• Some of Trump’s Most Devious Lies Are About Health Care

    Coming hot on the heels of my appearance on This American Life, I’ve got an op-ed in the New York Times today.

    As Democrats debate the best way to achieve universal coverage and lower health care costs, the Trump administration has a different approach to the challenges of our current system. It’s working overtime to make the system more fragile for the sick and the poor, even as it misrepresents to Congress and the American public what it’s up to.

    Speaking to reporters in late October, President Trump said that “we have a great Republican plan” to replace the Affordable Care Act. “Much less expensive. Deductibles will be much lower.” His statements came on the heels of a congressional hearing in which one of his top health officials, Seema Verma, said that the administration would do “everything we can” for Americans with pre-existing conditions. Under oath, she swore that the administration was aiming to help people find a pathway out of poverty.

    None of this is true.

    You can read the whole thing here.


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  • This American Life

    In one of those “wait, this really happened?” moments, I made an appearance on This American Life to discuss Texas v. United States. The story came from David Kestenbaum, who framed the case around the idea of dividing by zero. “Mathematicians,” he said, “call this kind of situation a singularity, where the math is not well-behaved.” So too with the weird possibility that eliminating the mandate penalty could bring the whole Affordable Care Act crashing down.

    Here’s my favorite part of the story:

    David Kestenbaum

    I talked to Bagley back in July on the day that the appeals court heard the case. We listened together online. The arguments the lawyers made were all about standing, severability doctrine, the meaning of the word shall. What did Congress intend when it set the tax to zero? It did not go well for the Affordable Care Act, for Bagley’s side. You could tell from the judge’s questions. Bagley’s exact words while we listened included things like–

    Nick Bagley

    Oh, Jesus.

    David Kestenbaum


    Nick Bagley

    This is really bad. This is really bad.

    David Kestenbaum

    And finally–

    Nick Bagley

    This is about as bad as you could expect from an oral argument.

    David Kestenbaum

    He was truly surprised. He thought the legal argument that zero could take down the whole law was, quote, “weak to the point of frivolousness.”

    I remain of that view, of course. The Fifth Circuit could decide the case any day. I’m waiting with bated breath.


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  • Does Poor Sleep Contribute to Alzheimer’s Disease?

    Alzheimer’s disease is no stranger in the news cycle. The latest headlines are dedicated to a new study on how the brain keeps itself clean, a process which scientists have long suspected to be involved in the disease. Let’s take a look.



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  • JAMA Forum: Making Health Care More Productive

    With a staggering amount of waste, as documented in the recent JAMA study, a key question is whether our health care system can produce the same or better outcomes for less money—in other words, can it become more productive or efficient? Until recently, the answer seemed to be “no.” But things may be changing.

    That’s me on the JAMA Forum attempting to put an optimistic spin on the future of U.S. health care. The rest of the piece points to areas where we have good evidence or reasonable expectation of increasing productivity. But, I’d be first to point out that they won’t purge all or even most of the waste from the system. Indeed, the piece ends,

    None of this means there isn’t waste in the health care system. The latest estimate suggests as much as 25% of spending in this area is wasteful. Even if the health care system is becoming more efficient in some ways, that doesn’t mean it’s as efficient as it could be or that we’re definitively on the road to driving out all the waste. History suggests that improving productivity in health care is extremely hard and extremely rare.

    Go read the whole thing. (Background research for the piece was supported by the Laura and John Arnold Foundation.)


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  • Food Insecurity and Health

    About 50 million people in the United States don’t have access to enough food to support a healthy lifestyle. The technical term for this is food insecurity, and over 40% of people in the United States will experience it during their adult lives. This pervasive problem has a lot of associated health effects, too.




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  • Sleep Can Be Good for Your Salary

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). It also appeared on page B3 of the print edition on November 6, 2019.

    Daylight Saving Time ended on Sunday, and for many of us the extra hour of sleep has provided a small energy boost. It’s widely known that sleep affects our mood and health. Less understood is how it can also affect our paychecks.

    A study published last year in the Review of Economics and Statistics found that workers who live in locations where people get more sleep tend to earn more than those in areas where people get less.

    One theory: Better-rested workers are more productive and are compensated for it with additional income. “There are other explanations, but we consider them less likely,” said an author of the study, Matthew Gibson, an economist at Williams College.

