• The exploitation of adjunct faculty

    Kevin Birmingham is the winner of the Truman Capote Award for his book,The Most Dangerous Book: The Battle for James Joyce’s Ulysses. The book also won the 2015 PEN New England Award for Nonfiction. You would think that an author of a first book that won multiple prizes would be a rising academic star. But Birmingham is just an adjunct faculty member at Harvard, where ‘adjunct’ means he is paid on a short-term contract and is not on the tenure ladder. He gave a speech titled “The Great Shame of Our Profession” as part of the Capote award ceremony, and the speech has been published in the Chronicle of Higher Education. It’s about the exploitation of adjunct faculty in the humanities.

    Here’s a sample.

    According to the 2014 congressional report, adjuncts’ median pay per course is $2,700. An annual report by the American Association of University Professors indicated that last year “the average part-time faculty member earned $16,718” from a single employer. Other studies have similar findings. Thirty-one percent of part-time faculty members live near or below the poverty line. Twenty-five percent receive public assistance, like Medicaid or food stamps. One English-department adjunct who responded to the survey said that she sold her plasma on Tuesdays and Thursdays to pay for her daughter’s day care. Another woman stated that she taught four classes a year for less than $10,000. She wrote, “I am currently pregnant with my first child. … I will receive NO time off for the birth or recovery. It is necessary I continue until the end of the semester in May in order to get paid, something I drastically need. The only recourse I have is to revert to an online classroom […] and do work while in the hospital and upon my return home.” Sixty-one percent of adjunct faculty are women.

    The problem is not exclusive to the humanities. There are also adjunct faculty in science and some argue that post docs are often exploited in science. And it is not a marginal problem: the majority of college faculty are now ‘contingent’.

    By 2011, 51 percent of college faculty were part-time, and another 19 percent were non–tenure track, full-time employees. In other words, 70 percent were contingent faculty, a broad classification that includes all non–tenure track faculty (NTTF), whether they work full-time or part-time.

    The proportion of college faculty who are contingent is growing.

    Read the whole thing, but a warning: if you are a scientist or a journalist you may have trouble appreciating the writing. Or at least I did. The first few paragraphs are a paean to “narrative historicism”, the humanities methodology Birmingham used in his prize-winning book. The tone then shifts abruptly and becomes a jeremiad against the universities.

    I sent the essay to a friend who is a professor of comparative literature, with a complaint about humanists who can’t write a proper introduction to an argument. He wrote back and (kindly) demolished my complaint: the essay is beautifully constructed, and the jeremiad is itself an example of the narrative historicist approach.

    In other words: be patient, the man is writing for humanists, not scientists. And he needs a job.


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  • Wearable Fitness Devices Don’t Seem to Make You More Fit

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    I once received a lot of blowback for an Upshot article in which I showed (with evidence) that exercise is not the key to weight loss. Diet is. Many, many readers cannot wrap their head around the notion that adding physical activity, and therefore burning more calories, doesn’t necessarily translate into results on the scale.

    Well, here we go again because some of those folks also believe that fitness devices — Fitbit, Vivosmart, Apple Watch — must be helpful in losing weight. Unfortunately, evidence doesn’t support this belief either.

    For some time, people have been trying to prove devices like these succeed in promoting weight loss. In 2011, a study compared four groups getting a mixture of behavioral weight loss programs and use of an armband that measured activity and energy expenditure. All the intervention groups lost weight, but those with behavioral programs and technology lost the most. The sample size of each group (fewer than 50) and the large dropout rate of the study should temper enthusiasm, though. The sample was also mostly female, and more than three-quarters of them had college degrees, so the results may not be entirely generalizable.

    In 2015, another study, the PACE-Lift trial, was also inconclusive. Researchers randomly assigned 250 people ages 60 to 75 to one of two groups. The first group received four physical activity consultations from primary care nurses over three months; a pedometer; and a physical activity diary. The other received “usual care.” All patients were given accelerometers to measure their activity, although only the control group saw the results. One year later, those in the pedometer group were taking an average of about 600 more steps per day, and had about 40 more minutes of activity a week.

