The Incidental Economist

The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and was jointly authored by Aaron Carroll and Austin Frakt. Click through to the original to cast your own votes in each health system face-off described below.

“Medicare for all,” or “single-payer,” is becoming a rallying cry for Democrats.

This is often accompanied by calls to match the health care coverage of “the rest of the world.” But this overlooks a crucial fact: The “rest of the world” is not all alike.

The commonality is universal coverage, but wealthy nations have taken varying approaches to it, some relying heavily on the government (as with single-payer); some relying more on private insurers; others in between.

Experts don’t agree on which is best; a lot depends on perspective. But we thought it would be fun to stage a small tournament.

We selected eight countries, representing a range of health care systems, and established a bracket by randomly assigning seeds.

To select the winner of each matchup, we gathered a small judging panel, which includes us:

• Aaron Carroll, a health services researcher and professor of pediatrics at Indiana University School of Medicine
• Austin Frakt, director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health

and three economists and physician experts in health care systems:

• Craig Garthwaite, a health economist with Northwestern University’s Kellogg School of Management
• Uwe Reinhardt, a health economist with Princeton University’s Woodrow Wilson School of Public and International Affairs
• Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute

A summary of our worldviews on health care is at bottom.

So that you can play along at home and make your own picks, we’ll describe each system along with our choices (the experts’ selections will decide who advances). When we cite hard data, they come from the Commonwealth Fund’s International Country Comparison in 2017.

But enough talk. Let’s play.

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With all the recent studies of medical marijuana and its benefits, some researchers have become interested in researching the use of psychedelics like psilocybin, LSD, and MDMA for treating mental illness. It’s hard to research though, because of the drugs’ legal status as Schedule I drugs. This makes them very hard for researchers to obtain, it makes it hard to get research approved, and it make it difficult to find funding for these studies. We’ve got the details.

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

@aaronecarroll

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

Many high-school-aged children across the United States now find themselves waking up much earlier than they’d prefer as they return to school. They set their alarms, and their parents force them out of bed in the morning, convinced that this is a necessary part of youth and good preparation for the rest of their lives.

It’s not. It’s arbitrary, forced on them against their nature, and a poor economic decision as well.

The National Heart, Lung and Blood Institute recommends that teenagers get between nine and 10 hours of sleep. Most in the United States don’t. It’s not their fault.

My oldest child, Jacob, is in 10th grade. He plays on the junior varsity tennis team, but his life isn’t consumed by too many extracurricular activities. He’s a hard worker, and he spends a fair amount of time each evening doing homework. I think most nights he’s probably asleep by 10 or 10:30.

His school bus picks him up at 6:40 a.m. To catch it, he needs to wake up not long after 6. Nine hours of sleep is a pipe dream, let alone 10.

There’s an argument to be made that we should cut back on his activities or make him go to bed earlier so that he gets more sleep. Teens aren’t wired for that, though. They want to go to bed later and sleep later. It’s not the activities that prevent them from getting enough sleep — it’s the school start times that require them to wake up so early. More than 90 percent of high schools and more than 80 percent of middle schools start before 8:30 a.m.

Some argue that delaying school start times would just cause teenagers to stay up later. Research doesn’t support that idea. A systematic review published a year ago examined how school start delays affect students’ sleep and other outcomes. Six studies, two of which were randomized controlled trials, showed that delaying the start of school from 25 to 60 minutes corresponded with increased sleep time of 25 to 77 minutes per week night. In other words, when students were allowed to sleep later in the morning, they still went to bed at the same time, and got more sleep.

There are costs to pushing back the start times of schools, of course. Our local school system, like many others, uses the same buses for elementary, middle and high school. Not wanting to start elementary school too early, it starts high school earlier to save money on transportation. Other costs to delaying start times come after school, when later school end times result in later after-school activities. These can interfere with parents’ work schedules and run into evening hours, when it gets dark and additional lighting might be necessary.

A Brookings Institution policy brief investigated the trade-offs between costs and benefits of pushing back the start times of high school in 2011. It estimated that increased transportation costs would most likely be about $150 per student per year. But more sleep has been shown to lead to higher academic achievement. They found that the added academic benefit of later start times would be equivalent to about two additional months of schooling, which they calculated would add about $17,500 to a student’s earnings over the course of a lifetime. Thus, the benefits outweighed the costs.

