healthcare

Which decreases abortion rates more? Contraception access or abortion restrictions?

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Pro-choicers frequently claim that making abortion illegal won’t decrease the number of abortions; it will only decrease the number of safe, legal abortions. They suggest that there is no practical use to restricting abortion legally and that if pro-lifers really cared about decreasing abortion rates, they would focus on decreasing unplanned pregnancies (through better access to contraception, better sex education, etc.)

So pro-choicers claim.

But there’s a lot of research to show that abortion law affects abortion rates–and not just legal abortion rates, but total abortion rates. Studies often measure the changes in fertility in areas where abortion access recently changed. Secular Pro-Life has compiled a list of such studies if you’re interested.

I’ve now had a few conversations where I point out this reality, and the pro-choice person’s response is to claim that even if abortion restrictions have some nonzero effect on abortion rates, that effect is dwarfed by the decrease in abortions thanks to contraception access. It’s easy for me to believe that both more access to contraception and less access to abortion will decrease abortion rates, and personally I’m for taking both approaches. But the claim that the effect of contraception access trounces the effect of abortion access sounds like just a slightly watered down version of the false claim that abortion access doesn’t affect abortion rates at all. That is, it’s an ad hoc, ill-founded claim to justify our country’s incredibly liberal abortion laws, but the evidence (at least what I’ve seen so far) doesn’t bear it out.

For example, in late 2017 the Daily Mail published “Abortion rate plummets to an historic low, CDC figures reveal.” Specifically the article claims

While the drop mirrors the closure of abortion clinics nationwide, experts say the figure is likely down to more effective use of contraception and the falling pregnancy rate.

The article references this CDC report, which has found a net decrease in the abortion rate (number of abortions per 1,000 women age 15-44) of 22% (from 15.6 to 12.1). This is great news, but it’s not clear from the CDC report the extent to which different factors contributed to the decrease. The CDC authors explain

One factor that might have contributed to this decrease is the increase that occurred during the same period in the use of the most effective forms of reversible contraception, specifically intrauterine devices and hormonal implants, which are as effective as sterilization at preventing unintended pregnancy (102–105). Although use of intrauterine devices and implants has increased in recent years, use of these methods remains low in comparison with use of oral contraceptives and condoms, both of which are less effective at preventing pregnancy (102,104).

So contraception likely played a role, but the CDC can’t quantify it, and they still find that the most effective forms of contraception are not used much compared to the less effective forms. They certainly aren’t asserting that the entire 22% decrease is due solely to contraception access, and their report doesn’t attempt to compare the effects of contraception access to the effects of abortion access.

There are studies that looked at both factors. For example, this Guttmacher report found that between access to the Pill and access to abortion, abortion was associated with a birth rate decrease twice that for the pill.

Among white minors, having had access to the pill was associated with a 9% drop in the overall birthrate and an 8% drop in the rate of nonmarital first births. In this same group, access to an abortion was correlated with a 17% decline in the nonmarital birthrate and a 16% decline in the rate of nonmarital first births.

Another study found that, for women under age 19, “liberalized abortion policy predicts a 34 percent decline in motherhood” whereas “the results do not provide evidence that pill policies had a substantial effect.” The author explains

The birth control pill’s effects on family formation are theoretically ambiguous: The pill was a technological innovation in contraception, but with a failure rate of about 9 percent in the first year of typical use (Trussell, 2004), it still provides an imperfect means of preventing pregnancy. Trends in sexual behavior suggest that any reductions in unintended pregnancies among teens due to safer, pill-protected sex were offset by large increases in sexual activity. Difference-in-difference estimates also provide little evidence to support the view that pill policies had a substantial influence on age at first birth and marriage. Results in Goldin and Katz (2002) and Bailey (2006, 2009) that suggest otherwise are not robust to reasonable perturbations of the authors’ research designs including addressing discrepancies in the legal codings, choosing alternative data sets, and/or adjusting sample selection procedures. Rather, the results robustly point to policies governing abortion, a second, less lauded but more certain means of preventing unwanted births, as the driving force behind delayed family formation in the 1970s. [Emphasiss added]

This study is not a perfect comparison to claims about more modern contraception. The idea is that the most effective forms of contraception (e.g. IUDs instead of the Pill) do a better job of decreasing unintended pregnancy rates because even if users increase their sexual activity as a result, the increase in risk-taking behavior does not offset the decrease in risk these more effective contraceptive methods provide.