    But it’s hard in a trial like this to know how much of that was because of the pedometer and the feedback, and how much was because of the nurse visits and coaching.

    What was needed was a large, well-designed study that truly teased out the contribution of wearable tech to weight loss programs. Last year, the results of such a study, the IDEA trial, were published.

    The trial took place at the University of Pittsburgh between 2010 and 2012, and it involved more than 470 adults between the ages of 18 and 35. All of them were put on a low-calorie diet, had group counseling sessions and were advised to increase their physical activity. Six months into the intervention, all were given telephone counseling sessions, text-message prompts and study materials online.

    At that time, though, half were also given wearable tech devices that monitored their activity and connected to a website to help provide feedback. All participants were followed for 18 more months.

    At the end of the two years, which is pretty long for a weight loss study, those without access to the wearable technology lost an average of 13 pounds. Those with the wearable tech lost an average of 7.7 pounds.

    It’s hard for many to accept, so I’m going to state the results again: Those people who used the wearable tech for 18 months lost significantly less weight than those who didn’t.

    You may rightfully point out that the primary reason to wear the devices isn’t to lose weight — it’s to be more active. But even in this respect, it didn’t work nearly as well as we might hope. In the IDEA trial, those who employed the technology were no more physically active than those who didn’t. They also weren’t more fit.

    Many new technologies, and dietary supplements and new diets, are sold to the public with little actual research behind them. Wearable technology to encourage fitness is no different. Somehow, in the past few years, it has become collectively understood that we need to take 10,000 steps a day. But there’s no magic behind that number. There’s no reason to believe that hitting this arbitrary goal is somehow life-changing.

    Exercise is worthwhile for its own sake. Of course, many people can enjoy using wearable tech without tying it to weight loss goals. I have owned a Fitbit, a Nike FuelBand and an Apple Watch. I still wear the watch because I like many of its features. When I first bought it, I liked how it tracked my daily 30 minutes of physical activity and reminded me to stand up every so often.

    But I realized over time that I didn’t really need it. After some months, getting 30 minutes of activity a day (the recommended amount) became part of my routine. I learned to be more mobile and less sedentary. I didn’t need the precision or the reminders anymore.

    It’s possible that the devices helped me make physical activity part of my regular routine. It’s possible that they provided a benefit. But my experience is just an anecdote, and there’s no counterfactual to help figure out whether I’d have become more active without the devices. For that, we’d need a trial. The ones that exist (like the IDEA trial) argue that the devices don’t make people exercise more.

    They don’t seem to hurt, though. Other than costing money, there’s no harm in seeing if it might improve your activity over time. But if your goal is weight loss, then you might think twice about using such a device. The evidence suggests that you may do better without one.

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  • Trading off harms and benefits – distinctions matter for beta-blockers in the elderly

    Such an important study in JAMA Internal Medicine. “Association of β-Blockers With Functional Outcomes, Death, and Rehospitalization in Older Nursing Home Residents After Acute Myocardial Infarction“:

    Importance  Although β-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential functional harms and uncertainty of benefit.

    Objective  To study the association of β-blockers after AMI with functional decline, mortality, and rehospitalization among long-stay nursing home residents 65 years or older.

    Design, Setting, and Participants  This cohort study of nursing home residents with AMI from May 1, 2007, to March 31, 2010, used national data from the Minimum Data Set, version 2.0, and Medicare Parts A and D. Individuals with β-blocker use before AMI were excluded. Propensity score–based methods were used to compare outcomes in people who did vs did not initiate β-blocker therapy after AMI hospitalization.

    Main Outcomes and Measures  Functional decline, death, and rehospitalization in the first 90 days after AMI. Functional status was measured using the Morris scale of independence in activities of daily living.

