• Healthcare Triage News: Lots of People Are Still Uninsured

    Although the ACA has significantly reduced the percent of Americans who are uninsured, we have not yet come close to universal coverage. This has become a topic of focused debate among Democratic primary candidates. Short of achieving full coverage by passing a single-payer plan (which seems very unlikely in the near future), further gains in insurance coverage will come through means available through the ACA.

    It’s worth revisiting, therefore, exactly who constitute the uninsured at this point. A better understanding could allow policymakers and advocates to focus their efforts on those populations. A recent report from the Robert Wood Johnson Foundation and The Urban Institute covered just that. So do we, in this episode of Healthcare Triage News.

    This is based on Friday’s post over at AcademyHealth. Go read that, too!


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  • Chetty, Justice, and the Evolution of Inequality

    Here’s my take on the Raj Chetty and David Cutler JAMA paper on the association between income and life expectancy in the US. It’s very simple. The paper is important because income and life expectancy are fundamental constituents of a good life and because the authors have data on the entire population. Their results show that in the US the linked and evolving distribution of these goods is profoundly unjust.

    Chetty and colleagues report that over the last 15 years,

    The annual increase in longevity was 0.18 years for men (which translates to an increase of 2.34 years from 2001-2014) and 0.22 years for women (an increase of 2.91 years from 2001-2014) in the top 5% of the income distribution. In the bottom 5% of the income distribution, the average annual increase in longevity was 0.02 years (an increase of 0.32 years from 2001-2014) for men and 0.003 years (an increase of 0.04 years from 2001-2014) for women (P < .001 for the differences between top and bottom 5% of income distributions for both sexes).

    Across the entire income distribution, it looks like this:

    Data from Chetty et al.: Change in Life Expectancy / year by Income Percentile.

    Data from Chetty et al.: Change in Life Expectancy / year by Income Percentile.

    The horizontal axes are the percentile* ranking of households by income at age 40. The vertical axes are the increases in life expectancy at age 40 per year. The bottom ventiles of the income distribution have experienced no gain in life expectancy. Life expectancy growth increases the farther up you are in the income distribution (until it plateaus at about $100,000/year).

    Now look at US Census data below on the growth in household income by selected percentiles. The orange line at the bottom of the graph is the same segment of the income distribution as the leftmost two points on the life expectancy graphs. Their income has grown at 0.4% per annum over the last 47 years and appears to be trending down in the last 15 years, whereas the 95th percentile has experienced a thrilling 12% per annum growth.

    US Census Data: Growth in Household Income By Percentile.

    This is unjust. The core of John Rawls’ ethical philosophy was that the basic institutions of society should first secure liberties for all and then guarantee everyone equal opportunities to compete for office or position. These commitments will necessarily result in inequalities in social and economic outcomes. However, these inequalities should function so as to

    be to the greatest benefit of the least advantaged members of society.

    The Chetty et al. data show that, to the contrary, the inequalities are of benefit to the most advantaged. The least advantaged get nothing.

    You may not share this view of justice. But if you agree that social and economic inequalities are justified when the rising tide lifts all boats, then what Chetty and his colleagues show is that how matters have evolved is starkly at variance with that ideal.

    *For some absurd reason, Chetty et al. have scaled the income ranks in this graph in freaking ventiles (twentieths) where the authors’ text (like any sane person) expressed the ranks in percentiles.


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  • Ignore GPS

    Via Christopher Ingraham:

    ignore gps


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  • Help me learn new things! – Cryptography

    This post is part of a series in which I’m dedicating a month to learning about twelve new things this year. The full schedule can be found here. This is month four. (tl;dr at the bottom of this post)

    Cryptography is fascinating. Seriously, way more interesting than I thought it would be. I knew some history about Turing and Enigma, especially from Neil Stephenson’s Cryptonomicon, but getting into the nitty gritty was really worthwhile.

    tcbThe good news here is that there is really only one book you need to read. The Code Book, by Simon Singh, is a masterpiece. What’s amazing about it is that he gives you the history as well as the math and logic. I knew about Caesar ciphers. I  knew about Vigenère ciphers. I even once installed PGP on an old copy of Outlook. Anything past that, and I was out of my depth.

    By the time I was done with his book, I understood how Enigma worked, and how they broke it. I understood how RSA worked. I even understood how public and private keys worked, and how fricking ingenious Rivest, Shamir, Adelman, Diffie, and Hellman were. Public key cryptography is goddamn amazing.

    Moreover, after reading the appendix, I understood the math behind it. Huge prime numbers, a few key equations, and you’ve got it. I felt like a genius after reading the book.

    When Singh gets into quantum computers and quantum money, it gets to be a little too much. But I don’t care. I went into this to learn about cryptography, and Singh gave me everything I wanted and more.

    Next up, I read Crypto, by Steven Levy. This book was much more about the people who created modern cryptography, and the ways in which they interacted with government and companies. If that’s of interest to you, then you might like this book. I found it to be ok, but I was interested in the knowledge more than the people, so it wasn’t as captivating to me, especially after Singh’s book.

