The Incidental Economist

Watching myself on television is a very painful experience.

It is a real privilege to be on Up with Chris Hayes this morning. It is such an intelligent and humane program. I really appreciated the opportunity.

There’s much wonderful reporting in Monica Davey’s front-page New York Times’ piece on Chicago’s current homicide challenge. But I hate the headline: “In a Soaring Homicide Rate, a Divide in Chicago.” To be more precise, I hate the first half of the headline. The second half is right on the money.

Why do I hate the headline? Below is the piece’s missing graph: Chicago homicides 1985-2012.

It’s obvious from the graph that the city’s homicides displayed a disturbing uptick. 2012 displayed an almost 20% increase over 2011.

That’s a serious concern. I co-direct the University of Chicago Crime Lab. We received many calls from reporters the night Chicago reported its 500^th homicide two weeks ago.

Without in any way diminishing the seriousness of the issue, I would emphasize that our homicide rate last year was far below Chicago’s rate in any year between 1985 and 2002. We had almost twice that homicide rate in the worst years of the crack epidemic. Chicago experienced a high homicide rate during the first quarter of 2012. Rates were quite similar to the past several years for the rest of the year.

Chicago is in the middle of the pack when compared with the broad swathe of American metropolitan areas. Chicago ranks 79^th on Neighborhood Scout’s list of the 100 most dangerous places to live in America. Chicago does not earn a place in the various “top ten” lists of the most dangerous cities in America…. Read the rest of this entry »

One sad outcome of yesterday’s vote didn’t get much attention: The demise of the Community Living Assistance Services and Supports Act (CLASS).

As many TIE readers know, CLASS was designed as a national voluntary insurance program for working adults who might someday face functional limitations. After a five-year vesting period, people with specific functional limitations would receive cash benefits, roughly on the order of $75/day. These benefits could be used to purchase specific services people require to live independently: a wheelchair ramp, maybe some direct care services, maybe modifications to a home or a vehicle to accommodate some disability:

It was an appealing vision. I was planning to enroll myself. I guess I’ll need a backup plan. The fiscal cliff agreement, passed Tuesday night in the House, repealed CLASS.

Yesterday’s vote made official what many people already knew. CLASS died because the financial numbers didn’t fully work, because the White House didn’t want to expend scarce political capital to fix it, and because our current polarized political environment so often thwarts efforts to repair complicated programs whose imperfections become known.

CLASS was a worthy, imperfect effort. Its lack of an individual mandate undermined the policy. Lack of a mandate also made it incredibly hard to predict who exactly would sign up, what self-financing premiums would need to be, and whether  CLASS would prove financially stable as required under the Affordable Care Act.

If CLASS went from a dead man walking to a dead man, it at least deserved a proper funeral with more than a few mourners. More from me here.

As Don Taylor reminds us, we can repeal CLASS, but we can’t repeal disability.

Yesterday’s New York Times included an obituary for the AIDS activist Spencer Cox. Dead at age 44 of AIDS-related causes well before his time, Cox played a key role in the Treatment Action Group, which did much to accelerate development and distribution of AIDS drugs. His death and the deaths of others remind us of one simple fact: HIV/AIDS is still with us. It’s still ending too many lives.

Overshadowed by the tragedy in Newtown and the fiscal cliff farce, CDC’s latest report–Estimated HIV incidence in the United States: 2007-2010–didn’t get the attention it deserves. It’s especially disappointing to see such limited attention within the blogosphere, and within the community of health policy wonks who comprise our core audience here.

Recent news is not very surprising. It is not especially good, either. An estimated 47,500 Americans became HIV-infected in 2010, about the same number of new infections as occurred in 2007. An estimated 29,800 of these infections occurred among men who have sex with men. MSM are the main risk group which demographically replenishes itself. As a result, MSM now account for more than 60% of all new HIV infections in the United States, and about 78% of all new infections occurring among men. The epidemic has already burned through the majority of injection drug users and several other groups facing particularly high risks.