    Beta blockers are so “standard of care” after having a heart attack, I barely think about them when I hear about them. But they aren’t used as much for older nursing home residents because of concerns over how much they might really benefit versus how much they might harm them. This study, therefore, sought to look at how beta-blockers were associated with mortality and rehospitalization as well as with functional harms.

    It was a cohort study of nursing home residents, age 65 years or older, who had suffered from an acute myocardial infarction. The researchers used propensity scores to compare how those treated with beta blockers fared versus those not treated with beta blockers. The main outcomes of interest were independence in activities of daily living, rehospitalization in the 90 days after their MI, and death.

    The cohort consisted of more than 11,000 women and more than 4500 men, with an average age of 83 years. The propensity matching left an analysis of about 55oo users of beta-blockers versus about 11,000 non-users.

    Those who used beta blockers had about the same rate of rehospitalization as those who didn’t (HR 1.06, 95% CI 0.98-1.14). So no difference there.

    Those who used beta blockers had a significantly lower rate of death (HR 0.74, 95% CI 0.67-0.83). So a definite benefit to beta blockers there.

    Those who used beta blockers had a significantly higher rate of functional decline (OR 1.14, 95% CI 1.02-1.28). So a definite harm there.

    BUT – that’s when it gets interesting. Those who had moderate to severe cognitive impairment or severe functional dependency to begin with were even more likely to experience functional decline (OR 1.32-1.34). But those with intact cognition or mild dementia showed no real decline (OR 1.03). The same was true for people with in the best (OR 0.99) or intermediate (1.05) tertiles of functional independence.

    The benefit in mortality, though, was the same for all subgroups of functioning and ccognition

    In other words, the definite benefits seen for those over 65 who have an acute MI are the same – and real – for all people. But the harms in terms of loss of functional independence seem confined to those who have at least moderate cognitive impairment or a severe functional dependence already. For the latter group, there are clearly tradeoffs to using beta blockers. They gain a reduction in mortality, but at a real cost of further loss of independence of living.

    But if you’re over 65, have little cognitive impairment and moderate or less functional dependence, then treatment with beta blockers may extend your life and not really harm your independence. That’s an important distinction – and one worth discussing with your doctor.

    This is all fascinating to me because beta-blockers in the elderly were one of those clear “don’t do it so widely” things before. We may need to reevaluate that. But we need RCT evidence, not just cohort studies. We also need to know when to stop beta-blocker therapy as people cognitively or functionally decline. More research is necessary. This is clearly a complicated issue.


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  • Healthcare Triage: Trump, Congress, and the Plan for Block Grants and Medicaid

    How Would Republican Plans for Medicaid Block Grants Actually Work? That’s the topic of this week’s Healthcare Triage.

    This episode was adapted from an Upshot column I wrote. Links to sources and further reading can be found there.


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  • Nerdcon: Nerdfighteria

    So you’ll either know what Nerdfighteria is or not. The Venn diagram of those who know what it is will likely overlap largely with fans of Healthcare Triage.

    There’s a convention this weekend to celebrate it!

    NerdCon: Nerdfighteria is the first-ever official Nerdfighter convention and celebration of 10 years of nerdfighting. It is a giant celebration of all things nerdy, creative, educational, fun, and weird.


    – Panels, workshops, discussions, & more
    – Signings with Featured Guests
    – Live podcast recording (including Dear Hank & John)
    – Lots of music
    – An expo hall with vendors, activities, and fan activism
    – A board game zone
    – Featured Guest kaffeeklatsches (Featured guests hang out with a dozen attendees and chat about anything & everything)
    – Amazing programming brought to you by YOU, the community!

    Plus, we have lots of weird and cool things up our sleeves that can’t be announced yet. Please join us for all manner of excellent goofiness. And in the meantime, DFTBA!