This was a reasonably simple analysis, though, and did not persuade many schools to change. A recent analysis by the RAND Corporation goes much further.

Marco Hafner, Martin Stepanek and Wendy Troxel conducted analyses to determine the economic implication of a universal shift of middle and high school start times to 8:30 a.m. at the earliest. This study was stronger than the Brookings one in a number of ways. It examined each state individually, because moving to 8:30 would be a bigger change for some than for others. It also looked at changes year by year to see how costs and benefits accrued over time. It examined downstream effects, like car accidents, which can affect lifetime productivity. And it considered multiplier effects, as changes to the lives of individual students might affect others over time.

They found that delaying school start times to 8:30 or later would contribute $83 billion to the economy within a decade. The gains were seen through decreased car crash mortality and increased student lifetime earnings.

Since it would take at least a year for any students affected by changes in start times to enter the labor market, there would be no gains in the first year. Costs, however, would accrue immediately. These included about $150 per student per year in transportation costs and $110,000 per school costs in upfront infrastructure upgrades. Even so, by the second year, the benefits outweighed the costs. By 10 years, the benefits were almost double the costs; by 15 years, they were almost triple.

We’d be remiss if we didn’t acknowledge other potential costs not included in this calculation, including parental difficulty in adapting to later school start times. But even in a model where the per-student, per-year cost was increased to $500, which would compensate most parents for delays, and where the upfront per school cost was increased to $330,000, the economic benefits to society would still outweigh the costs in the long run.

Further, it’s important to understand that these benefits may actually be underestimates. The researchers were careful to model only outcomes for which they had empirical data from sleep duration, such as car crashes and academic performance. They didn’t model other real, but quantifiably unknown, benefits, like improvements in rates of depression, suicide and obesity, or the overall effects on health.

Some schools are beginning to take this seriously, but not enough. When it comes to start times, the growing evidence shows that forcing adolescents to get up so early isn’t just a bad health decision; it’s a bad economic one, too.

@aaronecarroll

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Senate Republicans are going to give it one more try on repealing and replacing Obamacare. This week, Senators Bill Cassidy (LA) and Lindsey Graham (SC) plan to bring forward a bill to repeal and replace the Afffordable Care Act. It’s got a lot of hurdles to clear. We’ve got the details (such as they are).

@aaronecarroll

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Iowa has submitted a waiver proposal under section 1332 of the Affordable Care Act that, if granted, would radically reshape its individual insurance market; Oklahoma may soon do the same. Both states have been accused of relying on some magical numbers, and Iowa’s waiver appears to violate the ACA’s guardrails, which require states to assure that any new approach covers at least as many people with coverage that’s at least as comprehensive and affordable.

But what happens if HHS approves the waivers anyhow? Could the courts block them from taking effect?

You bet. Although neither of the two waivers that have been granted so far (Hawaii’s and Alaska’s) has attracted a court challenge, we’ve had decades of experience with challenges to waivers granted under section 1115 of the Social Security Act. Most of those challenges have failed, but back in 1994, in Beno v. Shalala, the Ninth Circuit ruled in favor of a group of welfare beneficiaries who challenged the grant of a California waiver.

Invoking the presumption in favor of judicial review of agency action, the court rejected HHS’s argument that the courts couldn’t review its decision to grant a waiver. “The statute does not give the Secretary unlimited discretion. It allows waivers only for the period and extent necessary to implement experimental projects which are ‘likely to assist in promoting the objectives’ of the [welfare] program.”

With that in mind, the court enjoined California’s waiver from taking effect. In the court’s view, HHS never explained how the waiver—which would have imposed work requirements on welfare recipients—was a genuine experiment or would advance the program’s objectives. In 2011, the Ninth Circuit issued a similar ruling when Arizona sought to impose copayments on Medicaid beneficiaries.

Courts in other circuits have universally agreed that the decision to grant an 1115 waiver can be challenged in court. Their reasoning should apply with equal force to 1332 waivers. (Although the ACA precludes the courts from reviewing some agency decisions, there’s no preclusion language for 1332 waivers.) All you have to do is find a litigant who can plausibly allege that the waiver will make her life worse. For waivers like Iowa’s, that won’t be remotely difficult.