Note also that research suggests when abortion is legalized the abortion rate increases more than the birth rate decreases. See Footnote 8 of this report, p8 of the PDF, which explains in part:

Note, however, that the decline in births is far less than the number of abortions, suggesting that the number of conceptions increased substantially –and example of insurance leading to moral hazard. The insurance that abortion provides against unwanted pregnancy induces more sexual conduct or diminished protections against pregnancy in a way that substantially increases the number of pregnancies. [Emphasis added]

People are less cautious about avoiding pregnancy when they know they can get abortions as a back up option. This idea is further substantiated by a study published in the June 2015 edition Perspectives on Sexual and Reproductive Health which concluded:

Women who lived in a state where abortion access was low were more likely than women living in a state with greater access to use highly effective contraceptives rather than no method (relative risk ratio, 1.4). Similarly, women in states characterized by high abortion hostility (i.e., states with four or more types of restrictive policies in place) were more likely to use highly effective methods than were women in states with less hostility (1.3).

This research also suggests that teasing out the effects of abortion access compared to contraception use may prove challenging, since the two appear to be inversely correlated.

So with that brief overview of just a few studies, so far these are the conclusions I’m drawing:

  1. Abortion restrictions decrease abortion rates (and likely also unintended pregnancy rates).
  2. Access to the most effective forms of contraception decrease abortion rates.
  3. Abortion restrictions probably decrease abortion rates more than access to less effective contraception (the pill) does, and
  4. It’s unclear whether abortion restrictions or access to the most effective forms of contraception decrease abortion rates more.

I’m open to other suggestions/studies if you have them.

Thoughts on Alfie Evans

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Anger is toxic, and it has no place in ordinary political disputes. I’m very reluctant to add to it.

And yet, it is less with anger and more with a sense of bone-deep bewilderment that I–reluctantly–read a few articles about Alfie Evans.

Aflie is a baby with a severe neurological affliction that–according to doctors–has left him in a vegetative state with no conceivable chance of recovery. This is tragic, and no one is to blame for Alfie’s condition.

The UK courts have decided that no further care should be given to Alfie because there’s no hope of his recovery. This is tragic, but also defensible. It’s not possible to expend unlimited resources on every tragic case, and hard calls have to be made.

But where things stop making sense to me is where the UK government has refused to allow Alfie to be transported to Italy for additional care. Alfie has been granted Italian citizenship, the Italian military sent a plane to UK to fly him to a hospital in Italy, and all of this was done–one guesses–largely in response to the Pope’s public support for Alfie.

The UK government’s response is, essentially, that Alfie’s parents don’t know what they’re doing. The doctors know better. That may be true. Even the Italian hospital admits it can do no more than keep Alfie alive while doctors study his case. No one things there is a miracle cure.

But here’s the thing: why does the UK government, or any group of doctors, get to decide?