    There are a lot of cool guests who will be there, most of whom are much more famous than me. I will be participating in many activities there, most of which are HCT related. Full agenda here.

    Are you near Boston this weekend? You should come!!! Meet me and the whole HCT gang, along with a lot of other great people.


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  • Healthcare Triage News: Good News! We Can Have Successes in Population Health!

    It can sometimes feel like there’s nothing we can do to improve population health. That’s just not true. This is Healthcare Triage News.

    For more information, go here.


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  • Medicaid expansion and reducing divorce rates

    Emma Sandoe is a PhD student in Health Policy, Political Analysis at Harvard and a former spokeswoman for Medicaid at the Centers for Medicare & Medicaid Services.

    This week David Slusky and Donna Ginther released an NBER working paper which suggested that Medicaid expansion reduced the prevalence of divorce by 5.6% among those aged 50-64.

    The thinking is this: Prior to the passage of the Affordable Care Act, the only way that many middle-income adults could qualify for Medicaid coverage was to spend down their assets to qualify for one of Medicaid’s eligibility groups. To avoid spending all of their assets on medical and long-term care services, many people engaged in what is known as “medical divorce.” When one spouse would become ill and need Medicaid services (particularly for long-term care services that Medicare does not cover), the couple would divorce so that the assets of the sick spouse would qualify them for the Medicaid asset test (often around $2,000 for an individual and $3,000 for a couple).

    Medicaid expansion changed things. It allows all people regardless of assets to apply for Medicaid coverage so long as their income is below 138% of the federal poverty level. Using a difference-in-difference approach comparing changes in divorce rates (pre to post ACA) in states that expanded Medicaid eligibility to 138% of the poverty level to states that did not expand, the authors found that divorce rates fell in expansion states.

    One problem is that Medicaid expansion did not entirely get rid of the asset test.

    Medicaid is not one program. There are many avenues that a person can take to get Medicaid. The benefits and structure of the program look different for each eligibility group. Broadly speaking we can break Medicaid eligibility into modified adjusted gross income (MAGI) and non-MAGI eligibility.

    The Affordable Care Act requires all states to use the MAGI to calculate the eligibility for certain types of applicants (pregnant women, children, and the newly eligible Medicaid expansion adult population). These populations receive benefits that are similar to private health insurance – hospital services, doctor services, and pharmaceutical drugs. They do not receive Medicaid long-term care services.

    There are certain groups that are exempt from MAGI eligibility (referred to as non-MAGI). These are Medicaid programs for the blind, disabled, and those over 65. These groups receive long-term care services and for those services they were (and still are) subject to asset tests. Despite some spousal impoverishment protections, this is the population that would likely engage in medical divorces because private insurance and Medicare does not cover long-term care and Medicaid is the primary payer for long-term care services. Without Medicaid, people often pay up to $60,000-$80,000 annually for long-term care services which could impoverish families.

    There could be some people that are early retirees or couples that might need cancer care or other expensive hospital procedures and would qualify for asset-test free Medicaid expansion, but these are likely rare cases linked to divorce.

    The paper may benefit from looking at divorce rates for populations over the age of 65 in states that have expanded versus those that did not expand. This might provide a more complete picture since the population over 65 is likely to include some people who would divorce because of Medicaid asset test eligibility. If divorce rates decreased by a similar amount for this group as for the under-65 group the authors studied, that would suggest that there are other factors other than Medicaid expansion causing rates to fall (because Medicaid expansion did not apply to the elderly population).

    Not only have (non-MAGI eligibility) asset tests not gone away, they’ve become more stringent. For example, in California, the asset test for a couple to qualify for Medicaid disability coverage was $3,000 in 2016. California has not increased that amount in nearly 30 years. The real value of that asset has halved since it was put into place in 1989. I wrote a longer explanation of this issue here.