Still, the courts tend to be very deferential to HHS. They’re not really equipped to second-guess the agency’s predictive judgments about a waiver’s on-the-ground consequences, as Judge Friendly explained more than 30 years ago. But deference only goes so far. For 1332 waivers, the courts will still ask hard questions about whether the waiver in question adheres to the guardrails.

That’s going to be a problem for waivers like Iowa’s, which would divert funding for cost-sharing reductions and eliminate protections against excessive out-of-pocket spending. As David Anderson notes:

The Iowa waiver submission will increase the number of low income residents with high percentages of their income devoted to health care costs. The hypothetical 40 year old who has an expensive chronic condition will see a dramatic change in his total out of pocket spending from 8.52% of income under the ACA to 44% of income … . There will be a number of individuals who will have significant, real and obvious harms from this waiver. I will be shocked if at least one of them does not file suit to stop the Iowa waiver for at least the 2018 plan year.

I’ll be shocked, too. How on earth does Iowa’s waiver provide “cost sharing protections against excessive out-of-pocket spending that are at least as affordable” as the ACA, as the statute requires? It eliminates those protections!

Deferential or not, the courts won’t stand for this. The guardrails are really restrictive. If you take them seriously—and the courts will, even if HHS doesn’t—they suggest that a state’s waiver can be approved if and only if it doesn’t make a substantial number of people worse off than they were under the ACA. Iowa’s waiver flunks that test.

Iowa is nonetheless pressing forward—and on an expedited, emergency basis so that its waiver can take effect for 2018. If the waiver is approved, however, there’s a very good chance a court will enter a preliminary injunction to prevent it from taking effect. That’s the worst of all worlds for Iowa. Inviting a legal battle on the eve of open enrollment will not give insurers the confidence they need to participate on the exchanges.

What’s true in Iowa is true for other red states. If they want to revamp their insurance markets, they’re going to have to ask Congress to relax the guardrails. Maybe Congress will oblige, either in Cassidy-Graham or in a bipartisan deal to include more targeted fixes. In the meantime, the courts probably won’t allow the states to radically change the ACA’s structure through waivers.

@nicholas_bagley

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The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and was jointly authored by Aaron Carroll and Austin Frakt.

The theory has gained such prominence that a United States senator is investigating it.

“Medicaid expansion may be fueling the opioid epidemic in communities across the country,” Senator Ron Johnson, Republican of Wisconsin, wrote recently.

Some conservative opponents of the Affordable Care Act have been passing around the same theory for months. It’s a politically explosive (and convenient) argument, but is it true? Substantial evidence suggests the answer is no, but let’s give it a fair hearing.

Some data seems to support this connection, and the idea has a certain logic. Coverage from Medicaid — or any kind of health insurance for that matter — plays a role in access to prescription opioids, just as it does for access to many other types of health care.

We know from earlier analyses that Medicaid enrollees tend to be prescribed opioids more frequently than people with other kinds of coverage. But that could be because of other factors also related to insurance. It’s important to remember that people who go on Medicaid are sicker than those with other forms of coverage, so they may have more pain that warrants opioids.

It is also true that the 31 states that expanded Medicaid experienced a larger increase in drug overdoses between 2013 and 2015 than states that did not. As Mr. Johnson wrote, “These data appear to point to a larger problem.”

But this is a weak foundation on which to base a conclusion that Medicaid is driving the opioid epidemic. Responding to these facts when they were first noted, a Department of Health and Human Services statement said, “Correlation does not necessarily prove causation, and additional research is required before any conclusions can be made.”

In a post on the Health Affairs blog, Andrew Goodman-Bacon, an economist at Vanderbilt, and Emma Sandoe, a Ph.D. student in health policy and political analysis at Harvard, recommend that, to understand the opioid epidemic and Medicaid’s role better, we should look much further back than 2013.

For example, OxyContin prescriptions for noncancer pain grew by a factor of almost 10 between 1997 and 2002, long before the A.C.A. was signed into law. Drug-related mortality rates doubled between 1999 and 2013, the year before most states expanded Medicaid.

Further, while it is true that drug-related deaths have grown more rapidly in expansion states than in other states, that more rapid growth started in 2010, before the A.C.A. expansion. This suggests that causes other than Medicaid are more likely. Given the timing of these findings, “there is little evidence to support the claim that Medicaid expansion caused the increase in opioid-related deaths,” Ms. Sandoe said.

