• The Reasonable Way to View Marijuana’s Risks

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

    Are we underestimating the harms of legalizing marijuana?

    Those who hold this view have been in the news recently, saying that research shows we are moving too far too fast without understanding the damage.

    America is in the midst of a sea change in policies on pot, and we should all be a bit nervous about unintended consequences.

    Vigilance is required. But it should be reasoned and thoughtful. To tackle recent claims, we should use the best methods and evidence as a starting point.

    Crime has gone up in Colorado and Washington since those states legalized marijuana. It’s reasonable to wonder about the connection, but it’s also reasonable to be skeptical about causation.

    The best method to investigate this may be synthetic controls. Researchers can use a weighted combination of similar groups (states that are like Colorado and Washington in a number of ways) to create a model of how those states might have been expected to perform with respect to crime without any changes in marijuana laws. Benjamin Hansen, a professor of economics at the University of Oregon, used this methodology to create a comparison group that most closely resembled the homicide trends and levels from 2000-12.

    “I picked those years because they were after the tremendous crime drop in the early ’90s and most predictive of crime today,” he said. “I ended in 2012 because that’s when Colorado and Washington voted to legalize marijuana.”

    This model showed that we might have predicted more of an increase in Colorado or Washington just based on trends seen in comparable states, even without legalization. When he compared the two states with the synthetic control, Colorado and Washington actually had lower rates after legalization than you’d expect given trends.

    This is not evidence that legalization lowers crime rates. But it does suggest that we shouldn’t conclude that it increases them. A number of other studies agree.

    A potential misperception involves automobile crashes. Drunken drivers are measurably impaired when their blood alcohol level is above a certain level. We can prove this in randomized controlled trials.

    The tests we use for measuring the presence of THC, though, do not measure the level of impairment. They measure whether someone has used marijuana recently. If we legalize the drug, and more people use it, more people will register its recent use even when they are not impaired. So it should be expected that more people involved in car crashes will test positive even if no one is driving while high.

    Using a synthetic control approach, Mr. Hansen and colleagues showedthat marijuana-related fatality rates did not increase more after legalization than what you would expect from trends and other states.

    Dr. Ziva Cooper is one of the authors of the National Academies of Sciences, Engineering, and Medicine’s comprehensive report on cannabis.

    She says some have misinterpreted the report to state that the report’s committee concluded that cannabis causes schizophrenia. It did not.

    “This was stated as an association, not causation,” she said. “We do not yet have the supporting evidence to state the direction of this association.”

    Dr. Cooper, research director of the U.C.L.A. Cannabis Research Initiative, went further: “We as a committee also concluded that a history of cannabis use is associated with better cognitive outcomes in people diagnosed with psychotic disorders. The blatant omission of this conclusion exemplifies the one-sided nature of some articles. Nonetheless, the strong association between cannabis use and schizophrenia means that people with predisposing risk factors for schizophrenia should most certainly abstain from using cannabis.”

    No one should be under the impression that marijuana is harmless. The potential downsides are well known, and I’ve covered them. Nor should anyone be irrationally exuberant about its upsides. It’s not a wonder drug, and the proven benefits are also minimal (as I discussed here).

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  • Healthcare Triage: That Low Salt Diet Probably Won’t Prevent Heart Failure

    There have been lots of recommendations over the years to eat a low-sodium diet. We’ve talked about the evidence on this before. Well, get ready to taste salt again. Research points to the conclusion that low sodium diets don’t do much to help with heart failure.

    This episode was adapted from a column I wrote for the Upshot. Links to sources can be found there.


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  • Blocking the Trump administration’s contraception rules (again).

    Yesterday evening, a California federal judge enjoined the Trump administration from enforcing two rules that would greatly expand the exemptions to the Affordable Care Act’s contraception mandate. The injunction applies only in the plaintiff states, which include California, New York, Virginia, and ten others, as well as Washington, D.C.

    I’ve written extensively about these rules, one of which offers an exemption for employers with religious objections to offering contraception coverage, and the other of which extends to those with moral objections.