It’s especially concerning that HIV incidence is growing among adolescents and young adults. In 2007, 13-24-year-olds accounted for 20 percent of new infections. By 2010, this age group accounted for 26 percent of new infections. Among MSM, 30 percent of new infections occur among those under the age of 25. HIV prevention through behavior change remains a huge challenge. (On Twitter, @jejunebug takes me to task for not noting the marked race/ethnic disparities in HIV incidence, with African-Americans accounting for 44% of new infections. Fair point. This indeed a very serious concern )

Notwithstanding wonderful treatment advances, HIV/AIDS still kills surprising numbers of Americans every year. It’s hard to be too precise here, since people living with HIV and AIDS can die of other causes. Since the epidemic began, more than 600,000 Americans have died after being diagnosed with AIDS. In 2009, there were another 18,000 estimated deaths of persons with AIDS diagnoses across the United States.* To put this in context, about 9,100 Americans died in gun homicides that same year. The annual AIDS death toll continues to rival the annual toll of American combat deaths during the worst years in Vietnam.

We should do better. The Obama years have included many public health advances. The language and values of public health are vastly better than the Bush era. The Obama administration embraces methadone maintenance, syringe-exchange, and evidence-based approaches to prevention education. Particularly in states that embrace Medicaid expansion, the Affordable Care Act (ACA) will markedly improve access to standard medical care, and to substance abuse treatment, and mental health care.  ACA’s Prevention and Public Health fund finances important HIV prevention interventions.

Yet the past four years have been times of lost opportunity, too. The great recession has greatly damaged state and local public health infrastructure. Tens of thousands of public health workers have lost their jobs. ACA’s prevention and public health fund has already been cut in the deficit ceiling fight. Sequestration would bring further public health cuts within the non-defense-discretionary components of the federal budget.

America’s $2.8 trillion health care economy will never give public health the emphasis it deserves. The political economy of this sector will always favor concentrated patient and provider constituencies who benefit from acute care investments over the relatively disorganized, low-income, and often politically marginal constituencies who benefit the most from HIV prevention and other investments in public health. The results are fairly predictable. That does not make them any more acceptable.

*In 2009, about half of deaths of Americans with HIV or an AIDS diagnosis were directly attributed to HIV/AIDS.  An unknown proportion of other deaths were hastened by the disease. So it’s probably more accurate to say that gun homicides and HIV/AIDS mortality are quite similar in their incidence in the U.S.

As I noted in my last post, Nicholas Kristof’s column left the impression that welfare dependence is a growing, chronic problem fed by ballooning SSI rolls:

More than 1.2 million children across America — a full 8 percent of all low-income children — are now enrolled in S.S.I. as disabled, at an annual cost of more than $9 billion.

To put this in context, I tracked down some trends in child poverty and welfare receipt over the period 1974-2010. (What I could find 2011 and 2012 seemed quite similar.) Here I included the number of children below age 18 who received either SSI or traditional cash welfare: Until 1996, this was known as Aid to Families with Dependent Children (AFDC). The 1996 welfare reform instituted the more constrained, time-limited program known as Temporary Assistance to Needy Families (TANF).

The ratio of children on cash assistance to children in poverty provides a useful, if imperfect measure of both program generosity and welfare dependence in America. As graphed below, the top green line represents the absolute number of children in poverty—more than 16 million people by 2010. The other two solid lines represent the number of children receiving AFDC/TANF and SSI, respectively, within a given year.

The most interesting curve is the dotted purple one, which is scaled to the right-vertical axis. This is the ratio of children receiving either form of cash assistance to the total population of children under the poverty line. About 28 percent of poor children received federal cash assistance in 2010. That’s less than half of the proportion observed at the passage of welfare reform.

As shown in the bottom curve, absolute SSI receipt is slowly rising. Yet after welfare reform, SSI rolls have held steady for fifteen years at just below eight percent of poor children. Of course, the most dramatic change is in the number and proportion of poor children who receive AFDC/TANF. Both have dropped by more than half in fifteen years. The absolute number of children receiving TANF has sharply declined, even as the absolute number of poor children has markedly increased.

Simply put, cash aid to families with children has failed to keep pace with a deeply punishing recession. As Kristof himself rightly notes,

Our political system has created a particularly robust safety net for the elderly, focused on Social Security and Medicare — because the elderly vote. This safety net has brought down the poverty rate among the elderly from about 35 percent in 1959 to under 9 percent today.

Because kids don’t have a political voice, they have been neglected — and have replaced the elderly as the most impoverished age group in our country.

For many years, SSI-eligible families faced strategic choices regarding whether to apply for SSI or traditional welfare. Families in more generous states were more likely to join AFDC. Families in low-benefit states were more likely to join SSI. The 1996 welfare reform obviously altered this calculation.

This reality creates both the temptation and the real human need to provide economic security and health coverage for families through SSI rather than traditional welfare. Medicaid expansion, CHIP, and health reform lessen the pressure, by providing a non-cash-assistance path to receive essential services. The dilemma remains pressing. Such pressures still provide one reason for the rising absolute number of SSI recipients during a deep recession.

