Health and Wealth: The Downside of Plenty

One would hope that beneath all the noise emanating from Washington DC, serious policy discussions were actually taking place. Prominent among these should healthcare. The relative value of the Affordable Care Act or any potential alternatives aside, an oft-overlooked aspect of national health is the impact of lifestyle factors that greatly impact health outcomes in the long run.

Even the most lightly informed individual can be trusted to know that America has one of the highest obesity rates in the world and is the worst in this regard among developed Western nations. Sure, Michelle Obama advocated for healthy diets in schools, but the impact of such advocacy hardly entered into policy discussions on healthcare. While healthcare spending in the US is the highest in the world, a cursory look at measures of outcomes leaves observers underwhelmed. A pair of lengthy posts at Random Critical Analysis get at why this connection between high healthcare expenditures and middling outcomes in the US misses the mark in some critical ways. First, "exceptionally high health care expenditures are well explained by [America's] unusually high material standard of living."¹ Secondly, "gaps in health outcomes are quite well explained by behaviors (or at least indicators there of) related to diet and lifestyle." These reasoning behind these points are put forward in great detail and backed up with data in the posts. Without delving into the rabbit hole of individual points brought up therein, a key takeaway is that wealth and a high standard of living can lead to some negative trends in national health.

Looking beyond the US and other wealthy nations, a case study demonstrating this negative relationship between wealth and health comes from a favorite country of mine, Cuba. With the fall of communism in Russia, Cuba faced severe shocks through the 1990s as the largesse of its greatest benefactor disappeared. The shortages of food and fuel during the "Special Period" wreaked havoc on the Cuban economy and disrupted the patterns of daily life. Buses no longer operated and Cuban farms could not support the population. The consequences of this for the average citizen were smaller portions, more walking, and a greater proportion of food supplied by local farmers.² Nationally, this meant that public health improved with regards to several measures.

A study published in the BMJ found that the average Cuban lost 12 pounds of weight in the early years of the Special Period, diabetes prevalance fell 53% between a peak in 1986 and 1997, coronary heart disease mortality rates fell 34.4% between 1996 and 2002, among many other markers of health. Not all the health impacts were beneficial during this crisis. The death rate for the elderly increased 20% between 1982 and 1993. The Special Period was an incredibly trying time for the Cuban people as all aspects of life were disrupted.

That weight loss occurs as a result smaller portions and more walking is not surprising. That diabetes and heart disease rates fall following weight loss is also unsurprising. What is surprising is that these would occur sharply on a national level. When the trend globally has been just the opposite.

The Special Period did come to an end in the second half of the 1990s. As economic normalcy returned, so did the aforementioned health measures begin to rise once again. Physical activity levels have tapered off as vehicles have returned to the roads, food intake returned to pre-crisis levels by 2002, and obesity rates have shot up. Diabetes measures have returned to or surpassed levels prior to the crisis, though heart disease mortality has stayed low.

This all is not to celebrate the glories of failed economic systems. Instead, it ought to display the complexity of healthcare and the difficulty of tackling public health issues. A country getting wealthier is objectively a good thing, but that wealth can come at a cost. Peculiar beneficial effects can be found in otherwise disastrous circumstances. Most Cubans would probably accept the tradeoff of higher obesity and diabetes rates for buses that run and reliable access to food. As debates in Washington go on about the merits and faults of single payer, insurance mandates, pre-existing condition coverage, and the litany, perhaps more heed should be given to examining how to decouple growing wealth from growing waistbands.

¹ One of the arguments presented is that the relationship to be examined should not be healthcare expenditures and per capita GDP, but rather healthcare expenditures and Actual Individual Consumption (AIC). AIC takes into account goods and services purchased by households in addition to services provided by non-profit institutions and governments. In this sense, it is a better reflection of standards of living and in this regard the US leads other countries. Further, the relatonship between healthcare spending and AIC is best modeled non-linearly. In this the US is no longer that outlier it appears to be when a simple linear analysis of GDP vs spending is conducted. As a country's standard of living increases over time, its healthcare spending and outcomes often look more like the US.

² The Special Period also demonstrated the ingenuity of responses to a crisis. Bizarre looking camello trailer buses were a much-maligned Havana staple for more than a decade. Organopónicos, public urban organic farms, are still commonplace today.

Jambo from Nairobi

5/10

I’m currently in Nairobi, the capitol of Kenya and East Africa’s largest city.  In the two days I have been here the city has yet to live up to its “Nairobbery” nickname.  I’m hoping that it stays that way.