    * * *

    The crux of the fight over the religious-exemption rule is whether a federal agency can invoke the Religious Freedom Restoration Act to craft exemptions from statutes that, in the agency’s judgment, burden religious exercise. (Judge Gilliam rejected, for the same reasons I gave here, an unrelated—and completely bogus—statutory argument for the exemption.)

    RFRA says that any statutes that Congress adopts are “subject” to RFRA “unless such law explicitly excludes such application.” So maybe Obamacare should be understood to contain within it a silent proviso: agencies must faithfully implement the law as written, except to the extent that doing so would conflict with RFRA. That’s what the Little Sisters of the Poor has argued: that Congress “delegated authority to the agencies to create exemptions to protect religious exercise,” such that RFRA “operates as a floor on religious accommodation, not a ceiling.”

    The view has some force. Agencies will usually have a better sense than courts of whether and how their own rules will burden religious exercise. They’re also more politically accountable than courts, which may equip them to weigh an incidental burden on religion against the substantiality of Congress’s interest in adopting the law. And they’ve got the wherewithal to create context-sensitive rules that offer the regulated community clarity about RFRA accommodations, without the need to resort to costly litigation.

    The trouble with that argument, however, is that RFRA contemplates that courts will grant relief for any violation, not agencies. Congress hasn’t explicitly delegated to agencies the power to craft exemptions from generally applicable laws, and the courts probably shouldn’t presume agencies can wield that open-ended power without some clearer indication from Congress. An agency’s views about RFRA’s application are entitled to respectful attention—but the courts still make the final call.

    That’s Judge Gilliam’s view, anyhow. As he sees it, after several rounds of litigation, the federal courts have almost uniformly coalesced around the view that a set of Obama-era exemptions are sufficient to comply with RFRA. He doesn’t think the Trump administration has the authority to go further: “the courts, not the agencies, are the arbiters of what the law and the Constitution require.” He explains:

    The Court questions the Little Sisters’ contention that RFRA effected a wholesale delegation to executive agencies of the power to create exemptions to laws of general applicability in the first instance, based entirely on their own view of what the law requires. As this case definitively demonstrates, such views can change dramatically based on little more than a change in administration. In any event, there is no dispute that both the prior and current Administrations have contended that they have administered the ACA in a manner consistent with RFRA. But the courts are not concerned, at all, with the Federal Defendants’ desire to “avoid litigation,” especially where that avoidance means depriving a large number of women of their statutory rights under the ACA.

    * * *

    The religious-exemption rule presents some thorny legal questions. The rule governing moral exemptions, which was crafted to benefit just two non-religious anti-abortion groups, does not. It’s flat-out illegal, and obviously so. Here’s my take from back in October 2017:

    In a truly baffling legal argument, HHS identifies a long string of statutes that ostensibly “show Congress’ consistent protection of moral convictions alongside religious beliefs in the Federal regulation of health care.” … [But n]one of th[ose] statutes purport to give HHS the authority to craft a freestanding “moral exemption” from the obligation to cover preventive services for women. To the contrary, the statutes demonstrate that, when Congress wants to add a moral exemption to a statute, it knows how to do so. Far from supporting HHS’s action, all of these statutes undermine it.

    In his opinion yesterday, Judge Gilliam came to the same conclusion:

    Congress mandated the coverage that is the subject matter of this dispute, and rejected a “conscience amendment” that would exempt entities like March for Life from this generally-applicable statutory requirement. The Final Rules note that “[o]ver many decades, Congress has protected conscientious objections including based on moral convictions in the context of health care and human services, and including health coverage, even as it has sought to promote access to health services.” But that highlights the problem: here, it was the agencies, not Congress, that implemented the Moral Exemption, and it is inconsistent with the language and purpose of the statute it purports to interpret.

    * * *

    I’d expect the Trump administration to appeal the decision, and fast. (Or as fast as possible, under the circumstances. The Justice Department has been asking courts to pause most of its cases during the shutdown.) Either the Ninth Circuit or the Supreme Court could vacate the injunction while the appeal proceeds. If they don’t, however, the injunction could remain in place through the 2020 election.