I don’t see much evidence that overall dependence is worsening or that parents gaming the system is the key numerical challenge facing SSI in these difficult economic times. I believe Kristof was led astray by real, powerful, yet unrepresentative impressions of one segment of the SSI population. He is a gifted and humane writer. I hope he returns to this topic, with greater depth and context than he did this week.

It’s hard to write about anything this weekend beyond the awful events in Connecticut. Maybe the best we can do right now to honor yesterday’s victims is to reach out a helping hand to someone in our own lives who is suffering or grieving. Very best to everyone affected by the tragedy.

I did want to consider Nicholas Kristof’s New York Times column this week. His title, “Profiting from a child’s illiteracy,” presents the main thesis. Kristof visited rural Kentucky. What he saw there disturbed him:

This is what poverty sometimes looks like in America: parents here in Appalachian hill country pulling their children out of literacy classes. Moms and dads fear that if kids learn to read, they are less likely to qualify for a monthly check for having an intellectual disability.

Many people in hillside mobile homes here are poor and desperate, and a $698 monthly check per child from the Supplemental Security Income [SSI] program goes a long way — and those checks continue until the child turns 18.

“The kids get taken out of the program because the parents are going to lose the check,” said Billie Oaks, who runs a literacy program here in Breathitt County, a poor part of Kentucky. “It’s heartbreaking.”

This is painful for a liberal to admit, but conservatives have a point when they suggest that America’s safety net can sometimes entangle people in a soul-crushing dependency. Our poverty programs do rescue many people, but other times they backfire.

Kristof’s column was excoriated by many liberals, most recently in a nice piece by Kathy Ruffing and LaDonna Pavetti from the Center on Budget and Policy Priorities. (If you have extra geldt this holiday season, the indispensible nonprofit cbpp.org is always a good place to put it….)

Not everyone on the left was fair or civil. Matt Bruenig’s takedown was titled, “Nicholas Kristof is an irresponsible moron.” Although Bruenig presents valid criticism–see below, Kristof deserves a more respectful hearing. He has risked his life to report on many profound global health problems and violations of human rights. I admire him greatly for that. Read the rest of this entry »

I just returned from a nice short visit to Duke University, where I met many faculty from their Center for Child and Family Policy. Over breakfast with the distinguished psychologist Kenneth Dodge, I had a great conversation about a common but critical mental mistake you may never have heard of, but which has important implications.

Suppose you are a 17-year-old kid walking down the hallway of a large Chicago high school. Another boy bumps into you. Was he playin’ with you? Was he just distracted by a text he received from his girlfriend? You’re a 50-year-old middle-manager in a meeting with colleagues. Someone notes an embarrassing editing error in a memo you just wrote. Was she trying to show you up in front of the boss? Was she just trying to fix some glitch, or what? You’re an 18-year-old single mom, and your three-year-old is up crying once again at 2am. Is he waking you (again) because he’s angry that you didn’t let him have dessert, or does he simply have a stomach ache?

You can understand why actual human beings could reach different conclusions in each situation. In part, this is a matter of probabilities and costs. If someone bumped into me at the University of Chicago, I wouldn’t think anything of it. There’s no real cost in believing otherwise. Life moves on. If you’re a student one mile from my office at a tough school, that minor hallway collision isn’t always so accidental…. Read the rest of this entry »

Ron Fournier is editor-in-chief of the National Journal. He produced a simple and moving piece about his life with his son Tyler, a bright teenager who is diagnosed with Asperger’s syndrome.

Several aspects of the piece are striking. One is the simple, but actually not-so-simple connection between a father and a son who love each other, but are also quite different from each other. As Andrew Solomon emphasizes in his encyclopedic, beautifully-written Far from the tree, parents can feel at-sea as they seek to parent a children who is markedly different from most other children and from themselves. Sometimes these differences are rooted in physical, intellectual, sensory, or behavioral disabilities. Sometimes a child has special abilities in mathematics or music. Sometimes a child differs in gender identity, sexual orientation, or in other ways.

Whatever the source of marked differences, parents can easily feel that they are parenting a stranger. A child doesn’t arrive with an instruction manual that explains the right way to nurture, embrace, accept, and love this stranger. No instruction manual explains the proper balance between the drive to treat, ameliorate, or cure specific disabilities and the need to simply accept children with their differences, to love them as they are.