    The financial security that Medicaid provides does have large scale effects. Financial insecurity is a leading cause of divorce in the US. It is conceivable that there are more financially secure couples who are less likely to divorce because of the safety net of Medicaid expansion. Alternatively, there are many other causal factors that could be reducing divorce as the authors note, but unfortunately asset limits remain a hurdle for many couples to overcome to receive Medicaid services.

    Update: David Slusky responded to this post in a tweet that includes a chart pertaining to the 65+ population.

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  • Docs can safely talk about guns with patients again in Florida

    There’s just so much S#!T in the news every day that important stuff seems to fly under the radar. Like this:

    A federal appeals court cleared the way on Thursday for Florida doctors to talk to their patients about gun safety, overturning a 2011 law that pitted medical providers against the state’s powerful gun lobby.

    In its 10-to-1 ruling, the full panel of the United States Circuit Court of Appeals for the 11th Circuit concluded that doctors could not be threatened with losing their license for asking patients if they owned guns and for discussing gun safety because to do so would violate their free speech.

    I’ve written a number of times, most importantly in the NYT, about the laws in some states (like Florida) that attempted to prohibit doctors from talking to their patients about gun safety. My prior pieces stand.

    The bottom line is that trying to restrict what doctors can talk about was found to violate First Amendment rights of physicians. The appeals court did find that one part of the law, which said doctors can’t deny service to patients because they own guns, was constitutional. That wasn’t what this lawsuit was about, but that much stands – appropriately.

    Regardless, you can still lie to your doctor if you want, about guns or any other issue; you’re not under oath. You can also refuse to answer any questions; you’re not under subpoena. Neither will help doctors to help you, but they’re entirely within your rights. Demanding doctors not ask you certain questions isn’t.


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  • Why the feds must take the lead on health reform.

    In yesterday’s post on my new draft essay, Federalism and the End of Obamacare, I emphasized the benefits of returning more regulatory authority to the states. Today, I’d like to draw out a different point: the need for the federal government to take the lead when it comes to financing health reform.

    The states face two enormous obstacles to achieving near-universal coverage on their own. First, the states don’t have the same fiscal capacity as the federal government. Keep in mind that the ACA is a large, countercyclical spending program:

    When a recession hits, many people will lose both their jobs and their employer-sponsored coverage. The ranks of those eligible for Medicaid and for ACA subsidies will predictably grow, leading to larger federal outlays. At the same time, the economic downturn will depress tax revenues. The federal government can deficit-spend to manage these countercyclical fluctuations. The states, however, cannot. With the exception of Vermont, the states are legally obliged to balance their budgets every year. And states are understandably reluctant to adopt large obligations that will require savage spending cuts or hefty tax increases when times get tough. Cuts and taxes are not only unpopular, but they would also depress the economy further, exacerbating the recession. Broad coverage expansions thus commit states to an economic policy that could inflict serious damage on their residents.

    Second, ERISA poses an enormous problem for states that want to tackle health reform.

    No government, state or federal, likes to impose new taxes. But governments face a special challenge when their residents can complain that the new tax is discriminatory. That problem arises with particular force when states try to impose new taxes to finance a coverage expansion. A resident who gets health coverage through her job—let’s call her Anna—already faces a reduction in take-home pay commensurate with the value of that coverage. Another resident who works at a similar job but does not get health coverage—let’s call him Bob—likely receives higher cash wages. Should Anna and Bob both face the same new tax, even if it finances a coverage expansion that will only benefit Bob?

    Penalizing employers who fail to offer health coverage to their employees avoids this problem. “Pay or play” laws thus have a clear political logic: employers that don’t offer coverage are failing to live up to their end of the social bargain. They have a certain economic logic, too: if Bob starts getting coverage through his employment because of a pay-or-play law, he will see an offsetting wage reduction, tying the costs of coverage to the person who receives it.

    The trouble is that ERISA preempts state laws that “relate to any employee benefit plan,” including a plan offering health coverage. Although there is some legal uncertainty, preemption probably means that states cannot impose a penalty on employers that refuse to offer health coverage. By taking pay-or-play laws off the table, ERISA complicates the politics of financing state efforts to achieve near-universal coverage.