    There’s a decent chance, then, that these contraception rules will never take effect in the 13 states that brought this lawsuit.


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  • Healthcare Triage: Rural Hospital Closures Impact the Health of a Lot of People

    Rural hospitals in the United States are having an increasingly hard time staying in business. Which is not great for the health of people who live in areas that no longer have a hospital.

    This episode was adapted from a column Austin wrote for The Upshot. Links to sources can be found there.


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  • Advantages of passive policies

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). It was jointly authored by Austin Frakt (@afrakt) and Gilbert Benavidez (@GBinsolidarity) and also appeared on page 5 of the Sunday Business section of the print edition on January 13, 2019.

    $100 billion dollar health care package was proposed by congressional Republicans this past summer, and afterward endorsed by some Democrats. It aims to save money by encouraging you to make big life changes. But the package will probably fail to achieve its goals for a simple reason: scarcity. Chances are you don’t have the time, money or bandwidth to follow through.

    The legislation is expected to be reintroduced in the first quarter this year, and it has laudable goals. It encourages exercise by treating gym memberships as tax-deductible medical expenses. It would help cover out-of-pocket costs for high-deductible health plans by allowing people to deposit more money in tax-shielded health savings accounts. And it would permit the use of flexible spending accounts and health savings accounts to buy sports equipment.

    In other words, the spending package is intended to nudge Americans to exercise more and to get a better handle on their finances. But it would require people to restructure their lives in response to modest financial incentives. The package is an active policy: It requires opting in.

    Most of us won’t. We’re experiencing multiple, and often compounding, types of scarcity.

    “Scarcity in one walk of life means we have less attention, ‘less mind,’ in the rest of life,” wrote Eldar Shafir and Sendhil Mullainathan, Princeton and Harvard University professors who study behavioral economics. They refer to scarcity as a “cognitive tax” that makes it hard for people to live healthy lives and make health-promoting choices.

    Perhaps the most familiar source of that cognitive tax comes from a busy professional and family life. After working a full-time job, many people spend the rest of the day chauffeuring children to activities, helping with their homework, making dinner and taking care of household chores. As Claire Cain Miller of The Upshot wrote recently, modern parenting seems unending, especially for working mothers.

    As a result, many people struggle to get to the gym or to muster theattention span to delve into finances.

    Choices involving money and health are especially tricky, as shown by a survey of studies on the relationship between stress and decision making. They often require people to make decisions despite inadequate information and lots of uncertainty. The resulting stress impairs the ability to make good choices. One experimental study, for example, found that stressed individuals tend to make riskier decisions.

    Scarcity is an especially tough problem for those struggling every day to make ends meet. In addition to time and money, some Americans might also lack educational opportunities and social support.

    That’s why active policies haven’t proved very helpful for the 50 million U.S. citizens who live in poverty. Work by the University of Southern California economics professor Leandro Carvalho and colleagues showed that low-income people were more “present-biased” after payday, worrying about the immediate more than the long-term effects of their decisions.

    Some people will benefit from active policies, but they’ll disproportionately be those who would have done what the policies encourage anyway. That’s a big part of why wellness programs — which provide financial incentives for healthy activities or preventive care — don’t work, as numerous studies have shown. Even without the programs, those people would have been likely to exercise, eat well and get preventive care. A wellness program tends to just throw another financial break at those who don’t need it.

    Likewise, studies have shown that health savings accounts are used primarily by wealthy people less in need of help with medical expenses. In financial literacy quizzes, a national survey found that college graduates and those making more than $75,000 per year did much better than other groups. This explains why people with an abundance of opportunity — those with higher incomes and more education among them — are likelier to make sound financial decisions, like investing in health savings accounts.

    In contrast, scarcity of money and education is correlated with lower rates of financial literacy, and, consequently, misinformed financial decisions like using costly payday or high-interest home loans. Moreover, tax-deferred vehicles like health savings accounts are less beneficial for those in lower tax brackets and virtually useless for families who lack surplus income to devote to the account.

