Thursday, May 25, 2017

An Ounce of Prevention is Worth an Ounce of Cure

People have long believed – and by long I mean 4,000 years – that the right sort of lifestyle, accompanied by the right sort of medical care, will stave off illness. Thus we are constantly urged to get regular checkups, mammograms, colonoscopies, etc. But the evidence that these things actually extend life is weak, and since they cost money many medical economists think they are a waste. The latest study finds that people often respond to slightly alarming signals picked up during checkups by getting a lot of health care that doesn't help them:
Using unique individual-level panel data, we investigate whether preventive medical care triggered by health checkups is worth the cost. We exploit the fact that biomarkers just below and above a threshold may be viewed as random. We find that people respond to health signals and increase physician visits. However, we find no evidence that additional care is cost effective. For the “borderline type” (“pre-diabetes”) threshold for diabetes, medical care utilization increases but neither physical measures nor predicted risks of mortality or serious complications improve. For efficient use of medical resources, cost effectiveness of preventive care must be carefully examined.
So far as we can tell, there isn't much reason for healthy people to see a doctor.

On the other hand there is strong evidence that women who get pre-natal care have healthier babies, even when the checkups lead to no interventions at all. So this is a complicated business, and there may well be interventions that help. The ordinary sort of medical check-up just doesn't seem to be one of them.

This has some political importance when it comes to health care policy. Liberals have long hoped that universal health insurance would save a lot of money, because people would get to the doctor when their problems were small and easily treatable, rather than waiting until they are really sick and going to an emergency room. But the evidence that this saves any money at all is weak, and the cold truth seems to be that the more health insurance you give people the more they spend on health care.


G. Verloren said...

Mammograms and colonoscopies don't extend life? I find that hard to believe, given the prevalence of cancer in the modern world, and I think anyone who could afford to get regular checkups of those sorts would want to do so for the increased chance of detecting cancer in the early stages, where mortality rates are lowest.

Now, I could absolutely believe the argument that they don't save money. I would imagine the vast majority of mammograms and colonoscopies come back with negative results, and from the point of view of economics, that's wasteful. Why pay for 10 sets of x-rays over ten years, when the first 9 of them don't actually improve your health? You save 90% of the cost if you only get a single set of x-rays done in the tenth year, once you've actually developed a tumor for them to detect.

But there's far more to consider about healthcare than just cost, of course. There's also dignity of life, eliminating human suffering, et cetera.

It would be highly economical to just euthanize people with severe injuries or sickness. Economists and insurers could pretty quickly bang out a set of charts and figures showing how cost-effective it is to treat the ill or wounded based on recovery rates, percentages, and probabilities, and then suggest a cutoff point where people who fall on one side of the projections receive care, and people who fall on the other side are simply thrown off cliffs like Spartan infants.

But returning for the moment to mammograms and colonoscopies, even if we can take everything this study says to be true, we're still only talking about length of life - not necessarily quality of life. Getting more regular mammograms might not, in terms of the averages of a population of 300+ million people, extend your lifespan meaningfully - but it very well could make you much happier than you would be otherwise.

An economic viewpoint cares only about dollars, not about the human condition, or promoting joy and eliminating misery. Treating an individual with a painful chronic condition may not make them live longer on average or cost less to care for, but it likely will make their projected lifespan far less horrible to endure.

Worse still, economic viewpoints lack the ability to compensate for future unforseen benefits and values. If back in 1921, the treatment of a certain Franklin Delano Roosevelt had been determined on purely economic grounds, a certain amount of money would have been saved, yes, but one of our country's greatest leaders would have been lost. Who could have ever predicted that this man would recover as much as he did, or that he would go on to be of such incredible value to the entire nation? No economist in the world can properly judge or value human potential.

It's important to note that the healthcare system of his time did in fact write him off as a loss. But Roosevelt was incredibly fortunate to have been born into a wealthy family, and could afford to seek private treatment. Yet, suppose that he hadn't had such means. Suppose, like millions of Americans today, he was reliant on the state to provide some or all of his medical coverage. What of him then?