View fullsize

Doing what he does best: Alex bringing tears to the face of a small Zimbabwean child.  Stay strong kid!

Somehow it seems that I always end up with Australian travel companions.  For the last two months my faithful padawan from Maputo to Zanzibar was Alex.  During that time, I tutored him on the finer points of the English language and he worked to explain to me the details of the English Premier League.  We both made significant strides in understanding, but have great lengths to achieving mastery.  Alex abandoned me to return to work and Europe.  Thus, I’m back to bringin’ da ruckus on my own to Kenya and beyond.  We had a good run and I owe Alex a great deal for keeping me sane during many of the more testing moments of this trip.

Among the biggest inconveniences of traveling in Africa and Europe is the time difference between here and back home.  It is terrible for sports fans.  I am always envious of European soccer fans and their exceedingly reasonable start times and the fact that English soccer games are shown everywhere.  Being in Nairobi with a decent internet connection gave me the chance to catch Game 4 of the Blazers-Warriors series on a live stream.  This meant waking up early in the morning, but it was worth it.  All season long this team has punched above its weight and it was fun to catch them live without too many interruptions today.  Of course, a Blazers victory would have been much preferred, but it's hard to stop Steph Curry when he catches fire.  There's still Game 5 to look forward to.  Go Rip City!

In honor of the many journeys on African public transport Alex and I shared.

I am alive after all- an update at last

4/29

As anyone who has visited this website in the last two months knows, I have been neglecting my blogging duties.  My legion of fans can rest assured that I have not fallen ill, been kidnapped by pirates, or forgotten how to use a computer.  The main two reasons for my inattention are poor internet connections and sheer laziness.  At times using the internet here in Africa has become a greater exercise in patience than a lifetime of supporting the Mariners (this is the year we make it back to playoffs).  I only have myself to blame for the lack of willpower to post updates when I have had the opportunity. I am now relaxing at Nungwi Beach on the northern tip of the island of Zanzibar.  The weather here has tended to cycle from blazing sun to pouring rain.  With the rain foiling any attempts to relax at the beach, I have finally run out of reasons to not write.

 Here is a summary of the places I have laid my head since the last post.  I will follow up with more details and (if I can get a decent upload connection) photos in the coming days. 

-Ezulwini, Swaziland
-Maputo, Mozambique
-Tofo Beach, Mozambique
-Vilanculos, Mozambique
-Mutare, Zimabwe
-Harare, Zimbabwe
-Bulawayo, Zimbabwe
-Victoria Falls, Zimabwe
-Livingstone, Zambia
-Lusaka, Zambia,
-Mfuwe (South Luangwa National Park), Zambia
-Lilongwe, Malawi
-Cape Maclear, Malawi
-Senga Bay, Malawi
-Kande Beach, Malawi
-Mbeya, Tanzania
-Dar es Salaam, Tanzania
-Stone Town, Zanzibar, Tanzania
-Nungwi Beach, Zanzibar, Tanzania

Back to SA (and a reading link)

3/2

After a week and a half in beautiful Lesotho, I've made my glorious return to South Africa.  I'm spending a day in Soweto before heading to Mozambique via Swaziland.  It's an interesting, and incredibly important, part of South Africa.  I've stopped into the Nelson Mandela House, Hector Pieterson Museum, and (unsurprisingly) Ubuntu Kraal Brewery.

Skiing Kosovo, Abandoned Lifts and All (NY Times)
It’s been years since done any snowboarding, but I can certainly appreciate a travel piece on Kosovo.  I loved visiting the Balkans and in my brief time in Kosovo I found a place that was quirky, inviting, and optimistic.  It also helps that “Americans are like Jesuses” to Albanian Kosovars, as stated by an Albanian Kosovar in the article.  (Probably not the phrasing I would have expected, considering that Albanians are Muslims.)  So for all my mountain sport enthusiast friends, make your way to Kosovo this winter.  You’ll love the place, the people, and hopefully you can take advantage of some budget time on the mountain.