    So if active policies fail most of us, what works? The evidence suggests it’s passive policies. These are programs that don’t require individual action; you’re not expected to add another task to the to-do list. Examples include default enrollment in a 401(k); in the health realm, they are public health efforts like water fluoridation and air quality improvement.

    Other advanced nations tend to have universal health systems that are simpler, while in the United States, the many types of plans and premiums introduce complexity and increase the time necessary to enroll. Millions of Americans select from a large variety of health plans each fall, for example, and research shows they tend to makes mistakes, often paying more than they need to.

    So long as they’re well designed, public health policy and programsthat work passively seem more likely to improve our lives by acknowledging and respecting just how busy and distracted we are.

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  • A more thorough analysis of marijuana use and homicide in Colorado and Washington

    I was annoyed by much of the media coverage recently on the dangers of marijuana. I was contacted by Benjamin Hansen, W.E. Miner Professor of Economics, University of Oregon, who wrote this post. TIE readers are simply the best. – @aaronecarroll

    Correlation is not causation.  These are the oft-repeated lines almost anyone can utter when they don’t agree with a statistic they come across.  Recently, the book “Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence,” has attracted both fierce fans and foes, based on its Amazon review rating which sits at exactly 3, with an even split of 1-star and 5-star reviews. When can we trust a correlation tells us something about causation? That’s where randomization helps.  However, for many studies randomization isn’t feasible due to either financial, political, or ethical constraints.

    Such is the case with marijuana and how it relates to violence in humans.  It is ILLEGAL to randomize exposure to marijuana for humans due to both marijuana’s scheduling and institutional review boards that require researchers seek to “maximize benefits while minimizing harm”.  Even if one could legally do this research, actually measuring impacts on violence might be impossible, because relatively few people commit violent crimes.  Putting this in context, there are only 4.9 murders per 100,000 people in the United States.  So even if we did a large scale randomized study of 10,000 participants with high compliance costing millions of dollars, we could never know anything about murder and weed.  Likewise, assault rates are roughly 250 per 100,000, so we’d only pick up effects on assaults if the impacts were gigantic.

    All of the constraints above are why social scientists have often relied upon quasi-experimental methods.  These methods allow researchers to construct control groups to try to predict what would have happened in the absence of medical treatment, a law change, or a new policy regime. Given the recent debate surrounding “Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence,” I decided to ask if the data supported the violence-marijuana hypothesis.  Using the approach of Abadie, Diamond, and Hainmuller, I predicted the best synthetic Colorado and synthetic Washington based on a weighted average of states that closely follow Colorado and Washington’s trends.  Below I plot the figures of each state relative to their synthetic counterpart.

    While it is true that homicide rates went up in CO and WA more than they rose for the nation as a whole, the homicide rates in Colorado and Washington were actually below what the data predicted they would have been given the trends in homicides from 2000-2012.

    This suggests, at best, we can’t conclude that marijuana legalization increases violence, and perhaps even there could be small negative effects. You might say, naturally, “That’s fine.  But could these approaches or other related approached reasonably have picked up increases in violence if they were present?  The answer is “yes”, and they already have, but for another drug: alcohol.  Anderson, Crost, and Rees found violent crime increased in Kansas after they legalized access to alcohol statewide in 1986.  Moreover, Carpenter and Dobkin found arrests for assault jump by 11 percent when people get access to alcohol (see figure 3 from their manuscript) using arrest records from California.  We replicated these findings using similar data from Oregon.

    Does this mean we shouldn’t caution our children about marijuana abuse and dependence? Of course not.  But it is also worth noting the sky isn’t falling in Colorado and Washington, at least any more than what we have predicted had they not legalized in the first place.