I would rather live in an economically poorer but morally richer nation. I would rather we lead the world in spending on healthcare than on warfare. I would rather worry about helping people live better than live longer. And I firmly believe there's a reason that the countries in our world rated highest for citizen happiness all have universal healthcare.

pootrsox said...

Bravo/a, G. Verloren!!

David said...

As someone who's had a serious illness discovered in the course of a routine physical, I must say that I always wonder what the point of studies like this is.

My treatment was expensive, mostly to my insurance company, which means it was mostly expensive to my fellow insurance buyers. And statistically, there are significant chances both that the treatment will not be a permanent cure, and that I could have survived for decades without it. Most likely is that we will never know for sure if my treatment helped. And yet, somehow, I'm not bothered by the expense, nor would I be too upset if my rates went up, to pay for mine and thousands of cases like mine. If anything, I feel fortunate that, if I had to go through this, it happened before the medical economists got too much of a say.

It's not as if the money is somehow lost to the economy. It just spends part of its life being spent on medical care.

As I've argued before, if we are in such a material emergency that we need to consider denying people the possibility of medical care--or more exactly, if we need to begin treating medical care as a luxury for the rich, other than the very most economically justifiable procedures--I'd like to see us sacrifice a lot of other things too. And I could think of a lot of things to cut other than just military spending. Instead, I'd like to see medical efficiency advocates give up things that are important to them personally.

But maybe we should start with golf. Think of all that expensive watering.

G. Verloren said...


But military spending is such an absurdly huge elephant in the room.

We spend more on our military than China, Russia, Saudia Arabia, India, France, The UK, Japan, and Germany COMBINED.

Our military spending comprises 36.25% of all military spending on the planet.

Our military spending accounts for 3.3% of our GDP, while total global military spending accounts for 2.2% of the global GDP.

China can field a total number of troops almost 2.5 times as large as ours, for roughly 1/3 the cost, accounting for only 1.9% of their GDP.

The only other major countries who devote a greater percentage of their GDP to military spending are all hotbeds of violence, oppression, and unrest: Columbia (3.4%), Pakistan (3.4%), Singapore (3.4%), Russia (5.3%), The UAE (5.7%), Israel (5.8%) Kuwait (6.5%), Algeria (6.7%), Saudi Arabia (10%), Oman (16.7%).

I assume you're joking about the golf irrigation, but here's a few numbers anyway.

Military spending comprises 16% of our combined federal budget (mandatory and discretionary spending combined), while food and agricultural spending comprises only 4%.

Disregarding mandatory spending, military spending comprises 54% of our discretionary budget, while food and agricultural spending comprises only 1%.

And while I could not readily find total figures, irrigation of golf courses is overwhelmingly a private expense, effectively not paid for at all by federal spending.

We spend 6x as much money on war as we do on education.
We spend 7x as much money on war as we do on transportation.
We spend 10x as much money on war as we do on housing.
We spend 12x as much money on war as we do on international affairs.
We spend 13x as much money on war as we do on energy and the environment.
We spend 25x as much money on war as we do on science.

And that doesn't even factor in the costs of veterans' benefits, which is higher than the cost of every one of the above non-military categories. Military and veterans spending combined accounts for 20% of our total federal budget (mandatory and discretionay spending combined), and 60% of our discretionary spending.

Spending less on the military would save money in itself, but would also promote less belligerent foreign policy, precipitating fewer wars, producing fewer casualties overall, and resulting in even further reduced costs for veterans' care over time.

Or we could always just give tax cuts to the ultra wealthy, increase military spending to even more dizzying heights, and place the extra burden on untold millions of the nation's poorest citizens by gutting healthcare, education, foodstamps, and countless other government systems that exist to help the weakest and most vulnerable among us, particularly children and the elderly...

John said...

I of course support medical insurance for everybody, whatever it costs. And I agree with G that we could find a lot of the money in the defense budget. But I feel compelled to point out that those who expect big savings from national health insurance (like Bernie Sanders) are fooling themselves.

David said...

