Wednesday, March 23, 2011

Does this article make anyone else angry?

Paul Krugman attached a link to this in one of his latest op-eds. This is obviously an argument that well-traveled people are smarter, more prosperous, and more liberal than others. Too bad not everyone can afford to travel the world and be as "enlightened" as this author. I also think the data is somewhat misleading as it uses states instead of individuals to find correlations.

26 comments:

PBM said...

I'm not sure your taking the right conclusions away from this. He says those states have higher average incomes, more efficient work forces, less blue collar jobs, more diversity, and more happiness (that graph is less convincing). I don't think he's attributing it to traveling, he's just putting a different spin on red state vs. blue state comparisons than are already out there.

Julia G said...

Yay New Jersey!
I also think you are reading into conclusions that aren't there. He's simply saying that more educated/more wealthy people tend to travel more, not that traveling makes you more educated.

Julia G said...

I don't think there is any kind of agenda here.

TJE said...

People in NJ just want to get out-- anywhere!

Just kidding. I'm a proud Jersey guy.

Megan said...

"It’s a fun map. With the exception of Sarah Palin’s home state, it reinforces the “differences” we expect to find between the states where more worldly, well-travelled people live versus those where the folks Palin likes to call “real Americans” preponderate."

No one thinks it's a tad outrageous?

Maggie said...

I see where you're coming from, Megan. There certainly is an arrogant tone to the article. Still, that doesn't mean the differences don't exist. And the author is careful not to make any sort of causal claims: "While my usual caveats stand—our analysis deals with associations only, correlation and causation are not the same thing—the results are intriguing and perhaps provide another window into America’s divide."

He's not really saying anything new. He's just showing yet another way that we notice the cultural divide between red and blue states.

Maggie said...

Also, do you have the link to the Krugman piece?

Megan said...

http://krugman.blogs.nytimes.com/2011/03/23/americas-superiority-complex/

Patrick_Landers said...

Like everyone else, I agree that the article on passports was probably a little snoody but was very careful to stress that it was just pointing out correlations, not causation. Also, it was really written to just offer another example of how America is bifurcated, with huge splits for many Americans in life experiences and countless other factors.

With the original Paul Krugman article, we can see the point Krugman was probably trying to make- namely, Americans need to accept the fact that we don't do EVERYTHING BETTER THAN EVERYONE ELSE. There are lots of things we can learn from Europe and other developed or developing nations, just as there are things those nations can learn from us. Health Care is just one prominent example of an issue were you can say, at the very least, our current system is not working as well as those systems found in other countries- we have large percentages of the country uninsured, we spend far more money per person, and we don't have any better outcomes to show for it. You can disagree about how we should reform our system- but I question the sanity of anyone who claims the American health care system is just fine and dandy (which lots of Republicans like Senator Ron Johnson frequently claim.) Well, I don’t actually question their sanity- I just realize their total lack of scruples in their willingness to lie about anything (America’s health care system is the best in the world!) to score political points on an issue (the devil’s work!, also known as OBAMACARE!!!). Some Democrats fall into similar traps- I just wish both sides would stop it and stick to the facts.

But back to the point, Krugman was probably pointing out how people from liberal states are more likely to have passports, so presumably they are more likely to have first-hand experience with alternative countries and forms of government and provision of services.

As someone who has only been out of the country once (a hop and a skip across the Canadian border when I was… 1?, so I clearly don’t remember anything), and whose family doesn’t take vacations and foreign excursions for the exact financial reasons you mention- I completely understand the fact that most Americans can’t afford to go gallivanting off to Europe. However, since Americans have to work so hard and concentrate so much time on their daily lives, they don’t have time to study international comparisons on issues like health care. Besides study, personal experiences are really the only way Americans can make informed evaluations of other countries. You don’t have to accept that other countries are better- people just shouldn’t assume they’re worse when they don’t actually know anything about other countries. I know you don’t have a problem with this fallacy Megan- I just worry that some conservatives reinforce ethnocentrism and close-mindedness among many Americans with their constant harping on and on about American exceptionalism. That is certainly an important concept with some justification, but it also deserves lots of qualifying statements. There are lots of great thinks about America, as evidenced by the fact that the world has generally moved in our direction for centuries- but we’re not the best on many, many issues. There’s a lot we could learn from others.

TJE said...

Patrick, at the risk of being accused of being one of those krugmanian ugly Americans:

http://www.hoover.org/publications/hoover-digest/article/5589

Megan said...