Yes, Medicaid could still be playing a role, but as with all correlations, it’s important to consider both directions of causality. It’s possible that states experiencing larger growth in drug deaths might have been more eager to expand Medicaid programs. After all, Medicaid also provides financial support for drug abuse treatment. One study found that prescriptions for medications that treat opioid addiction increased by 43 percent in Medicaid expansion states, relative to states that did not expand their programs. When Gov. John Kasich, a Republican, talks about why he’s happy that Ohio expanded the Medicaid program, he often cites the opioid crisis in his state.

Craig Garthwaite, a Republican labor economist of Northwestern University’s Kellogg School of Management, said: “It’s not that there isn’t a single case of an individual insured by Medicaid developing an opioid habit or illicitly obtaining drugs. But the evidence to date doesn’t suggest that this is the net effect.”

Another way to test the Medicaid-opioid connection is to examine a dose response. States with higher levels of uninsurance saw greater coverage gains through Medicaid. If more Medicaid causes more opioid death, then states that added more Medicaid beneficiaries should see greater increases than states with smaller coverage expansions. But Mr. Goodman-Bacon and Ms. Sandoe show that the opposite holds. Counties in states with historically higher levels of uninsurance (and therefore greater subsequent growth in Medicaid) had lower growth in drug-related death rates from 2010 to 2015. This relationship holds within expansion and nonexpansion states separately.

Or course, drug-related deaths include those from prescription opioids as well as those from black-market drugs (like heroin and fentanyl). Medicaid directly enhances access only to the former. This makes it hard to identify the role of Medicaid in the opioid crisis definitively, which is all the more reason to be cautious about suggesting the program is fueling it.

“The really sad thing here is that these numerical arguments have the veneer of seriousness, and as a result, they can drive really bad policy,” Mr. Garthwaite said.

Providing health care through insurance means providing access to both its benefits and harms. No one seems concerned that the increased access to health care that private insurance provides might lead more people to take opioids — only that Medicaid could. It’s also interesting to note that no one makes assertions that increased coverage, even increased Medicaid coverage, probably leads to more deaths by medical errors.

We should not look at harms in isolation. Even if Medicaid does enhance access to prescription opioids, thereby playing a role in their misuse, that is far from the only thing the program does. Medicaid provides many other benefits, about which we’ve written, including increased access to substance use disorder treatment.

To use a theoretical Medicaid-opioid connection (for which the evidence is weak anyway) to justify scaling back Medicaid ignores the larger picture — that it is a crucial aspect of our safety net, providing access to health care and financial protection that many low-income Americans could not otherwise obtain.

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Senator Sanders has released the text of his Medicare for All Act. This bill won’t be enacted in this Congress, so the point of introducing it now is to stimulate discussion, above all about the principles that should guide the design of the American health care system. Most of the discussion so far has focused on universal coverage, and the bill delivers that:

Every individual who is a resident of the United States is entitled to benefits for health care services under this Act.

But there’s a lot more than just universal coverage in Senator Sanders’ bill and I want to quickly highlight some of those features.

Comprehensive benefits. The Act requires the provision of hospital, ambulatory care, preventive care, and prescription drugs. It also covers several important domains of health care that have not been adequately supported: oral health (that is, dentistry), mental health, substance abuse, and

comprehensive reproductive, maternity, and newborn care.

In any reasonable construal of comprehensive reproductive care, this would require providers to supply contraceptive care. This will be controversial, to say the least. Because it includes mental health, substance abuse care, and dentistry, this list is notably better than covered services required by the Canada Health Act.

Non-discrimination. By design, the Act eliminates discrimination on the basis of pre-existing conditions. But it also bans discrimination

on the basis of race, color, national origin, age, disability, or sex, including sex stereotyping, gender identity, sexual orientation, and pregnancy and related medical conditions (including termination of pregnancy) [emphasis added]

Working out what the italicized words require will be, let’s say, interesting.

Health disparities. The Act identifies health disparities associated with

race, ethnicity, gender, geography, or socioeconomic status

as a quality of care problem. The mention of geography is particularly interesting, in that accessibility problems associated with living in rural or remote areas are an underappreciated dimension of health disparities.

Evidence-based policymaking. The Act requires HHS to

develop methodological standards for evidence-based policymaking.