    Taken together, these legal obstacles—state balanced-budget rules and ERISA—will predictably frustrate state efforts to achieve near-universal coverage. (Massachusetts and Hawaii, as I discuss in the essay, are the exceptions that prove the rule.) Federal money is thus the lifeblood of health reform; the states can’t go it alone.


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  • Federalism and the End of Obamacare

    That’s the title of my new essay, which the Yale Law Journal Forum has published in draft form. Here’s the abstract.

    Federalism has become a watchword in the acrimonious debate over a possible replacement for the Affordable Care Act (ACA). Missing from that debate, however, is a theoretically grounded and empirically informed understanding of how best to allocate power between the federal government and the states. For health reform, the conventional arguments in favor of a national solution have little resonance: federal intervention will not avoid a race to the bottom, prevent externalities, or protect minority groups from state discrimination. Instead, federal action is necessary to overcome the states’ fiscal limitations: their inability to deficit-spend and the constraints that federal law places on their taxing authority. A more refined understanding of the functional justifications for federal action enables a crisp evaluation of the ACA—and of replacements that claim to return authority to the states.

    The upshot of the piece is that there’s much to be said—more than the ACA’s supporters generally acknowledge—for returning power to the states. That’s so even with respect to some of the ACA’s most sacrosanct provisions:

    [C]onsider the ban on medical underwriting. The ACA reflects the judgment that it is unfair to deny coverage to the sick or to ask them to pay more for their coverage. The ACA thus embraces policies—in particular, the much-maligned individual mandate—that its drafters thought necessary to cope with the risk that people will wait until they got sick to purchase coverage. For the ACA’s supporters, the individual mandate is a reasonable price to pay to prevent discrimination against the sick. But many people don’t see it the same way. Some reject the claim that the government should be in the business of guaranteeing coverage for everyone. Others don’t think that medical underwriting, however distasteful, warrants a heavy-handed purchase obligation. Still others doubt that the individual mandate is strictly necessary to prevent adverse selection, and would prefer less-intrusive alternatives. If those who disagree with the ACA’s approach command the levers of political power within a state, why shouldn’t those states be allowed to try something different?

    The argument can be generalized to most of the ACA’s insurance reforms. And I can already hear the response: Because this “something different” will not work. The ACA’s opponents are completely unrealistic about the tough tradeoffs that health-care policymaking entails. They will take federal money and squander it, leaving millions of people without coverage.

    That might be right; indeed, I suspect it is right. But that’s my judgment. Lots of smart people do not share that judgment. And if federalism means anything, it is that national judgment should not supersede state judgment, absent a good reason for federal intervention. Yes, federal money might be squandered in a state that adopts stupid insurance rules. People could go bankrupt and even die as a result of the lack of coverage. But that’s an issue between the state and its voters. If other states use the money more effectively, the state with the stupid rules will come under pressure to improve them. And what if it turns out that what seemed stupid is not so stupid after all?

    Democracy rests on the conceit that we all have an equal voice in determining what the good is, which is why Michigan voters don’t get to tell Ohioans how to spend their tax dollars, even if Wolverines know in their hearts that they make better decisions than Buckeyes. And while the federal government can make decisions for Ohio, it should not do so just because it doubts the wisdom, intelligence, or values of Ohio residents. “The states have bad ideas” is a poor justification for federal law (unless, again, those bad ideas turn on views about the inferiority of minority groups). Federalism thrives when we recognize the limits of what we know, appreciate that good people can hold views that many others find repugnant, and acknowledge that our own misconceptions and prejudices can blind us. Sometimes federalism means letting the states wave their crazy flags.

    I’d welcome any suggestions and criticisms. And a big thank you to the Yale Law Journal, which has moved with stunning speed to get the piece up.


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