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  • Come hear the Apollo Ensemble of Boston

    What: “An Evening in Vienna”

    Beethoven: Overture to Egmont, op. 84
    Schoenberg: Chamber Symphony No. 1
    Mozart: Symphony No. 41 (“Jupiter”)

    When: Friday, January 11, 2019 at 8 PM

    Where: St John’s Church, 1 Roanoke Ave, Jamaica Plain, Massachusetts 02130 (House open 30 min before concert. Venue is wheelchair accessible, restrooms require assistance for wheelchairs.)

    Tickets: Available online or at the door

    $25 General Admission
    $20 Senior
    $10 Student
    Pay What You Can
    Season Passes Available

    More About the Concert: Beethoven’s most loved concert overture, his overture to Egmont starts this exciting program. This is followed by an early masterpiece of Schoenberg’s, his Chamber Symphony No. 1. Written before he developed his famed twelve-tone technique, this work grows out of Richard Strauss’ style and provides a fascinating bridge between the music of the late German Romantics (Mahler, Strauss, and even Brahms, in particular) and 20th century modernism. Indeed, Schoenberg is able to successfully channel the immensely diverse color palette of a Mahler symphony into a work for only 15 instrumentalists. A brief intermission will follow, and the evening will close with Mozart’s greatest symphonic masterpiece, his “Jupiter Symphony.”

    About the Apollo Ensemble: Founded in the summer of 2018 by Elias Miller and Michael Tabak, the Apollo Ensemble of Boston is a new, 40-member chamber orchestra made up of some of the area’s best musicians. Apollo’s inaugural concert, a performance at the First Baptist Church of Medford in June, 2018 featured the music of Strauss, Wagner, and Stravinsky. Elias Miller conducted the well-attended and well-received event. In the future, the Apollo Ensemble looks forward to many more community concert performances in the Boston area featuring music written for both chamber orchestra and for large chamber ensemble.

    (I am honored to join the ensemble on trumpet. If you attend the concert because of this post, please find me during intermission or afterwards and say hello.)


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  • Congratulations on the Promotion. But Did Science Get a Demotion?

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    number of recent news articles have brought renewed attention to financial conflicts of interest in medical science. Physicians and medical administrators had financial links to companies that went undeclared to medical journals even when they were writing on topics in which they clearly had monetary interests.

    Most agree such lapses damage the medical and scientific community. But our focus on financial conflicts of interest should not lead us to ignore other conflicts that may be equally or even more important. Such biases need not be explicit, like fraud.

    “I believe a more worrisome source of research bias derives from the researchers seeking to fund and publish their work, and advance their academic careers,” said Dr. Jeffrey Flier, a former dean of Harvard Medical School who has written on this topic a number of times.

    How might grant funding and career advancement — even the potential for fame — be biasing researchers? How might the desire to protect reputations affect the willingness to accept new information that reverses prior findings?

    I’m a full professor at Indiana University School of Medicine. Perhaps the main reason I’ve been promoted to that rank is that I’ve been productivein obtaining large federal grants. Successfully completing each project, then getting that research published in high-profile journals, is what allows me to continue to get more funding.

    A National Institutes of Health regulation sets a “significant financial interest” as any amount over $5,000. It’s not hard to imagine that being given thousands of dollars could influence your thinking about research or medicine. But let’s put things in perspective. Many scientists have been awarded millions of dollars in grant funding. This is incredibly valuable not only to them but also to their employers. Journals and grant funders like to see eye-catching work. It would be silly not to think that this might also subtly influence thinking and actions. In my own work, I do my best to remain conscious of these subtle forces and how they may operate, but it’s a continuing battle.

    Getting positive results, or successfully completing projects, can sometimes feel like the only way to achieve success in research careers. Just as those drivers can lead people to publish those results, it can also nudge them not to publish null ones.

    As a pediatrician, I’ve been acutely aware of concerns that relationships between formula companies and the American Academy of Pediatricsmight be influencing policies on feeding infants. But biases can occur even without direct financial contributions.

    If an organization has spent decades recommending low-fat diets, it can be hard for that group to acknowledge the potential benefits of a low-carb diet (and vice versa). If a group has been pushing for very low-sodium diets for years, it can be hard for it to acknowledge that this might have been a waste of time, or even worse, bad advice.