This brief phrase tells us nothing about the scope of such standards, what criteria would be used to develop them, or how evidence should constrain policy-making. Nevertheless, if we could do this right…!

National reporting. Currently, Medicare is too much about just cutting checks and policing fraud. Medicare for All would have a mandate to improve system performance on

outcomes, costs, quality, and equity.

The inclusion of equity in this list is important and — please correct me — a first. At the same time, the Act would require providers to supply data while balancing this with a goal to minimize

the administrative burdens of data collection and reporting on providers.

These goals are in tension, but that doesn’t mean that the Act is incoherent. They are in tension because that is how the world is. The legislation also includes whistleblower protections for providers who report problems in billing and quality.

Negotiation of prices. The government would be able to negotiate prices on prescription drugs, medical devices, and equipment (and, please God, let this allow the government to negotiate prices for information technology).

Destruction of Employer-Sponsored Insurance. As Aaron has described,

The single largest tax expenditure in the United States is for employer-based health insurance.

The expenditure is wasteful and highly regressive. The Act bans employer-sponsored benefits that duplicate the comprehensive benefits offered by Medicare for All.

Automatic enrollment. The plan to automatically enroll people into Medicare for All might seem like a detail. However, many Americans cannot exercise rights or access entitlements because they have difficulty completing burdensome enrollment procedures.

No-balance billing. The Medicare for All Act bans co-pays. This will generate much discussion. But note that the Act also states that

no provider may impose a charge to an enrolled individual for covered services for which benefits are provided under this Act.

This would, among other benefits, eliminate surprise billing.

Increased coverage of long-term care. I study kids and long-term care is beyond my remit. But I read this act as seeking to increase Medicare’s coverage of long-term care.

When I wrote about the Canada Health Act, I noted that we have many significant gaps between the principles in the Act and its implementation. In that light, there are many points in the Medicare for All Act which require further clarification. There is also a list of points that worry me.

Nevertheless, if the Medicare for All were passed and successfully implemented, it would have far reaching effects on US health care beyond universal coverage.

DISCLOSURE: I provided Senator Sanders’ staff with comments and suggested language in the drafting of the bill.

@Bill_Gardner

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

The opioid crisis is so complex and so large — drug-related deaths now exceed those caused by cars, H.I.V. or guns — that there is no single solution. Among the partial ones: prescription drug monitoring programs, an approach highlighted in the draft report from President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis.

The epidemic has led every state but Missouri to establish one of these programs, which allow doctors and regulators to track how many opioid medications and other controlled substances have been dispensed to patients. A new analysis shows that prescription drug monitoring programs can reduce the overuse of narcotics — but that many states have adopted relatively weak versions.

Opioid medications, like Vicodin, Percocet or OxyContin, can be useful in treating pain. But when patients receive many prescriptions — whether from multiple doctors at the same time or from the same one for a long period of time — it can signal a problem. Patients with more pills than they need could endanger themselves or divert them to the black market. Longer-term use increases the risk of addiction and other bad outcomes.

Data from the Centers for Disease Control and Prevention show that opioid overdoses and prescriptions grew in parallel between 1999 and 2010. Though prescriptions have fallen more recently, they have been written for longer durations. Black-market opioids — heroin and, in particular, fentanyl — also contribute to overdose deaths. But many who use these drugs also use prescription opioids and may have become dependent on them first.

That’s where prescription drug monitoring programs come in. They collect data from pharmacies to track what prescriptions for controlled substances patients have filled. The databases can be used to assess whether patients are getting more opioids than they can safely use. In addition, they can be used to tell if patients are getting other drugs, like a benzodiazepine, that are dangerous to use in combination with an opioid.

According to research summarized by the Leonard Davis Institute of Health Economics at the University of Pennsylvania, prescription drug monitoring programs can help reduce the amount or strength of opioids prescribed and dispensed. When physicians or dentists check the database and see a worrisome pattern of dispensed opioids, they can deny or change a prescription, screen for an opioid or other substance use disorder, and even counsel the patient to seek other forms of pain management or addiction treatment, if warranted.

Dr. Zachary Meisel, an author of the Leonard Davis review, uses a drug database when he practices in the Hospital of the University of Pennsylvania emergency department. In related work, he found that the databases often prompt conversations about opioids between provider and patient. In other cases, he said, prescription drug monitoring programs “help dispel a suspicion that a patient is seeking additional opioids.”