    It’s not as if simply sleeping more will cause your boss to pay you more. In fact, if you get that extra sleep by being late for work, you might earn less or even lose your job. So how would the sleep-income relationship actually work?

    Studying the issue is complicated by reverse causality: Not only does sleep affect work, but work also affects sleep. On an individual level, people who work more, and earn more for it, often sleep less. Studies show that higher-income earners sleep less than lower-income ones.

    That could be because higher-income people are spending more time working, so they have less time for sleep. Additionally, working more is stressful, and stress disrupts sleep.

    But poor sleep contributes to stress, too. A study in Sleep Health found that a poorer night’s sleep is followed by more stress and distracting thoughts at work. Other studies also find that less and poorer sleep is associated with more conflict and stress the next day.

    Consider this possible sequence: Good sleep habits could help a person land a high-income job, but the new job could be so demanding and stressful that the person sleeps less. To achieve a promotion, though, and even higher income, it could be helpful to make adjustments to get better sleep again.

    More generally, many studies find worse work performance follows poor sleep. For example, tired doctors make more mistakes, and tired students get lower test scores. This is one rationale for starting school times later to give children a better chance at more sleep. It not only lifts academic performance but their long-run incomes as well, research shows.

    One study found that delaying school start times to 8:30 a.m. or later would contribute $83 billion to the American economy within a decade. The gains would come in part through decreased car crashes — lowering the costs in mortality and lifetime productivity. Another contributor would be the students’ increased lifetime earnings from better school results.

    The Review of Economics and Statistics study dodged reverse causality when comparing average earnings in different locations by exploiting the variation in sunset time within time zones. Our circadian rhythms are partly tied to sunlight: We tend to go to bed earlier when sunset is earlier. But the time of sunrise has less effect on sleep habits. Workers in similar jobs wake up at roughly the same time, because work and school tend to start at the same time throughout a time zone. Therefore, workers farther east in a time zone, where the sun sets earlier, get on average more sleep than comparable workers farther west.

    Of course, many other factors besides sunset time can influence how much individuals sleep. We’ve all heard of people who seem to get by just fine on short rest. Some studies in recent years have identified a genetic explanation for why some can thrive despite getting a lot less than eight hours of sleep.

    But few other factors could affect sleep duration for an entire region. The time-zone study found that an additional hour of weekly sleep could increase earnings by 1.1 percent in the short run and as much as 5 percent in the long run.

    “You likely won’t get a 5 percent increase in your income from sleeping an extra hour if your neighbors and co-workers don’t do the same,” said Jeffrey Shrader, the other study author and an economist at Columbia University. “The income boost relies on everyone in an area sleeping more.”

    The idea is that the entire economy is running at a slightly faster pace when everyone in it is better rested.

    The Boston area has a sunset that is about 50 minutes earlier than in Ann Arbor, Mich., which is at about the same latitude but farther west in the same time zone. As a resident of the Boston area, I probably get more sleep than my health economist colleagues at the University of Michigan, holding other things equal. That’s true of Boston workers in general, relative to comparable ones in Ann Arbor.

    This is far from the only difference between Boston and Ann Arbor that might affect incomes. There are probably different job opportunities, management styles and variation in negotiating leverage among unions in the two areas, for example. There are also lots of differences that influence cost of living and quality of life. So it would be silly to move just for a bit more sleep and associated increase to income.

    What’s not silly, and what a broad body of research highlights, is that sleep can be important for our mood and health, and our finances, too.


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  • Healthcare Triage Podcast: How Data and Tech Can Improve Healthcare

    We talk a lot about different areas of health research, and how that research may lead to treatments. Today we’re talking about research into healthcare itself, and how systems can be improved to deliver better outcomes and better healthcare. Our guest today is Dr. Peter Embi, MD, who is president and CEO of the Regenstrief Institute at the IU School of Medicine. He’ll tell us about the Institute’s work, and how making positive changes to how care is delivered on an institutional level can change care for millions of patients.


    The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.

    IU School of Medicine is leading Indiana University’s first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma and prevent type 2 diabetes and Alzheimer’s disease.

    Available wherever you get your podcasts! Including iTunes.


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  • Diet and Depression

    A recent study is getting a lot of press for its results on diet and depression, and it’s a randomized controlled trial!