G., the reason I don't want to talk about military spending in this context is because I don't want people to talk their eye off the ball. Witness the huge post you wrote about military spending. I want the debate to be about medical spending, and not change the subject--which is what happens if you raise the topic of military spending.

Also, military spending is, to most people, an abstraction. Medical spending is personal. So I want the concomitant sacrifices I'm demanding to also be personal, and precious.

And no, deep down I wasn't actually kidding about golf. I mean it when I say that, if we're in such a national emergency that we need to start curtailing medical care, then I want to see us start living like we're in a national emergency. In everything. Like we were Britain in 1940.

Otherwise, we're just kowtowing to Grover Norquist.

David said...

John, inspired by your response, I decided to click on the link to the study. For those who haven't clicked, this takes you to a Tyler Cowen post that introduces the study with the words, "yet another paper suggesting that medical care, or at least some forms of it, has relatively low marginal value." I have no idea what marginal value is. So I tried Wikipedia, and within about a minute concluded I was neither smart enough to understand this concept without significant effort, nor interested enough to expend the effort.

I understand that all this is part of an extended discussion about how to improve health care delivery given the financial constraints that the current state of our politics seems to impose, and that the vast majority of participants in a discussion like this act in good faith.

But I would suggest a political lesson. To most non-technically minded folks like myself, ANY discussion like this sounds like a argument for health-care rationing, and we take this personally. Very personally. To us, to let a discussion like this go by without a constant accompanying reassurance that we're not going to let the medical efficiency experts go wild, sounds like allowing our enemies to get a nuclear weapon (in the sense of Scott Alexander's analysis of why identity-politics types can't let their opponents have the slightest leeway). A study that merely amounts to an interesting datum to the technically-minded can sound like powerlessness to a layperson. And think how often that ends up being the case in, say, economic life. You could get up, dress up, show up, shut up, and never give up, and, if there are two of you doing that, any day some technic could tell your boss that he could get along just as well with only one. And out you go. That's powerlessness. That's a Scott Alexander nuclear weapon.

John said...

David, I get what you're saying about bean counting and health care. But consider what happened in Vermont a few years ago: a legislative proposal was introduced to create a statewide universal system, and it got a lot of support. But once people started looking into the actual numbers they found that the cost was going to be triple or quadruple what the original backers of the law said, requiring a massive tax hike, and the whole thing died.

If we're going to create a good system, we need to face up to the costs from the beginning.

David said...

I suppose in my fantasy world liberal reformers would stop making "we, too, want to save you money!" arguments, and start making a forthright, full-throated case for the common good and the worth of sacrificing one's treasure for that. I'd want this sense of common to be based on humanity, rather than blood, faith, language, or any other sectarian identity. I don't think I'm going to get my wish on either count anytime soon.

G. Verloren said...


The easiest way to sell the idea of "Raise Taxes, Get More Benefits" is probably to point to all the countries in the world that have already done that and succeeded admirably.

Point to all the places in the world where people happily pay higher taxes because it means they end up paying far less elsewhere. Look at the nations with free or highly subsidized healthcare, free or highly subsidized college, free or highly subsidized job training programs, free or highly subsidized child care, free or highly subsidized maternity/paternity leave, free or highly subsidized public transportation, et cetera, et cetera. Note how international studies routinely and consistantly find that quality of life in those countries is some of the highest on the planet, as their citizens the happiest.

Heck, maybe once you've pointed all that out to people, stop and play for the scene of Charlie Chaplin giving his immortal speech from The Great Dictator:

"In this world there is room for everyone. And the good earth is rich and can provide for everyone. The way of life can be free and beautiful, but we have lost the way. Greed has poisoned men's souls, has barricaded the world with hate, has goose-stepped us into misery and bloodshed.

We could achieve such incredible good in the world, if only so many of us weren't such selfish and miserly skinflints; if only so many of us weren't too short sighted to see that we stand to gain so much from being generous and kind than we ever could from being greedy and cruel; if only we more of us valued cooperation and reviled competition, instead of the other way around.