I agree that our health care system does not work as well as other countries, and after looking into it, I am warming up to the ACA a bit (although I think it has A LOT of flaws that need to be addressed and I think it will fail miserably if none of the cost control measures work).

Still, call me an exceptionalist (if that's a word), but I think America was founded on different principles than other countries. The Constitution's emphasis on upholding individual liberty and protecting property (sometimes at the expense of what would be best for the majority) makes America the best country in the world. Yes, I am proud to say I think America is the best country in the world.

Still I think America has flaws and we can and should learn from other countries.

Back to the original article, the fact that Paul Krugman was criticizing a Republican for being ignorant about other countries, and then links an article that basically is trying to say liberals travel more than Republicans and are therefore somehow more worldly and enlightened than the people Sarah Palin calls "regular Americans" (which, by the way this article does not prove that liberals travel more) shows that Paul Krugman is making the case that Conservatives are more ignorant than Liberals.

PBM said...

But the flipside of this is offensive too. Sarah Palin classifying some Americans as "real" and others as not. Just because I'm liberal and live in or near a city doesn't mean I'm not American.

Megan said...

True

Megan said...

I just think a lot of you would be more outraged by an article that said that Republican states have more people who have read the Constitution than liberal states (even if it was true and even if the author was very careful not to imply causation).

TJE said...

http://www.gallup.com/poll/22579/church-attendance-lowest-new-england-highest-south.aspx

TJE said...

http://www.usacarry.com/forums/general-firearm-discussion/9841-percent-firearms-ownership-state.html

TJE said...

http://www.buzzfeed.com/digg/american-beer-consumption-per-capita-by-state-ma

Patrick_L said...

Here’s a quick preview (though I encourage people to read my detailed rebuttal in full) of my full response to the article Professor Eismeier referenced. What do conservatives have on their side when defending the American health care system being “in better condition than you might suppose”?

1) Input data. Because inputs are great predictors of how effective a system is in so many fields! Aren’t conservatives the ones always pointing out how education inputs aren’t very good predictors of outcomes, and how we need to concentrate on structural reforms that use inputs better? Health care is the same thing- alternative models use inputs (better ones, different ones, less of bad ones) far more successfully and efficiently to get better outcomes and lower costs.

2) Self-reported health “feelings.” Once again, where’s the ACTUAL EVIDENCE? Oh wait! Conservatives can’t cite it because it shows their side is WRONG! Actual medical outcome data clearly shows are system provides no better outcomes across the American health care sector- even though it takes us almost twice as much money per person just to achieve similar outcomes to our peer, developed countries.

3) A handful of misleadingly presented mortality rates for a handful of cancers. When you actually control for confounding factors, you find that there is only a handful of conditions where the U.S. looks marginally (and I mean marginally) better than comparative nations. Then there are a great deal of conditions (including cancers) for which the U.S. does marginally worse, and then their other conditions for which we do significantly worse. The overall picture is clear- American health care spends far more money for no discernible improvement in outcomes. Our phenomenally high-costs are not only a burden on our state and federal budgets, but are also a drag on our economy by making the nation less competitive. Similarly, out system leaves tens of millions uninsured and traps others into jobs they’d prefer to leave just because health insurance is so essential for the many Americans who are uninsurable due to pre-existing conditions.

Now let’s take these 1 by 1…. (you’ll notice my use of citations- luckily I have papers I’ve written in the past to draw upon in rebutting these arguments from a health expert who clearly needs to familiarize themselves more with the public health literature field.) I’ll note before I get personal anecdotes and responses from people that I am discussing aggregate health statistics- which are what we consider when comparing countries. You may be one of the lucky ones who knows people who did well because of the treatments and American health care system that I am going to discredit- just know that on almost any condition, people would be far better served by the European/Canadian/etc. health care models, and that these models have much lower costs per person even while maintain a similarly-high level of quality. In short, the U.S. system is a failure.

Patrick_L said...

1) Cancer mortality rates. Conservatives LOVE to cite these statistics, because it’s about the only health outcome for which the United States APPEARS to look good on. Of course, mortality rates as they define them frequently for these statistics are based on how many people are diagnosed with a condition and their survival outcomes. The U.S. just diagnoses people far more often on these conditions, even though in many cases treating the condition leaves people no better off, and actually can leave them worse off. But by diagnosing people (and even not treating them, since they aren’t going to die OF the condition), U.S. mortality rates look great! Prostate cancer is a great example of this phenomenon, since it is a very slow-moving type and is found in nearly half of all men who die in their 70’s and 80’s though it’s rarely their cause of death (Gosselaar et al, 2005). The treatment for this usually non-threatening cancer can often result in impotence and incontinence. Prostate cancer is found in most men by a certain age- they just don’t die from it, they die from other conditions.