It gets more baffling still. Now Alfie’s parents, haven given up on the Italian option, just want to take him home. But even that they cannot do unless the doctors say so. In what universe is that a morally defensible position to take? Quoting an anonymous British father:[ref]Corrected to reflect the fact that this quote wasn’t from Alfie’s father as I at first thought.[/ref]

When my son was born nearly 16 months ago, I found to my amazement that I could not take him home until a paediatrician had signed a small slip of paper, to be handed in at the exit, authorising his release. I joked to my wife that we were only parenting under licence from the State. It seems less of a joke now.[ref]American Conservative[/ref]

The last straw–and the cause of the anger I can’t deny I feel about this–is the insufferable arrogance of the UK politicians and medical experts. For example:

Lord Justice McFarlane said parents, like those of Alfie Evans, could be vulnerable to receiving bad medical advice, adding that there was evidence that the parents made decisions based on incorrect guidance.[ref]United Press International[/ref]

and:

Hospital officials at Alder Hey say they have received “unprecedented personal abuse” from the global backlash to Alfie’s case. The Liverpool hospital has faced several protests in recent weeks, organized by a group calling itself “Alfie’s Army.”

“Having to carry on our usual day-to-day work in a hospital that has required a significant police presence just to keep our patients, staff and visitors safe is completely unacceptable,” the hospital’s chairman, Sir David Henshaw, and chief executive Louise Shepherd said.[ref]United Press International[/ref]

Oh, is it “completely unacceptable” for people to protest what is essentially government-sanctioned kidnapping? I’m so sorry! I come from this crazy moral universe where parents–and not the government–are the guardians of their own children.

Or here’s another one:

Sometimes, the sad fact is that parents do not know what is best for their child,” Wilkinson said. “They are led by their grief and their sadness, their understandable desire to hold on to their child, to request treatment that will not and cannot help.[ref]CNN, this one added after the post was initially published.[/ref]

The UK was, in many ways, the birthplace of our political heritage of individual liberty and rights. It’s mystifying–and tragic–to see the sorry state of decay it has fallen into today.

So tell me, folks, am I missing some really vital aspects to this story that make it something other than a micro-dystopia?

Are CON Regulations Barriers to Entry?

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Image result for con regulations

A 2016 Mercatus working paper argues that “certificate-of-need (CON) laws restrict healthcare institutions from expanding, offering a new service, or purchasing certain pieces of equipment without first gaining approval from regulators.” Drawing on data from the Standard Analytic Files and the American Health Planning Association, the authors review the 21 states with CON requirements “for at least one of three regulated imaging services: MRI (magnetic resonance imaging) scanners, CT (computed tomography) scanners, and PET (positron emission tomography) scanners. Medicare claims provide an estimate of the utilization of these different services and allow their utilization and accessibility to be compared between CON and non-CON states.”

The results?:

  • CON Regulations Have a Negative Effect on Nonhospital Providers
  • The association of a CON regulation with nonhospital providers is substantial, ranging from −34 percent to −65 percent utilization for MRI, CT, and PET scans. Nonhospital providers in CON states experience significant decreases in the utilization of imaging services compared to hospital providers.
  • CON Regulations Have No Effect on Hospitals, Thus Increasing Their Market Share
  • CON regulation has no measurable effect on hospitals’ utilization of imaging services. The volume of services provided in hospitals is not affected by CON regulation. This may explain why hospital providers have a stronger market presence in CON states than in non-CON states.
  • Consumers Are Driven to Seek Imaging Services in Non-CON States

The researchers conclude,

CON laws act as barriers to entry for nonhospital providers and favor hospitals over other providers. In consequence, consumers of MRI, CT, and PET scanning services are driven to seek these services either out of state or in hospitals. More research is needed to determine whether additional costs and barriers in the healthcare industry restrict specific market providers and affect where procedures occur. 

Healthcare Inequality

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Image result for healthcare insuranceA June 2016 study from George Mason University’s Mercatus Center finds “that both scholars and politicians have largely overlooked a key contributor to earnings inequality: the role of rapidly increasing healthcare costs.” The study “analyzes the link between earnings inequality and rising healthcare costs using unpublished data from the Bureau of Labor Statistics. The study finds that the increasing cost of employer-provided healthcare benefits accounts for a significant portion of rising earnings inequality.[ref]It doesn’t help that premiums have been increasing under Obamacare.[/ref] The study urges policymakers interested in addressing earnings inequality to shift their focus from failed redistributive policies to policies aimed at lowering the cost of healthcare benefits.” The key findings:

  • Most previous analyses of inequality focused exclusively on earnings, ignoring total compensation (including healthcare benefits). This oversight significantly inflated the perceived severity of workers’ earnings inequality.
  • While dollar earnings have grown significantly faster for higher-income workers than for lower-income workers, total compensation (including increasingly expensive healthcare benefits) has not.
  • Surging healthcare costs have depressed the annual earnings growth rate for lower-paid, full-time workers four times as much as for the top 1 percent of workers.
  • Redistributive policies do not address the root cause of the apparently increasing inequality, and may be counterproductive because of their negative implications for overall economic growth.
  • The key to lessening earnings inequality is to reduce the rate of increase for healthcare costs.

Check it out.

Religion and the U.S. Economy

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Economist Steve Horwitz once made the point, “Critics of markets sometimes say “you can’t eat GDP.” What they miss is that you can’t eat, or learn to read, or go to school, or leave a bad marriage, or do pretty much any of the basics that we might see as required for a flourishing life without the wealth and time created by the market economy.” This is why I tend to focus on economic growth: it is growth that lifts people out of poverty. This is why I’m happy to report that religion, according to a new study, is good for the economy.[ref]Religious freedom is good for business as well.[/ref] As reported in Christianity Today,

Specifically, religion is a $378 billion to $4.8 trillion boost to the US economy, the Grims found. Even at the lowest estimate, religious organizations make more than the global revenue of Apple and Microsoft combined; at the high end, religion makes the roughly the same amount as a third of the United States GDP.

The researchers’ first estimate only takes into account “the revenues of faith-based organizations falling into several sectors: education, healthcare, local congregational activities, charities, media, and food.” The largest chunk of these–healthcare–raises about $161 billion a year. Congregations raise $84 billion a year, religious schools raise $74 billion, and religious charities bring in $45 billion. Furthermore, the money is increasingly spent on social services like food assistance, parenting classes, and drug and alcohol abuse recovery programs ($9 billion in 2012).

“Their second estimate—that religion has an economic value of $1.2 trillion—adds in the price of social services provided by congregations,” the article continues.

Churches sponsor more than 1.6 million social services programs in America each year, and provide 7.6 million volunteers. More than 9 in 10 congregations actively recruit volunteers for outside projects (93%), half allow their building to be used for non-congregational purposes (50%), and close to half have groups that think about how to meet community needs (48%).

The Grims also added in the halo effect a community receives from the benefits of having a church nearby: it encourages investment in family and children; stimulates the local economy by buying goods and services; provides a place to host weddings, funerals, or large community events; may run schools or day cares; provides outdoor space for leisure activities; and augments the city’s social services.

The result: $418.9 [billion] worth of value.

When religious businesses are considered, the estimate is $1.2 trillion. “The study wasn’t perfect, the Grims admitted. It didn’t add in any of the financial or physical assets of religious groups, or subtract any negative impacts of religious groups, like fraud or abuse of children by clergy…Still, they wrote, “the data are clear.””

Glad to see religion making a big impact in the real world.

If the Chair Industry Was Regulated Like the Drug Industry

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Image result for epipen

There is another pharma scandal in the news over the astronomical increase in EpiPen’s price. Yet, before we begin to blame and denounce the abstraction “capitalism” for all our woes, it might be useful to recall my post on the Shkreli/Daraprim scandal and its discussion of healthcare regulations. This new case appears to be incredibly similar and the site Slate Star Codex has an excellent post contrasting the way the drug industry operates compared to the chair industry:

when was the last time that America’s chair industry hiked the price of chairs 400% and suddenly nobody in the country could afford to sit down? When was the last time that the mug industry decided to charge $300 per cup, and everyone had to drink coffee straight from the pot or face bankruptcy? When was the last time greedy shoe executives forced most Americans to go barefoot? And why do you think that is?