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  • CPAP advice you won’t find on the internet

    The purpose of this post is to save others in the market for a travel CPAP some time and effort, particularly if they’re ResMed customers.

    I love everything about my ResMed AirSense 10 CPAP* machine except traveling with it. It’s just bulky enough to not fit into the bags I ordinarily use, so it becomes another item to tote around and keep track of. As a fanatical light packer, I hate that.

    But, there are travel CPAPs, quite a few of them in fact, including one made by ResMed. The ResMed AirMini would be the natural choice for me, keeping me entirely in the ResMed family. That would ensure my ResMed mask works with it. No hassles!

    But, it’s one of the most expensive travel CPAPs out there (nearly $900). That’s one strike against it. Another is that ResMed hasn’t done anything to address noise that accompanies its use, the biggest complaint. (It’s not machine noise, it’s hose noise. Bigger devices have no such noise, but I guess one thing lost in miniaturization is some kind of muffling structure.) Also, my supplier would not allow a trial period for the ResMed. HDM allows returns in 15 days for a full refund.

    According to my research, all travel CPAPs worth considering are about equivalently noisy. (They’re really not that noisy. More below.) But, ADM’s Z1 Auto has a muffler attachment — the Qtube — that attenuates the noise. Plus, it’s about half the price of the AirMini. The three ways ResMed is bad (expensive, doesn’t address noise, no ability to return), ADM has done the right thing.

    For these reasons, I went with ADM, but not without some annoyances. To my amazement, neither ADM nor ResMed could tell me if my ResMed mask would work with the ADM device. And, best I can tell, there are no mask-device compatibility crosswalks on the internet, or at least none that deal with my mask and the ADM Z1 Auto.

    I’m baffled why ADM wouldn’t test masks for compatibility in order to increase its market share. Consumers would be more likely to buy the device if they knew in advance their preferred masks worked with it. It’s not rocket science. All one need do is buy the common masks (they’re not that expensive) and see if their hoses fit the ADM hose. In fact, maybe this can be done by examination of specs, without even buying anything.

    To solve this problem for myself, I bought an ADM hose ($17 on Amazon) before I invested in the device. To my delight, I could get my ResMed P10 mask to fit into the ADM hose. Probably all the ResMed masks would work. Now, it’s not a perfect fit. It’s a bit tight, but it does work.

    Moreover, now that I have the ADM Z1 Auto in hand, I found that the ResMed hoses kinda work with it too. Again, the fit isn’t perfect, but it’s doable. And, though I’ve yet to spend a night with it, I don’t find the device noisy, and I’m super sensitive. I’ll try it overnight and see how it goes.

    Here’s another thing you might wonder: how do you get to the clinical settings on your CPAP machine? That information is definitely out there. Just Google around. For the ADM Z1 Auto, it’s a bit hard to find, but you can get a copy of the clinical manual emailed to you from the Apnea Board.

    Obligatory warning shot: Clinicians who don’t want patients to mess with settings, don’t complain to me about it. We already do. As you well know, it’s not an insubstantial challenge to get a busy clinician to do it for you. We don’t want to wait a night or two! Yeah, I’m sure there are patients who can’t responsibly handle this task, but I’m not one of them. I damn well know when I can’t sleep because my machine is moving pressures around too wildly or dropping too low, causing apnea events.

    Anyway, so long as it is possible to get into the clinical settings, patients will do it. Best bet is to educate them, not try to hide the settings from them. That doesn’t work.

    * Technically, APAP, but whatever.


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  • Misconceptions About Health Costs When You’re Older

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company). It also appeared on page B3 of the print edition on December 25, 2018.

    Some significant expenses decline as we age: Most mortgages are eventually paid off, and ideally children grow up and become self-supporting.

    But health care is one area in which costs are almost certain to rise. After all, one of the original justifications for Medicare — which kicks in at age 65 — is that older people have much higher health care needs and expenses.