Gosselaar, C., Roobol, M. J., & Schroder, F.H. (2005). Prevalence and characteristics of screen- detected prostate carcinomas at low prostate-specific antigen levels: aggressive or insignificant?. BJU Int., 95:2, 231-237.

For a look at overall cancer death rates, as well as several specific types, check out this blogpost http://theincidentaleconomist.com/wordpress/senator-johnsons-odd-dislike-of-the-ppaca/ . The Incidental Economist is a blog run by several health economists who definitely have mixed things to say about health care reform- they like some parts, they don’t like others. However, so you can be an informed consumer of their information- I’ll note that Aaron Carroll is in favor of the Affordable Care Act. Of course, that doesn’t limit his ability to convey simple information like comparative cancer mortality rates.

If you really want to get into a conversation on cancer mortality rates in more detail, I’d be happy to (once I get back to my apartment), cite dozens (literally!) of books and academic journal articles which have intensely studied cancer mortality rates (there are hundreds, but I only have some on hand with me this semester). I can bring some of them to tonight’s debate (I have a number of relevant books on hand with me this semester for instance), or I could start posting to this blog.

However, I think I’ve already adequately discussed why these cancer mortality rates are extremely misleading and don’t actually address the relative efficacy of the American health care system on cancer treatment. I will note that there are several cancers were studies with extensive controls have found the U.S. system performs marginally better (though of course our outcomes vary far more by socioeconomic status than health outcomes for our peers who are far more likely to provide quality care to ALL of their citizens). Of course there are many other cancers were the U.S. does worse. It’s important to note that in the public health literature, cancer is the area where America actually looks best! On other conditions, particularly chronic ones, the U.S. looks like an abysmal failure. The area where we do best is the only are where we even look comparable to our peers. As I’ve said before, the American health care system has no better outcomes, and in fact actually has worse outcomes for a variety of conditions even after controlling for various confounding factors- all the while our system can costs anywhere from 50% to 100% more per person. Aka, our system sucks.

Patrick_L said...

While this isn’t a direct response to this very narrow cancer mortality rate discussion, I’d thought I’d point out something really interesting in the public health literature related to this topic. In his book (I highly recommend it!) Disease, Diagnoses, and Dollars, UCLA Public Health professor Robert Kaplan reveals the paradox that treatments that reduce the likelihood of dying from one condition often leave the overall death rate unchanged. He establishes this argument through extensive literature reviews of high-quality studies examining cancer, blood pressure, cholesterol, and diabetes treatments. Although a treatment can reduce the likelihood of dying of a heart attack for example, there is often no difference in the likelihood of dying from all causes between a treatment and a control group in a medical study. Oftentimes the media and advocacy groups fail to recognize the fact that while a treatment may be effective for a given condition, it may have little or no effect on public health and overall chances of dying. Basically, even if the U.S. did do better on cancer treatment (which it doesn’t)- we still don’t actually reduce people’s mortality rates. We just help them with one issue while they die from another one.

Kaplan, R. M. (2009). Disease, Diagnoses, and Dollars: Facing the Ever-Expanding Market for Medical Care. New York, NY: Copernicus Books.

Patrick_L said...

2) See above for a discussion about cancer mortality rates.

3) Drugs like statins are an input, not a health outcome. That tells us nothing about the efficacy of a nation’s health care system. At one point doctors’ use of leeches and bleeding was widespread- that was thought to be an effective intervention, even though if you had public health data you’d know it was disastrous for patients. Just because we give our patients statins more often than European countries doesn’t mean they don’t provide SUPERIOR health care treatment. After all, this presentation doesn’t account for (the many high-quality) alternative medical approaches to conditions like heart disease. Statins were one of the most frequently discussed examples in Kaplan’s book. Statins have medical value for SOME patients (the U.S. massively overprescribes them- which actually leads to worse outcomes for many patients), but they aren’t the only thing that’s effective, nor are they the only thing doctors should be doing. Foreign health care models are much more successful for a variety of reasons, including better coordination of care, greater emphasis on evidence-based medicine (which doctors and Hospitals struggle to do in the U.S. because it actually often costs them money to improve patient outcomes), and more emphasis on public health interventions.