Nor do children have their own instruction manual to show them how to navigate their own way with parents, and how to address the human concerns, disappointments, and ambivalence so many accurately recognize in their parents from an early age. Awkwardly navigating a White House reception, 13-year-old Tyler says, “I hope I don’t let you down, Dad.” Millions of children will hope the same thing today.

Although there’s no instruction manual, loving and committed families such as the Fourniers find their path in a quietly heroic way.
Two details especially struck me.

One is the way a father was deeply committed to involving his son in team sports, and how Ron Fournier’s overly-directive efforts to force Tyler’s participation actually forced this loving father to recognize the challenges his son faces. I suspect that many parents of kids with autism spectrum disorders have some related experience around team sports.

Young parents come to sports with great aspirations for their kids. This is especially true of dads and their boys. Soccer and basketball require a wide range of cognitive, social-emotional, motivational, and motor skills. Kids must exercise these skills, on public view, alongside 15 or 20 classmates and peers. I know several people who say something of the form: “Watching that scene, I couldn’t avoid seeing that something really wasn’t right.”

It’s also striking for the humanity of two former presidents: Bill Clinton and George W. Bush. It’s pretty darned funny to hear Tyler’s reaction to a bloviating President Clinton:

“Nice guy,” Tyler whispered to me during a break in the tour. “He talked a lot about himself and his stuff.”  

Then there’s George W. Bush, who displays an unfeigned compassion and simple feel for people that I admire. He bears responsibility for a disastrous presidency. Yet there’s more to the man, too.

This is my second book club post on Kim Cordish’s and John Wilding’s Attention, Genes, and Developmental Disorders. My previous post can be found here.

Chapter 2, “What is attention?” jumps right to the substance.

As my commenter Weiwen already observed, attention is a multi-dimensional concept. One might define attention as coherent, organized, and goal-directed behavior…maintained in the face of distractions. This is a useful and plausible definition, but it can’t be fully right.

For one thing, your brain must decide what actually counts as a distraction. The inability to shift one’s attention in response to urgent information is—itself–an attentional disorder.  Sometimes the right response to important new information is to alter or abandon one’s immediate goal. Suppose, for example, that I’m at the store searching for yogurt. A fellow shopper falls to the floor in front of me because he’s having a heart attack. That’s not a distraction. If I stepped over him to continue my obsessive yogurt search, such behavior wouldn’t indicate concentration and focus. It would instead reflect a serious failure of executive function.

Our brains use many capacities to process a variety of external information. This information arrives in a steady stream. The simple act of yogurt buying requires a surprisingly complex sequence of skills: remembering where the yogurt is located, being alert to pertinent new information, being able to avoid the potential distraction provided by other information.

Pondering even very simple tasks, it’s obvious that attention can fail for different reasons in different ways. Some of the earliest research on these attention processes concerned vigilance: maintaining attention in low-input situations. How, for example, can radar operators spot rare but crucial signals that randomly appear after long periods of boring nothingness and false alarms?

Experiments indicate that vigilance declines depressingly rapidly. You might think that people become fatigued and just miss things. It’s more complicated than that. People seem to become jaded or complacent. They adjust their prior probability assessments to become more skeptical that an incoming signal represents a true threat. They detect fewer threats, and report fewer false alarms, too. You’re driving at night from Chicago to Cleveland on I-80. Two hours in, you catch an initial glimpse of something ahead of you in the road. Surely that’s not a person. There must be a smudge on the windshield or some blowing snow.

Other attention research concerned similar technologies but the opposite problem, in high-input situations. How do air traffic controllers recognize and address crucial problems that are often hidden within a barrage of other incoming data. In college, I worked as a short-order cook in a busy restaurant where cashiers would shout out a succession of orders during the crush of the dinner hour. I found it quite difficult to maintaining constant vigilance, particularly as I experienced physical and mental fatigue from the work. One’s circuits overload, perhaps literally.  As Dan Kahneman emphasizes in his own research and his recent book, maintaining attention in both high-input and low-input situations requires difficult mental effort that can exceed our available capacities.

These efforts are heavily dependent on control processes that occur in the brain’s frontal lobe. These processes coordinate our short-term switching of attention from one task or piece of information to another, as well as the holding of attention despite potential distractions.