The answer?:

The problem with the pharmaceutical industry isn’t that they’re unregulated just like chairs and mugs. The problem with the pharmaceutical industry is that they’re part of a highly-regulated cronyist system that works completely differently from chairs and mugs.

If a chair company decided to charge $300 for their chairs, somebody else would set up a woodshop, sell their chairs for $250, and make a killing – and so on until chairs cost normal-chair-prices again.

And in his final act, he drives the point all the way home (worth quoting at length):

Imagine that the government creates the Furniture and Desk Association, an agency which declares that only IKEA is allowed to sell chairs. IKEA responds by charging $300 per chair. Other companies try to sell stools or sofas, but get bogged down for years in litigation over whether these technically count as “chairs”. When a few of them win their court cases, the FDA shoots them down anyway for vague reasons it refuses to share, or because they haven’t done studies showing that their chairs will not break, or because the studies that showed their chairs will not break didn’t include a high enough number of morbidly obese people so we can’t be sure they won’t break. Finally, Target spends tens of millions of dollars on lawyers and gets the okay to compete with IKEA, but people can only get Target chairs if they have a note signed by a professional interior designer saying that their room needs a “comfort-producing seating implement” and which absolutely definitely does not mention “chairs” anywhere, because otherwise a child who was used to sitting on IKEA chairs might sit down on a Target chair the wrong way, get confused, fall off, and break her head.

Image result for chair break gif…Imagine that this whole system is going on at the same time that IKEA spends millions of dollars lobbying senators about chair-related issues, and that these same senators vote down a bill preventing IKEA from paying off other companies to stay out of the chair industry. Also, suppose that a bunch of people are dying each year of exhaustion from having to stand up all the time because chairs are too expensive unless you’ve got really good furniture insurance, which is totally a thing and which everybody is legally required to have.

And now imagine that a news site responds with an article saying the government doesn’t regulate chairs enough.

Hospital Competition, Pricing, and Quality

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AEI’s James Pethokoukis has a brief blog post on a brand new study looking at healthcare costs. He reports:

“We have this large body of evidence covering many, many years that consistently shows if you happen to live in an area with only one hospital you are going to pay a lot more,” [Carnegie Mellon economist Martin] Gaynor said.

That helps explain why a C-Section in one Oregon market costs more than $15,000 and can run for as little as $3,000 in St. Louis, where there’s lots of competition. For years, hospital executives have defended these prices saying it’s about quality, or that they see sicker patients, or lots of folks on Medicare. “That’s just not true,” said co-author Yale economist Zack Cooper.

I mention Pethokoukis’ blog specifically because it provides a number of informative links on the subject, including one from The New York Times appropriately titled “The Experts Were Wrong About the Best Places for Better and Cheaper Health Care.” This is what makes central planning so dangerous: experts are often wrong when it comes to making sweeping societal changes via laws and policies. When the market is allowed to work, as in the case of hospitals, prices drop and quality improves.[ref]For example, recent research suggests that competition between hospitals improves managerial quality and thus hospital performance (e.g. increase in survival rates of emergency heart attacks).[/ref]

Give it a read.

 

Rich Weinstein, Jonathan Gruber, and Consent of the Governed

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2014-11-17 Jonathan Gruber

Bloomberg has a long piece on Rich Weinstein, whom you probably have not heard of. He’s the guy who unearthed the footage of Jonathan Gruber (one of the architects of the Affordable Care Act[ref]AKA ObamaCare[/ref] bragging about how the American people had to be misled in order to pass the bill because they are too stupid to k now what is good for them. You can find lots of videos on YouTube now, but I’ll give you just one as an example of the category:

Weinstein, for his part, is not a journalist, blogger, or political activist of any kind. From Bloomberg:

“When Obama said ‘If you like your plan, you can keep your plan, period’—frankly, I believed him,” says Weinstein. “He very often speaks with qualifiers. When he said ‘period,’ there were no qualifiers. You can understand that when I lost my own plan, and the replacement cost twice as much, I wasn’t happy. So I’m watching the news, and at that time I was thinking: Hey, the administration was not telling people the truth, and the media was doing nothing!”