Statins are also an example of the high-intervention, high-cost approach that American health care emphasizes. Unfortunately, the evidence shows that this doesn’t work. Dartmouth’s Atlas Project researcher Elliott Fisher and his colleagues have convincingly demonstrated that more intensive, expensive care can result in worse outcomes. For their studies they utilized Medicare beneficiary records to construct cohorts of patients differentiated by medical condition, and then categorized these patients cohorts into one of five spending quintiles determined by Medicare hospital referral region and the average amount of money spent in that region for Medicare beneficiaries’ last six months of life. The Dartmouth team discovered that high-spending regions unsurprisingly utilized more intensive medicine, as evidenced by the “60 percent more care in the highest-spending regions than in the lowest-spending regions” (Brownlee, 2007, p. 50). Yet after controlling for various confounding factors, Fisher et al. shockingly found that the patients from high-cost, intensive treatment regions were two to six percent more likely to die compared to those from the low-spending hospital referral regions.

This increased mortality rate is almost certainly due to unnecessary treatment which results in none of the benefits but all the dangers of hospitalization and various treatments. First, most treatments and drugs come with potential complications that strike individual patients, even if the benefits on aggregate outweigh the complications. In addition to providing excess discretionary care which has fewer usage protocols (Brownlee, p. 60), these regions are less likely to provide essential care based on evidence and professional consensus. Researchers found that the prevalence of 24 yardsticks of basic, quality care was inversely correlated with Medicare spending (Baicker & Chandra, 2004). Elliott Fisher and Elizabeth McGlynn, a RAND Corporation researcher, found similar results in separate studies (Brownlee, p. 66). Not only are high-spending regions using excessive care with little benefit, they are also failing to use well-established and evidence-based fundamental practices. This provision of unnecessary care and too little essential care is partially linked to the greater number of specialists and the fewer number of family/general practitioners found in high-spending regions.

Patrick_L said...

Unfortunately, these critiques (which refer to specific geographic regions in America versus others), also describe well the differences between the American versus the European/Canadian approach. Not only do international comparisons show that their way is better, but studies just looking at American health care providers that emphasize more of what Europe/Canada does also do better. The evidence is overwhelming. The American health care system is high-cost, high-intervention, little-evidence, worse outcomes, etc. model when compared to our foreign counterparts. European/Canadian health care systems provide better incentives for health care providers to focus on quality-care, better outcomes, and innovating to find equivalent or better health care strategies that actually lower costs.

For more details and references, see:

Mahar, M. (2006). Money-Drive Medicine: The real reason health care costs so much. New York, NY: HarperCollins Publishers.
Brownlee, S. (2007). Overtreated: Why too much Medicine is making us Sicker and Poorer. New York, NY: Bloomsbury USA.
Fisher, E. What are the Underlying Causes of Poor Quality and High Costs? [PDF document]. Retrieved from Lecture Notes Online Web site: http://www.ftc.gov/ogc/healthcarehearings/docs/030527fisher.pdf
Baicker, K. and Chandra, A. (2004). Medicare Spending, the Physician Workforce, and Beneficiaries’ Quality of Care. Web Exclusive, Health Affairs.
Halvorson, G. C. (2007). Health Care Reform Now! A Prescription for Change. San Francisco: John Wiley & Sons, Inc.

Patrick_L said...

4) Cancer screenings- again! See above, it’s an input, not an output. And most of these inputs are horrible ones, because they clearly don’t help health outcomes. For instance, my previous discussion of prostate cancer. The prostate specific antigen (PSA detects “tumors on average eleven years before a digital rectal exam” (Brownlee, p. 200), but does little for American men besides making more of them go through painful and unnecessary treatment processes.

5) Ooh! Self-reported health statistics. Why would we trust survey (aka highly biased) information when we actually have evidence on outcomes which shows how different countries do on treating conditions. Self-report health evaluations are awful and should never be used when we have so many, higher-quality and inherently less-biased information sources. Self-reported surveys…so biased. I can’t even respond to this point- every social scientist, and scientists in general, know about the major problems with survey data! OMG!!! I can’t even take this point seriously.

But just in case you’re not convinced, I’ll point out two additional flaws with 5) This survey only cites two groups- below-median income seniors and WHITE, young people. Seniors- uhm…Medicare, Medicaid, and Social Security anyone??? And yay!- our health care system makes WHITE people think their health is better than the Canadian system makes their WHITE young people feel. Whew- and I was worried there for a moment that our system wasn’t doing a good job.