    One thing to note, though. The same anecdote appeared in both books – Diffie and his wife’s first date – in very different tellings. It made me think about how some stories about historical figures likely are apocryphal and dependent on the teller. Something to think about.

    The last book I read was Secrets and Lies, by Bruce Schneier. This book was much more about how cryptography works in the modern Internet and networked world. It does a pretty good job of explaining how all the different protocols work, and what makes them different. I did learn a lot, but it was less about cryptography, and more about security and networking. Read it if that’s your thing.

    This was a light month in terms of numbers of books read, but a huge month in terms of my gaining a real grasp on a difficult subject. So worth my time.

    tl;dr: Read The Code Book. Seriously, don’t waste any more time. Go buy and read it now.


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  • AcademyHealth: Who are the remaining uninsured?

    Although the ACA has significantly reduced the percent of Americans who are uninsured, we have not yet come close to universal coverage. This has become a topic of focused debate among Democratic primary candidates. Short of achieving full coverage by passing a single-payer plan (which seems very unlikely in the near future), further gains in insurance coverage will come through means available through the ACA.

    It’s worth revisiting, therefore, exactly who constitute the uninsured at this point. A better understanding could allow policymakers and advocates to focus their efforts on those populations. A recent report from the Robert Wood Johnson Foundation and The Urban Institute covered just that.

    So do I, over at the AcademyHealth blog in my latest post. Go read it!


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  • How much exercise do we really need?

    Many of you have sent me this piece in the NYT which argues that a new study says that one minute of strenuous exercise achieved the same benefits as 45 minutes of endurance exercise. Let’s let Gretchen Reynolds describe the experiment:

    One group was asked to change nothing about their current, virtually nonexistent exercise routines; they would be the controls.

    A second group began a typical endurance-workout routine, consisting of riding at a moderate pace on a stationary bicycle at the lab for 45 minutes, with a two-minute warm-up and three-minute cool down.

    The final group was assigned to interval training, using the most abbreviated workout yet to have shown benefits. Specifically, the volunteers warmed up for two minutes on stationary bicycles, then pedaled as hard as possible for 20 seconds; rode at a very slow pace for two minutes, sprinted all-out again for 20 seconds; recovered with slow riding for another two minutes; pedaled all-out for a final 20 seconds; then cooled down for three minutes. The entire workout lasted 10 minutes, with only one minute of that time being strenuous.

    This went on for 12 weeks. The outcomes of interest were process measures, including peak oxygen intake, insulin sensitivity index, glucose tolerance tests, and skeletal muscle mitochondrial content. Bottom line, the gains were the same in the interval and the endurance group.

    This is being touted as “one minute of strenuous exercise is as good as 45 minutes”. I’m… not so sure.

    First of all, this was a study of 25 men, not evenly divided between groups. It’s process measures, so my usual grain of salt there. But the biggest thing I see here is that it wasn’t really “one minute of strenuous exercise”. It was probably 10 minutes (at least) of activity that likely led to an increased heart rate for more than that amount of time. Is this really different from, say, walking briskly for 10 minutes?

    Cause if the take-home message of this is that you don’t need to exercise for an hour to get benefits, I’m all in. I already said that:

    The recommendations are for 30 minutes of moderate activity five times a week. Is it possible that less would get the same goals? Maybe. I’d love to see more studies investigating that.


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  • Can we please talk about kids and guns now? If not, when?

    I admit that I’d heard on the news that a two-year-old child killed himself with a gun from his mom’s purse in Indiana this week. I also admit that I’d heard a 13-year-old girl was accidentally shot in Indiana this week as well. The problem is that I hear about this kind of stuff so often, I guess I got kind of inured to it and didn’t really react.

    Then Austin tweeted this passage from Richard Perez-Pena in the NYT, covering the story of a mother who was killed in Wisconsin on Tuesday by her two-year-old, with a gun:

    In the seven days that ended Tuesday, in addition to the death of Ms. Price, a 3-year-old in Georgia, a 3-year-old in Louisiana, a 2-year-old in Missouri and a 2-year-old in Indiana fatally shot themselves; a 4-year-old in Texas shot and wounded a family member; a 16-year-old in California killed a 14-year-old friend in a shooting that officials called accidental; a 15-year-old in Texas accidentally shot and wounded a 16-year-old friend; and a 13-year-old in Indiana accidentally shot and wounded herself.

    This was in a week. A week.

    In 2009, about 7400 kids were hospitalized with gun injuries. Homicide is the number three killer of kids age 1-4 years. Accidents are the number one. Guns are a health risk for kids, and in some states, we aren’t allowed to talk about it by law.

    So can we talk about it now? If not, when?


    P.S. Kudos to Perez-Pena. Sometimes it takes some great writing to get me off my ass.

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  • AcademyHealth: How good is telemedicine?

    As I wrote in my previous AcademyHealth blog post, the vast majority of the two hours or so it usually requires to see a doctor is spent not seeing the doctor. Travel and waiting time take big chunks out of our day. With modern technology, for some kinds of care, that wasted time can be avoided. My new post explains.