    But there are a few common misunderstandings about health costswhen people are older, including the idea that money can easily be saved by reducing wasteful end-of-life spending.

    Half our lifetime spending on health care is in retirement, even though that represents only about 20 percent of a typical life span. Total health care spending for Americans 65 and older is about $15,000 per year, on average, nearly three times that of working-age Americans.

    Don’t expect Medicare to provide complete protection from these expenses.

    Traditional Medicare has substantial gaps, leaving Americans on the hook for a lot more than they might expect. It has no cap on how much you can pay out of pocket, for example. Such coverage gaps can be filled — at least in part — by other types of insurance. But some alternatives, such as Medicare Advantage, aren’t accepted by as many doctors or hospitals as accept traditional Medicare.

    On average, retirees directly pay for about one-fifth of their total health care spending. Some spend much more.

    One huge expense no Medicare plans cover is long-term care in a nursing home.

    Over half of retirement-age adults will eventually need long-term care, which can cost as much as $90,000 per year at a nursing home. Although most who enter a nursing home don’t stay long, 5 percent of the population stays for more than four years. You can buy separate coverage outside the Medicare program for this, but the premiums can be high, especially if you wait until near retirement to buy.

    Although Medicare is thought of as the source of health care coverage for retirees, Medicaid plays a crucial role.

    Medicaid, the joint federal-state heath financing program for low-income people, has long been the nation’s main financial backstop for long-term care. Over 60 percent of nursing home residents have Medicaid coverage, and over half of the nation’s long-term care is funded by the program.

    That isn’t because most people who require long-term care have low incomes. It’s because long-term care is so expensive that those needing it can frequently deplete their financial resources and then must turn to Medicaid.

    recent working paper from the National Bureau of Economic found that, on average, Medicaid covers 20 percent of retiree health spending. The figure is larger for lower-income retirees, who are more likely to qualify for Medicaid for more of their retirement years.

    A widely held view is that much spending is wasted on “heroic” measures taken at the end of life. Are all the resources devoted to Medicare and Medicaid really necessary?

    First, let’s get one misunderstanding out of the way. The proportion of health spending at the end of life in the United States is lower than in many other wealthy countries.

    Still, it’s a tempting area to look for savings. Only 5 percent of Medicare beneficiaries die each year, but 25 percent of all Medicare spending is on individuals within one year of death. However, the big challenge in reducing end-of-life spending, highlighted by a recent study in Science, is that it is hard to know which patients are in their final year.

    The study used all the data available from Medicare records to make predictions: For each beneficiary, it assigned a probability of death within a year. Of those with the very highest probability of dying — the top 1 percent — fewer than half actually died.

    “This shows that it’s just very hard to know in advance who will die soon with much certainty,” said Amy Finkelstein, an M.I.T. economist and an author of the study. “That makes it infeasible to make a big dent in health care spending by cutting spending on patients who are almost certain to die soon.”

    That does not mean that all the care provided to dying patients — or to any patient — is valuable. Another study finds that high end-of-life spending in a region is closely related to the proportion of doctors in that region who use treatments not supported by evidence — in other words, waste.

    “People at high risk of dying certainly require more health care,” said Jonathan Skinner, an author of the study and a professor of economics at Dartmouth. “But why should some regions be hospitalizing otherwise similar high-risk patients at much higher rates than other regions?”

    In 2014, for example, chronically ill Medicare beneficiaries in Manhattan spent 73 percent more days in the hospital in their last two years of life than comparable beneficiaries in Rochester.

    “There absolutely is waste in the system,” said Ashish Jha, director of the Harvard Global Health Institute. But, he argues, waste is present throughout the life span, not just at the end of life: “We have confused that spending as end-of-life spending is somehow wasteful. But that’s not right because we are terrible at predicting who is going to die.”

    Of course, beyond any statistical analysis, there are actual people involved, and wrenching individual decisions that need to be made.

    “We should do all we can to push waste out of the system,” Dr. Jha said. “But spending more money on people who are suffering from an illness is appropriate, even if they die.”


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