6) From the Hoover post, “Canadian and British patients wait about twice as long—sometimes more than a year—to see a specialist, have elective surgery such as hip replacements, or get radiation treatment for cancer.” Once again- inputs!!! That’s like saying one army is better because it has more bullets- even though it has no trained soldiers!!!! Are these specialists actually helping their patients more than general practioners? A: NO!!!!!! But what does America have shortages of (so that many patients see a specialist as their primary physician)- general, family practioners. The ones who provide better outcomes for much less money. Yay-America does a better job with ELECTIVE procedures like hip replacements!!! We just let lots more people die from a variety of chronic conditions than our peers- but at least we provide elective surgery faster! Radiation treatment from cancer? Once again- another thing the evidence shows us we provide too much of. All of these inputs conservatives constantly cite are actually great examples of how our system is doing worse.

7) People in other countries aren’t completely satisfied with their care? What a surprise- it’s generally so easy to satisfy people- they never want even better care at lower costs! High percentages of Americans think the system is broken and needs fixing. This point is completely worthless- just because Americans are marginally (very marginally) more satisfied with their system doesn’t mean it’s better for them- the evidence is overwhelming that the alternatives are superior. People in these other countries are NOT pushing for their system to be more like America’s- they KNOW their system is better. Why is the fact that people in America are happier with their system not a good explanation for why American health care is great? Because it just shows how uninformed Americans are about how MUCH BETTER their health care would be if they were living in another country. Conservatives have been lying to them!!!

8) Once again, conservatives trying to cite people’s “opinions” and “feelings.” Why? Because they know the EVIDENCE shows that these people’s “feelings” don’t actually match reality- higher costs, worse outcomes. That’s how to describe our system compared to our peers.

Patrick_L said...

9) Once again, an input. Once again, an input which the evidence shows us is a very bad predictor of outcomes. The public health literature shows overwhelmingly that these other countries provide more than enough medical tools and advances to improve their patient’s health to the U.S. level and beyond. In many cases, more medical imaging is not only a problem because it costs so much money and has no positive impact on outcomes. It actually makes things worse. Why? Part of the problem with medicine and its rapidly advancing technology is the fact that new and better tools can actually lead to a worse performance. Due to advancing imaging technology, doctors are able to “see” and learn more about a patient. After all, people think “it’s better to know too much than too little” (Brownlee, p. 158). Unfortunately patients and doctors can be reassured by a clean scan and lose their vigilance, or be falsely led to seek intensive treatment. As Maggie Mahar notes, “the more refined the technology, the more likely it is to produce false positives,” plus these “tools are more likely to produce false negatives… simply because doctors accept the results so readily” (p. 189). And the public health evidence shows us just how much this is true- these useless input measures are not good predictors of actual outcomes.

Another interesting thing comes out in Kaplan’s book- using autopsy studies, scientists have actually discovered that there has been a remarkable stagnation in the diagnoses and treatment of Americans’ health care conditions since the 1980’s. All of these fancy imaging systems aren’t actually helping. Doctors, like many patients, are just following well-established irrational thought processes and assuming that technological advances must improve outcomes. The evidence shows us they don’t.

10) Once again, all the Hoover Institution fellow can cite are INPUTS, this time for medical innovation. He provides no evidence that American innovation has had a greater impact than innovation from other countries (which is extensive). He shows no evidence that this innovation has had a positive impact (the evidence shows that much of medical innovation has mixed impacts).

Once again, a hack from a conservative institution (this time the Hoover Institution) has been unable to show that the American system actually DOES A BETTER JOB- they just show us indicators they argue should result in the American system being better. Of course, the evidence shows that these indicators and inputs don’t lead to the American health care system doing a better job. That’s the whole purpose of health care reform- we know our system isn’t working even though we’re giving it every resource it needs (far more than our peers have to use). That’s why the Affordable Care Act does a variety of things to restructure the American health care sector to increase efficiency and realign incentives so that providers, insurers, and consumers all make better health care decisions that improve health outcomes and reduce costs. There is so much inefficiency in the American health care system that it’s a great example of low-hanging fruit. Reforming the system will actually make every important measure of our system (outcomes, access, equity, cost, etc.) can be made better- simultaneously!

TJE said...

Bypassing Patrick's rant (As a survivor of prostate cancer, who was diagnosed early and had robotic surgery performed by one of the nation's top surgeons, I beg to differ that I should have trusted the highly aggregated and disputed data of technocrats and done nothing but hope for the best.Is this the future of American medicine?), I call your attention to other ways in which states vary. It seems that not only is the world not flat but neither is the United States.

TJE said...

http://www.nytimes.com/2010/06/03/business/03dartmouth.html