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  • Jama Forum: History Suggests that Most Physicians Likely to Remain as Participants in Medicare

    As “Medicare for all” gains steam in the Democratic primary, many physicians are concerned about reduced revenues from the program compared with private insurance. Even an expansion of the program, as many candidates’ plans call for “Medicare for more,” causes angst. Inevitably, some physicians will threaten to opt out of Medicare and refuse to see patients.

    Should this be cause for angst? Read the rest here!


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  • It’s Halloween. Beware Urban Legends (and Cars).

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company)


    American children are more likely to be hit by cars on Halloween than on any other night of the year.

    But many of the concerns expressed each October — in the news media and among family and friends — are instead about the danger from candy poisoning by strangers.

    Almost all such cases have been found to be hoaxes or scares that lack substantiation. Some health centers even offer to X-ray treats to see if they’ve been tampered with. Studies have failed to show this does any good. If anything, the tests may provide a false sense of security.

    (Consider that our health system makes scans very expensive for patients who actually need them for serious illnesses or injuries, while offering this needless service free.)

    Pranks, hoaxes and folk tales — although perhaps in keeping with the Halloween spirit — can also spread misinformation, and the news media shares some culpability.

    In 1964, a woman named Helen Pfeil gave children packages of insect traps (clearly marked as poison), steel-wool pads and dog biscuits wrapped in aluminum foil. She said she had done so as a joke, because she felt many of the children trick-or-treating at her house were too old to participate. Though no children were harmed, she was arrested and committed to a state hospital for observation. The episode made national news.

    Joel Best, a professor of sociology and criminal justice at the University of Delaware who literally wrote the book on this, was a co-author of a study in 1985 that examined cases of “Halloween sadism”: episodes like Mrs. Pfeil’s, as reported in major newspapers across the country. First, he tabulated the number of reported cases each year from 1958 through 1984, then investigated each one further, with calls to police stations and hospitals.

    He found that they were all pretty much jokes gone awry or unverifiable rumors. In all the data, he found no evidence that any child had been seriously injured, let alone killed, by strangers tampering with candy.

    Of course, just because he couldn’t find a case doesn’t mean it never happened. He has continued his work, updating his findings online. Through 2012, he has found no proven cases of injury attributed to strangers tampering with candy.

    But certain cases are still cited. In 1970, Kevin Totson was reported to have been killed by heroin sprinkled over Halloween candy. Later, it was determined that the heroin hadn’t come from the candy, but from his uncle’s stash. Years later, Timothy O’Bryan died from a cyanide-laced pixie stick on Halloween. It turned out his father had killed him after taking out a life insurance policy on him.

    In both these cases, the danger came — as a Halloween-themed movie might demand it — from inside the house: from relatives, not strangers.

    There have been other cases in which candy was initially faulted. News reports in 1990 blamed candy tampering for the death of Ariel Katz in Santa Monica, Calif., but hospital tests failed to confirm poisoning. Something similar happened with Patrick Wiederhold in 1978 in Flint, Mich.

    The panic du jour seems to be marijuana candy, which authorities have already been warning parents about; opponents of marijuana legalization have sounded the same alarms for years, with little evidence. (It has never made much sense that people would give out their expensive edibles to children.)

    Yes, some children have ingested marijuana they should not have, and that’s a concern for parents. But in most cases, as it was with poisoning, the pot came from people the children knew well or were related to, almost certainly accidentally, not during trick-or-treating.

    That doesn’t mean children are safe on Halloween. A study published in JAMA Pediatrics this year reviewed the data on all American pedestrian fatalities on Halloween. The average Halloween, compared with other nights, resulted in four additional pedestrian deaths.

    Looking specifically at 4-to-8-year-olds, the pedestrian fatality rate was 10 times higher on that night compared with non-Halloween nights. Many more were surely injured.

    This danger gets comparatively less news coverage. Parents let children run rampant across streets as the sun sets. They let them go out in dark costumes that make it hard for drivers to see them. They let them wear masks that restrict their ability to see cars.

    The absolute number of children harmed on Halloween, of course, is small. Parents can weigh the risks for themselves, against the benefits in terms of their children’s delight and lifetime memories.

    But if people are going to worry about keeping children as safe as possible on Halloween, it seems they should focus on the dangers that are real: cars, not poison.


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