In honor of my recent excursion:

Reading Links

2/26

More links for your reading pleasure:

How Federal Cash Harms State Governance (Real Clear Policy)
Since the federal government covers states' costs in the short- and medium-terms under the ACA, it seems sensible that they would expand their Medicaid coverage.  Largely lost in the debate has been the long-term costs to states of Medicaid expansion.  Undoubtedly, states will be hesitant to go back to pre-ACA levels of Medicaid coverage once the federal drip dries up.  This leaves a higher spending burden without a matching increase in revenues.  (This assumes that Congress would not decide to provide more funding to states.)  This is the ratchet effect that occurs with temporary flows of money from a higher level of government to a lower one- though a similar effect has been observed with government spending in general since World War II.  This should not be construed as an argument for the repeal of the ACA, it just happens to be a prominent example, but rather an argument for reconsidering the financial relationship between federal, state, and local governments.  Essentially, our current system is not as efficient as it could be.  We should be able to achieve the same goals (a wide social safety net, good infrastructure, etc.) with much less waste using a different framework.  Efficiency, however, has never been the strong suit of government.

Academic Drivel Report (The American Prospect)
Having spent some time recently in an academic environment, I can say that much of what is produced by academics really is drivel with no meaning outside of their silo.  On the other hand, a lot of academic production is great and humanity is richer for it.  The issue is that the drivel gives a bad name to academic work in general and turns society at large away from engaging with the good products of academia.  Not all ideas can expressed in the most simple of terms, but ideas should not depend on nonsensical obfuscation to appear valid.

Romer and Romer on Friedman (Conscience of a Liberal)
Krugman condenses the detailed criticism of Sanders' economic projections by Romer and Romer.  (The actual document is linked in Krugman's post.)  One of my biggest issues with Sanders and his supporters is that seem content to ignore or manipulate the full costs of his proposals.  On their face alone, the projected growth numbers seem to warrant scrutiny.  Now that scrutiny has been applied they simply don't hold up.  There would be economic losers under Sanders' policies beyond the 1%.  Perhaps that is acceptable, but we should not be led into fantasyland thinking.  The Sanders campaign has prided itself on Bernie's integrity and frankness, but this has been a consistently misleading point, though by this election cycle's standards this is a very minor transgression.

How Biden killed John Roberts's nomination in 1992 (Washington Post)
This goes back to what I wrote the other week.  Clearly obstructionism is a bipartisan practice.  Republicans can fairly point fingers to Biden for doing this 24 years ago, but that does not mean that they should follow that example.  It might be worth mentioning that as far as SCOTUS nominees were concerned, the obstruction was hypothetical.  

Bonus Video:

Is this the saddest debate moment of the debates?

Lumela from Lesotho

 

2/23

After about six weeks in South Africa I’ve finally made a break from that country and found my way to Lesotho. 

Some background on Lesotho- if you look on a map Lesotho is the small country entirely surrounded by South Africa.  It is a mountainous, mostly rural independent country.  The lowest point in the country is nearly a mile above sea level, making Lesotho the highest country in the world.  The Basotho people, the occupants of the country, were united under King Moeshoeshoe the Great in the early 19th century as they sought to defend themselves from Zulu and Boer attacks.  In 1868 then-Basotholand became a British protectorate as a means of ensuring protection from the Boers.  This established the current borders between Lesotho and South Africa.  Lesotho gained its independence from Britain in 1965.  By having maintained autonomy from South Africa and its antecedent states, Lesotho avoided the stain of apartheid that affected the country surrounding it.  However, political turmoil was a regular occurrence from the time of independence until the early 2000s.  Contemporary Lesotho is a relatively stable constitutional monarchy

The stretch of South Africa from Cape Town to Port Elizabeth that I visited was great.  There were good experiences and great people everywhere I went.  I would not have spent so long passing through if I did not enjoy it.  The scenery, wildlife, and summer sunshine all lead me to believe that nature was on my side for this part of journey.  I have been lucky to have had good company from both travelers and locals.  I have been surprised at how much I enjoy the South African lexicon.  It reminds me of Australian English in its peculiarity and casualness.  Particularly, “Howzit” is a great greeting and I’d say it’s probably superior to “Whatsup.”

While traveling through South Africa was incredibly convenient on the Baz Bus, getting to Lesotho required slightly more leg work.  It took nearly 24 hours, one mainline bus, two minibus taxis, one border crossing, and two city taxis, but I made it the village of Semonkong from Port Elizabeth.  The area surrounding Semonkong is idyllic.  Green fields and gentle, though deceptively steep, hills are everywhere.  From a high point I can turn around and for 360 degrees the horizon is broken by mountains.  There are no real restrictions on hiking anywhere as long as you’re considerate.  It’s liberating to just pick a direction and go as far as my legs feel like taking me.

Justice Scalia is Dead- Now What?