Monitoring programs are mitigating the opioid epidemic. One study, published in Health Affairs, found they’re associated with a decline in the chance a patient with pain will receive a Schedule II opioid prescription, to 3.7 percent from 5.5 percent. The study was based on a sample of 26,275 doctor’s office visits in the 24 states that started drug monitoring operations during 2001-2010. The results of another study— of Medicare beneficiaries over 2007-12 in 10 states — suggest that such programs are associated with reductions in the strength of opioid medications dispensed and the duration of opioid prescriptions. Deaths related to oxycodone use fell 25 percent in 2012, after Florida created a monitoring program.

But other work shows that having access to a prescription drug monitoring program is not enough. States can make the programs much more effective by mandating prescribers to engage with it. Twenty-five states require prescribers — physicians and dentists — to register with their state database. This forces prescribers to push through the first barrier to use — just signing up — and seems to make a difference.

One study, published this year in Health Affairs, found that states that required prescriber registration saw a 10-percentage-point reduction in use of Schedule II opioids among Medicaid enrollees, relative to states that did not require registration.

Most, but not all, states with mandatory registration also require prescribers to consult their state databases before prescribing an opioid. A study published in Health Services Research this year found that states requiring this experienced a reduction in the duration of opioid prescriptions in the Medicare population. Another study, also of the Medicare population, found that mandatory use was associated with fewer patients getting opioids from multiple doctors — so-called doctor shopping — and with patients holding a smaller supply of the drugs.

Studies expanding beyond the Medicare population to include younger Americans find that use mandatesreduce admissions to treatment facilities for opioid use disorder. A New York study of prescriptions by dentists in an urgent care center found that when its mandatory program went into effect, opioid pills prescribed went down 78 percent.

When states roll out monitoring programs, opioid-related overdose deaths fall, according to one study. And they decline more in states that mandate their use. Though some studies have not found that such programs reduce opioid use or opioid-related mortality, it could be because they do not distinguish between programs with such mandates and those without.

Nevertheless, prescription drug monitoring programs have limitations. They can track only dispensed drugs, not black-market drugs (like heroin and fentanyl). And though they can be used to tell how many and what kinds of opioids are dispensed, they can’t tell who takes them or if they’re diverted to the black market. The programs could also be more effective if more prescribers used them. One study found that only about half of primary care physicians use the database. Among those who use them, many do not do so routinely.

The data monitoring programs could be more useful if integrated with other health data and shared across states, as recommended by the opioid commission. Doing so could make it easier to combine prescription data with other data that could indicate problems — like a history of mental health or substance use disorders. These data, together, can help predict who is most likely to suffer adverse outcomes from prescribed opioids. This is an approach being adopted by the Department of Veterans Affairs, with an evaluation underway. [Disclosure: I am involved in that evaluation.]

Prescription drug monitoring programs are not the only tool to combat the opioid crisis. Other state laws that tighten regulations of pain clinics and combat doctor shopping can help, too, reducing overdose deaths and admissions to treatment facilities. Wider distribution of naloxone, which can reverse an opioid overdose, and public education on its delivery can also help, as can greater access to safe means of disposing of unused pills.

Prescription drug monitoring programs have shown promise, but so long as relatively inexpensive heroin and fentanyl are available on the street, they will never be a full solution on their own.

@afrakt

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The wind and rain and flooding and destruction that happen during a hurricane are dangerous, and have obvious impacts on the health of people who live in hurricane-prone regions. But many of the health impacts of hurricanes and floods are non-obvious, and can have long-term negative effects.

This episode was adapted from an Upshot column written by Aaron and Austin. Links to further reading and references can be found there.

@aaronecarroll

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I guess you could find something wrong with some kid, somewhere, but come on. Data are from the 2016 National Survey on Drug Use and Health. In each of these charts, kids 12-17 are the RED LINE.

Cigarette use:

Alcohol use:

Pot use. And this is after legalization, when lots of you started screaming that this would HAVE to lead to increased use:

Cocaine:

Heroin:

Things don’t look good for all age groups, but for adolescents – the red line – we’re pretty much at the lows. Not to mention teen pregnancy rates and teen births continue their all time lows. What more do you want from them?

@aaronecarroll

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