 2009, the US average was $8000 per person; in France, $4000.  (Canada came in at $4800). Why do we spend so much?  Ezra Klein (here) quotes the title of a 2003 paper by four health-care economists: “it’s the prices, stupid.”

And why are US prices higher?  Prices in the other OECD countries are lower partly because of what US conservatives would call socialism – the active participation of the government.  In the UK and Canada, the government sets prices.  In other countries, the government uses its Wal-mart-like power as a huge buyer to negotiate lower prices from providers.  (If it’s a good thing for Wal-Mart to bring lower prices for people who need to buy clothes, why is it a bad thing for the government to bring lower prices to people who need to buy, say, an appendectomy? I could never figure that out.)

There may also be cultural differences between the US and other wealthy countries, differences about whether greed, for lack of a better word, is good. Is it an unlimited good? Are there realms, medicine perhaps, where it is not good?  Klein quotes a man who served in the Thatcher government:

Health is a business in the United States in quite a different way than it is elsewhere.  It’s very much something people make money out of. There isn’t too much embarrassment about that compared to Europe and elsewhere.

So we Americans roll along, paying several times what others pay for medical procedures, doctor visits, and drugs.**

Ludwig Bemelmans died a half-century ago, but Madeline lives on.  If publishers are considering an American version – like what Hollywood did in “The Birdcage,” “Dinner for Schmucks,” and other Americanized remakes of French movies – I’ve finished the first draft of my manuscript (rough and in need of editing, I admit).  Here’s the ending.

And all the little girls cried, “Boohoo,
we want to have our appendix out, too!
We want a real scar
Not just some tattoo.”

“Good night, little girls!
Let this fantasy drop.
Appendectomies here
Cost thirteen g’s a pop.

“And that’s not including
The hospital stay –
The US average:
Sixteen big ones a day,

“And that pretty penny
For hospital care is
Four times as much
As the price back in Paris.

“So please go to sleep!
Let’s have no more drama. There
Might be improvement ahead
With Obamacare.”

-------------------------------------------
*  See Steven Brill on the bitter pill of the medical bill - here.)

** The most viewed SocioBlog post ever was this one from 2009.  It consisted mostly of four graphs on health care costs.  It got Boinged because of one line: “Our Lipitor must be four to ten times as good as the Lipitor that Canadians take.”

Grand Olds Party

March 17, 2013
Posted by Jay Livingston
Cross-posted at Sociological Images

Jeb Bush told CPAC that the Republican party had an image problem.

Way too many people believe that Republicans are anti-immigrant, anti-woman, anti-science, anti-gay, anti-worker.

People have good reason to believe those things. But the “way too many” suggests that the GOP’s problem is not image or brand, it’s demography. For five years or longer, the Republican faithful have been complaining that “their” country was being taken away from them, and they were going to take it back. (See my “Repo Men” post from 2011.)

They were right. Their country, a country dominated by older white men, is fading in the demographic tide. The groups whose numbers in the electorate are on the rise don’t look like them.  Andrew Gelman (here) recently published these maps on who votes Republican and who votes Democrat. The maps are an update to his 2009 Red State, Blue State.

(The exit poll the data are based on sampled only in the 30 most competitive state. Texas and Georgia are large, and they have significant non-White populations. But demographic changes there are unlikely to have much effect on which party gets their electoral votes.)

The non-White proportion of the electorate will continue to grow. The female proportion may also increase, especially as education levels of women rise (more educated people are more likely to vote than are the less educated).  The key factor is party loyalty.  And, at least in presidential elections, people do remain loyal. I think I once read, “If you can get them for two consecutive elections, you’ve got them for life.”  Or words to that effect.  If that’s true, the age patterns of the last two elections should be what the Republicans are worrying about.

Trying to make themselves more attractive to younger people will not be easy. Oldsmobile tried it not so long ago (a post on that campaign is here).  “This is not your father’s GOP” might have similar lack of success.  But insisting that this is still your father’s GOP (or more accurately, some white dude’s father’s GOP) seems like a formula for failure.

New Yorkers

March 11, 2013
Posted by Jay Livingston

Ben Yagoda has a note on language, a hell of a note, on the disappearance of the phrase “a hell of a note.”  (It’s in the Chronicle, here.) Yagoda says

I seem to recall that it was a favorite expression of Harold Ross, the founding editor of The New Yorker

The Chronicle article included  picture of Ross, and while I don’t recall having seen it before, there was something familiar about it, something that reminded me of another legendary New Yorker.

(This was the best I could find at Google Images.  A good still shot of Dr. Van Nostrand would have been better.)

Fish Oil and Snake Oil

March 10, 2013
Posted by Jay Livingston

At a medical conference years ago, my friend Ron, a psychiatrist and former public health official, was seated at breakfast next to a cardiologist.  The man was slathering his toast with butter.  He also noticed Ron glancing at him and the butter-laden toast – a glance of puzzlement tinged with disapproval, like an AA member watching Bill W ordering a martini. 

“Only two things matter,” said the cardiologist, answering the question Ron had been too polite to ask.  “Good genes, no smoke.”

Ron told me this story as he was unwrapping the massive corned beef and chopped liver sandwich he’d picked up at the local Carnegie-Deli-style restaurant in my neighborhood. 

The good doctor was ahead of his time.  Now, years later, the old consensus on cholesterol and heart disease is fraying if not unraveling completely.  In today’s Times Magazine, Gretchen Reynolds (here) cites

studies showing that assiduously sticking to a diet rich in fish oils, another heart-healthful fat, doesn’t necessarily protect people from heart attacks or strokes.

It’s not that we’re now getting low-quality fish oil from the “slightly irregular” bin. It’s just that like so many other discoveries, the fish oil effect has fallen victim to the erosion that comes with more and more research. The JAMA (here) recently had this chart showing the fading of fish oil findings. 

(Click on the chart for a larger view.)

The social sciences too suffer from this law of diminishing results.  The first publication of some interesting, even startling, effect makes us take notice.  But further studies find correlations that are weaker; subsequent experiments fail to replicate.  The Chronicle recently reported on the pitfalls of “priming,” particularly the problems of one of its principle proponents, John Bargh.  In one of his better-known experiments, participants (didn’t they used to be “subjects”?) were primed with words suggesting advanced age – wrinkles, bingo, alone, Florida, etc.  The words were embedded in an irrelevant task so subtly that participants were unaware of them. Yet when Bargh timed these college-age kids walking down the hall, compared with the control group they walked more slowly, as though wrinkle and Florida had hobbled them behind an invisible walker. 

But other researchers have been unable to replicate these results.  The interesting thing is that they have, however, been able to get their findings published.  Usually, the positive-results bias among journals would consign these to the rejection pile.

I was telling another friend about this. She’s a neuroscientist and professor of psychology. “There are lots of failures to replicate. You don’t always get the results,” she said.  “That doesn’t mean the effect doesn’t exist.”
I asked her if she knew about the Bargh controversy.  No, she said, but she knew of this experiment.  “I tried it with my students in my course,” she said.
“And?”
“We couldn’t replicate.”

But maybe that’s the way it is in social science and medical science. If a magician pops the balloon to reveal inside it the three of clubs when the card you chose was the ten of hearts, he’s not much of a magician, and “But I get it right most of the time” is not much of a defense.  But science isn’t stage magic.  “Sometimes it works, sometimes it doesn’t” is not completely devastating.  We deal in probabilities, not certainties.


(HT: Keith Humphreys at the Reality Based Community for publishing the otherwise pay-walled JAMA chart.)