Many researchers have sought to clarify the executive functions behind these processes. Some common themes are worth noting (p. 50):

1. Planning a strategy to address complex novel tasks, including situations where multiple tasks must be undertaken. Our brains analyze specific situations to determine the specific tasks that must be accomplished, and the specific operations required to accomplish the task, including establishing and controlling “the execution of sequences of selecting inputs and responses.” We must also hold the required information in working memory to accomplish the task. No less important, we must inhibit inappropriate responses, for example suppressing habitual responses to related familiar situations that don’t work in performing this novel task.
2. Maintaining attention to a plan, particularly when there are either frequent competing demands on our attention or when the required information arrives rarely and therefore might be missed.

If you are a policy person, your own attention may wander to organizational themes. How can homeland security agencies maintain the vigilance to recognize rare but deadly terrorist conspiracies? How can we design the control room of a nuclear reactor so that human beings actually respond to rare but crucial danger signs? How can we design surgical teams to minimize risks of medical errors or to improve vigilant responses to emergencies?  These are interesting questions. I hope to return to them.

But that’s not where Cornish and Wilding are headed. They want to understand what goes wrong in human brains that produces attention disorders: How genes and environment interact with these problems, how attentional problems can be ameliorated through training or through medications.

Chapter Three, “Genes and atypical attention,” takes up these questions. It introduces some important genetic conditions associated with attentional disorders.

@haroldpollack

…when he said: “What I would do if I were a Democrat running four years from now, I’d say, you know what, dental care will be included in Obamcare.”

Oral health continues to pose significant access and public health concerns. I’ve worked with various disadvantaged and low-income populations. So many people have obvious dental problems that create broader health problems, are quite painful, and are often stigmatizing in people’s everyday lives.

Aside from basic access issues, oral health care is a huge missed opportunity for broader public health. To take one example, most adults who report that they face individual HIV risks and yet have not been tested have recently visited a dentist. Many of these at-risk young adults have seen no other health care provider. The dental setting is a largely untapped context to diagnose hypertension and other conditions. Particularly with the emergence of improved oral diagnostics for HIV, diabetes, and various other conditions, we can do better.

A 2011 Institute of Medicine report outlines useful responses to these policy failures. Improved training would improve the capacity of dentists and other oral health professionals to serve vulnerable populations. Federally Qualified Health Centers provide particularly important services. Their capacity to provide dental services could be expanded.

We might also reconsider the multidisciplinary character of the oral health care workforce. Licensure requirements and reimbursement practices should be revisited to see which services could be economically and effectively provided by non-dentists in dentists’ offices or in other settings.

One basic problem is dental care’s segregated financing through plans that demarcate specific boundaries from medical care. The Affordable Care Act is embarrassingly silent about oral health. (Just do a word search on the word “dentist.”) Some help was provided to children. ACA included some provisions for the dental work force. Most importantly, FQHCs received significant support. There’s virtually nothing to improve adult access, to improve dental delivery systems, to improve reimbursement for evidence-based clinical dental services. Little public attention has been paid to whether and how dental plans should participate in health insurance exchanges.

We also ask too little of the dental profession itself, which remains ambivalent about its own involvement in public insurance programs. At times, the profession also adopts a guild-like protectionist stance against involvement of others in providing oral health. Even in basic matters such as smoking cessation, many dentists report that they are poorly-equipped to deliver basic preventive services. Dental insurers could provide better coverage for these services, which some plans are now exploring.

This issue hits home for me, particularly as I see state Medicaid programs retrench to limit access to adult dental services.

When my intellectually disabled brother-in-law Vincent moved into our house eight years ago, he hadn’t had a teeth cleaning in years. So we scheduled an appointment with our family dentist. We knew we needed to prepare him for it. So my two daughters, then ages 8 and 10, read him a picture book about going to the dentist.

When the dentist donned her mask, he smiled and said: “Like Hannah said,” The dentist scraped off layers of plaque. He was a fantastic patient; this couldn’t have been a lot of fun. Fortunately, his underlying oral health was good. That’s a sweet memory, for many reasons.

We’ve had various challenges finding a good dentist through the Medicaid program.  One day recently, Vincent announced that he and his housemates had all been to the dentist. My wife looked quizzical and asked Vincent to open his mouth. The dentist had barely cleaned Vinnie’s teeth. The guy had made a cursory effort and then just prescribed a prophylactic antibiotic for gum disease.

Since then, Illinois became one of the many states—including many traditionally liberal ones–that have retrenched coverage or consigned adult dental coverage to an emergency-only program.

Romney is right. I only hope that Democrats take his advice.

Postscript: For more, see Sarah Kliff here.