2/14

The passing of Justice Antonin Scalia looks to have some very interesting consequences in the coming months.  As the longest serving justice at the time of his death and the leader of the court’s right flank, Scalia leaves behind a strong legacy.  Few Supreme Court Justices provoke as strong reactions from the public as he did.  Though the other three reliable conservatives on the court (Roberts, Alito, and Thomas) all voted with Scalia at least 86% of the time, none gets the same fawning from conservatives (particularly Roberts at this point) nor the disdain from liberals that Scalia attracted.  He was looming figure and one that was obviously intelligent, principled, and influential.  He will continue to live on as an intellectual and philosophical giant among conservative legal circles.

Senate Majority Leader Mitch McConnell has stated, ““The American people should have a voice in the selection of their next Supreme Court Justice. Therefore, this vacancy should not be filled until we have a new president.”  This is absurd on its face.  It is the president’s constitutional duty to “nominate…judges of the Supreme Court.”  While this is done with the “advice and consent of the Senate,” there is no reason for a senator to exhort the president to maintain a vacancy on the Supreme Court for what would certainly amount to over a year.  Further, the Supreme Court is not the People’s Court.  By design, the Supreme Court is the least democratic institution laid out in the Constitution.  It is a check on political branches that are beholden to the people.  To suggest that for this nomination the public deserves any more input than they have always enjoyed is to dismiss Article II of the Constitution and more than two centuries of precedent.  Informed voters should know that the Supreme Court is an incredibly powerful institution with the ability to change the functioning of the country overnight.  Any abortion foe or gay marriage advocate is well aware of this.  When voting in a presidential or Senate election voters should consider the secondary or tertiary impacts of their votes, the constitution Supreme Court being one of these.  Still, the Supreme Court always has been distant from the whims of voters and ought to remain so.  It is irresponsible for a six term senator to propagate any myth about the people deciding what the court looks like.

The process of replacing Scalia on the highest bench is going to be dramatic.  Despite Mitch McConnell’s fantasies, I think everyone can anticipate President Obama naming a nominee.  The real question is whether President Obama will name someone who can satisfy the Senate.

Republicans should be wary of overplaying their hand and delaying until after the elections.  While the have the ability to be absolutely obstructive now, they do stand to lose the both the Senate and White House in November.  The general election is months away, but I remain skeptical of the GOP’s chances to get their man, whoever that may be, in the White House.  Prediction markets agree with me on this point (or maybe I should say that I agree with the markets).  Of course, this is subject to change.  The primary process is long and we are no closer to knowing the general election matchup than we were a month ago.  The emergence of a strong consensus Republican candidate and further erosion of support for Hillary Clinton could lead to a change in parties in the executive.  As it stands though, the Republicans face an uphill battle.  Retaining the Senate seems more realistic, but here the Republicans are stuck defending 24 seats while the Democrat defend only 10.  If Obama names a squishy conservative or a moderate to the court and Republicans block it and subsequently get drubbed in the election by the Democrats, they could end up looking particularly foolish.  A new Democratic president with a Democratic Senate could then install a liberal Justice that would fundamentally shift the Supreme Court.

The Supreme Court with Scalia was quite balanced though right-leaning.  With four reliably liberal conservatives and four reliable conservatives, no ideology can be seen as dominating the Roberts Court.  President Obama will seek to push the Court to the left.  It is unfathomable that he would nominate a Scalia clone.  However, I would be similarly surprised if he nominated a hardened liberal judge.  With the current Senate makeup, he stands no chance of getting a liberal dream pick through.  It would seem that for Obama his best hope is to pick a nominee that will satisfy at least a sizable minority of Senate Republicans and not scare away Democrats.  Nonetheless, we can anticipate that he will push for a leftward shift.  When replacing a Justice near one bound of the ideological spectrum, any nominee closer to the mean will be seen as creating a shift.

I am curious to see how President Obama plays this, whether he opts for a politically pragmatic pick or shoots for the moon.  The last significant shift in the Supreme Court came under George W. Bush when Sandra Day O’Connor’s seat was taken by Samuel Alito, transforming a swing vote into a conservative spot, though even this was not a revolution.  Justice O’Connor, like Anthony Kennedy, could viewed as a conservative, albeit a squishy one.  My money would be on Obama to name someone in this mold, though perhaps someone who is reliably pro-life as means of assuaging conservatives.  In any case, this will create ripple effects through the election cycle as Supreme Court nominations gain the spotlight as a consideration when voters pick candidates.