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  • Healthcare Triage: Health Services Research, Diabetes, and the YMCA

    More than 86 million people, including 22 million people 65 or older, have pre-diabetes, which increases their risk of heart disease, strokes or diabetes. As we’ve watched that number grow, it has somehow felt that despite billions of dollars of research and intervention, there’s little we can do.

    That feeling shifted last week when Sylvia Mathews Burwell, the secretary of health and human services, announced that Medicare was planning to pay for lifestyle interventions focusing on diet and physical activity to prevent Type 2 diabetes. It’s an example of small-scale research efforts into health services that have worked and that have expanded to reach more people.

    That’s the topic of this week’s Healthcare Triage.

    This was adapted from a column I wrote for the Upshot. References and links to further reading can be found there.


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  • Avoiding Peanuts to Avoid an Allergy Is a Bad Strategy for Most

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company).

    It has become an article of faith among many women I know to eliminate some foods during pregnancy, out of concern that their children could become allergic to them: shellfish, dairy and, most of all, peanuts.

    After their babies arrive, they continue to abstain from certain foods while breast-feeding, and they certainly keep their children from eating them.

    But research in the last few years has consistently shown that all this avoidance often does more harm than good. In many cases, we need to be doing the opposite.

    Mothers didn’t adopt this behavior out of nowhere. In 2000, the American Academy of Pediatrics released guidelineson reducing a child’s risk for developing allergies. They recommended that mothers “eliminate peanuts and tree nuts (e.g., almonds, walnuts, etc.) and consider eliminating eggs, cow’s milk, fish, and perhaps other foods from their diets while nursing.”

    Further, they recommended that children at high risk for allergies be given no solid foods until six months of age, no dairy products until 1 year old, no eggs until age 2, and no peanuts, nuts or fish until age 3.

    A debate has been raging in the health care system for decades on this topic. I was part of a systematic review that examined the relationship between early solid food introduction and allergic disease in children. We found no good evidence to support the idea that being exposed to solid foods earlier led to persistent food allergies.

    To its credit, the A.A.P. changed its recommendations based on new research. In 2008, updated guidelines reported that maternal restrictions in pregnancy or breast-feeding no longer seemed like advice that should be widely recommended. It also acknowledged that there didn’t seem much reason to delay the introduction of “allergy” foods like peanuts after six months, which is around the age babies move from milk or formula to a wider range of food.

    Unfortunately, this did little to change people’s behavior. Many had already internalized the advice. It seemed logical to them that avoiding foods would give children less of a chance to develop allergies. If it was still a good idea not to expose children until they were six months old, why not keep going?

    A study published in the New England Journal of Medicine last year turned all of this on its head. Researchers enrolled 640 infants at high risk for allergies, between 4 and 11 months of age, in a trial and randomized them to one of two groups. One of them was told to avoid peanut protein; the other was told to eat at least six grams of peanut protein a week given in three or more meals. All participants were followed until they were 5 years old.

    What was most surprising in this work was that 15 percent of the infants already had evidence of peanut sensitivity by allergy testing. They were enrolled in the trial despite this, and half of them were given peanut extract every week.

    The results were remarkable. At the end of the study, about 3 percent of those exposed to peanuts had developed a peanut allergy, compared with more than 17 percent among those who avoided peanuts.

    More surprising, if you looked just at the children who already had evidence of peanut sensitivity when they were babies, fewer than 11 percent of those regularly exposed to peanuts developed an allergy. But more than 35 percent of those who avoided peanuts developed an allergy.

    Children who had proven sensitivity to peanuts, but consumed them in their diet regularly, were less likely to develop a peanut allergy than children without sensitivity but who avoided them.

    Recently, follow-up results were published. After the trial ended, researchers asked all the participants who had been regularly consuming peanuts to avoid them for the next 12 months.

    At the end of that period, when the children were 6, there was no significant increase in new peanut allergies in that group. Avoidance at this point made no difference. The critical need for exposure appears to be somewhere from infancy until age 5.

    These results were so convincing that, once again, experts are changing their recommendations. In September 2015, the A.A.P. — along with others— argued that “health care providers should recommend introducing peanut-containing products into the diets of ‘high-risk’ infants early on in life.”

    These changes dovetail nicely within what has become known as the hygiene hypothesis, the gist of which is that as we’ve made our environment more and more sterile, our immune systems develop differently than they used to. Without exposure to outside things to fight, our defenses turn inward and toward more benign substances, leading to increased levels ofeczema, asthma and allergies.

    Of course, many people used to die from infections that no longer threaten us because of advances, so no one should take this as a call for living in filth. Nor should anyone take these recent findings as advice to feed babies and small children peanuts and other foods without concern. All changes to an infant’s diet, especially in children with allergies, should be done in consultation with a health care professional.

    As with many things in health care, however, we went too far with our response to peanut and other food allergies. Avoidance is sometimes needed for those with severe reactions. When we apply those same rules to everyone else, however, things can backfire.


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