He did his own research, found a bunch of guys who called themselves architects of the law (Jonathan Gruber was one of them), and then started fanatically looking for everything that any of them had ever said about the law. Eventually, he found the clip above. The University of Pennsylvania yanked the video once it started making the rounds, leading to a classic case of the Streisand Effect, and the rest was history. Three thoughts.

1. I agree with Weinstein that it’s disturbing no one else found these videos. As he put it: “It’s terrifying that the guy in his mom’s basement is finding his stuff, and nobody else is.”

2. To be totally honest, I have a lot of sympathy for Jonathan Gruber. As much as the Fox News crowd might jump all over him for calling the American people stupid, he’s got a point. It might be unkind, but it is–when you’re talking about economic concepts–completely accurate. I’m just as exasperated as he is with American ignorance of basic economics, which leads to such wonderfully silly policies as the minimum wage and corporate taxation continuing to be wildly popular. I empathize with both his frustration and with his glee in successfully pulling an end-run around the electorate and accomplishing something that (in his view) is beneficial for everyone. He’s not a mustache-twirling villain. He’s a guy who was trying to do the right thing, and was willing to be sneaky to get results.

3. As a lawyer friend of mine pointed out, if you get someone’s consent through deceit, you don’t actually have their consent. And for us Americans, the principle of consent of the governed is one of the bedrocks of our entire system of government. If the people are willfully misled–and Jonathan Gruber makes clear the law was intentionally written to do just that–than this is an attack on American democracy.

Sometimes the partisan angle is actually accurate, and this is one of those cases. Conservatives have long warned of the arrogance of liberalism, centralized planning, and a do-gooder technocracy that knows better than you do what’s good for you. Trying to provide healthcare for more Americans is one of the most noble imaginable motivations, but if the process is fundamentally anti-democratic that’s just not good enough.

Feeling the Love…at Work

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A new blog post at Harvard Business Review looks at a longitudinal study forthcoming in Administrative Science Quarterly, which

surveyed 185 employees, 108 patients, and 42 patient family members at two points in time, 16 months apart, at a large, nonprofit long-term healthcare facility and hospital in the Northeast. Using multiple raters and multiple methods, we explored the influence that emotional culture has on employee, patient, and family outcomes. What we learned demonstrates how important emotional culture is when it comes to employee and client well-being and performance. Employees who felt they worked in a loving, caring culture reported higher levels of satisfaction and teamwork.  They showed up to work more often. Our research also demonstrated that this type of culture related directly to client outcomes, including improved patient mood, quality of life, satisfaction, and fewer trips to the ER. While this study took place in a long-term care setting ­— which many people might consider biased toward the “emotional” — these findings hold true across industries. We conducted a follow-up study, surveying 3,201 employees in seven different industries from financial services to real estate and the results were the same.

This is why organizational and management research has been a major part of my work in theology. I’m excited for the future of management.

Leading Health Care Innovation

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With the debates over Obamacare raging, the editors of Harvard Business Review and the New England Journal of Medicine have collaborated to produce an online forum entitled “Leading Health Care Innovation.” As the “Editors’ Welcome” post explains,

It is a forum for the debate and a place where members of the health care sector can share the results of their efforts to innovate. The insight center is pilot endeavor designed to test the waters for a permanent publication, and we welcome your feedback.

The insight center will run from Sept. 17 until Nov. 15. Its contents will span three broad areas:

  • The “Big Ideas” section will feature articles about the foundational principles in the formulation of a high-value health care system.

  • The “Managing Innovations” section will focus on the organization and delivery of health care and how to orchestrate change.

  • The “From the Front Lines” section will offer accounts of solutions to specific problems that practitioners have implemented in their organizations.

Definitely worth checking out.