Big News From Oregon--Not All of It Good

There is study in progress with a randomized control group design—the gold standard of evaluation research—to evaluate the effects of Medicaid expansion in Oregon. The second wave of results from that study were published yesterday. To summarize briefly, Oregon wanted to expand Medicaid but didn't have enough money. They invited anyone who was eligible to apply, and 90,000 people applied. They then randomly selected 10,000 of them to receive Medicaid, while the others became eligible for the control group. The first wave of results, with about 6000 adults in each group, showed that the Medicaid recipients were more likely to rate themselves in “good” or “excellent” health, were less likely to report a recent decline in their health, had more doctor and hospital visits, more preventive care, and fewer unpaid medical bills.

Unfortunately, the second wave study, published in the New England Journal of Medicine, is gated, so I am relying on the abstract and a summary by Aaron Carroll and Austin Frakt in The Incidental Economist blog.

The corporate media are spinning the second wave study as showing Medicaid expansion to be a failure. For example the New York Times says:

It found that those who gained Medicaid coverage spent more on health care, making more visits to doctors and trips to the hospital. But the study suggests that Medicaid coverage did not make those adults much healthier, at least within the time frame of the research . . .

Later the article notes that Medicaid expansion under the Affordable Care Act will be costly. “Health economists anticipate that new enrollees to the Medicaid program will swell the country's health spending costs by hundreds of billions of dollars over time,” it warns. If you go online and check the comments following any article about the study, you'll find that it has unleashed a torrent of criticism from the political right claiming that providing health care for the poor is a waste of money. The study is certain to be used by Republicans such as Pennsylvania Governor Tom Corbett to justify their opposition to Medicaid expansion.

So what does the second wave study actually show? First, the bad news. The three objective indicators of physical health, blood pressure, cholesterol and blood sugar level, were all lower in the Medicaid group than the control group, but the differences were not statistically significant. Here are the data. (HDL is “good” cholesterol, so the fact that there are fewer people with low HDL cholesterol in the Medicaid group is a good outcome. High hemoglobin A1c is high blood sugar.)

Now the good news. Medicaid reduced the incidence of depression by 30%, which was statistically significant. It also significantly increased preventive care, including a 50% increase in cholesterol monitoring, a doubling of mammograms, and an increased likelihood of being diagnosed with diabetes.

Finally, the economic news. Health care spending was 35% higher in the Medicaid group. Of course, Medicaid practically eliminates catastrophic medical costs. As a result, the Medicaid recipients were significantly less likely to report borrowing money or skipping other bills in order to pay medical expenses.

There are several reasons we should not accept the conservative rush to judgment that this study shows that Medicaid is not helpful.

• Medicaid recipients were healthier on all three measures of physical health. The problem is that the differences were not statistically significant. There are several reasons why that might be the case, but the most likely is that the sample sizes were too small to detect the effect. The authors state:
  
  
  [O]ur power to detect changes in health was limited by the relatively small numbers of patients with these conditions; indeed, the only condition in which we detected improvements was depression, which was by far the most prevalent of the four conditions examined. The 95% confidence intervals for many of the estimates of effects on individual physical health were wide enough to include changes that would be considered clinically significant . . .
  
  
• These data were collected only two years after the program began. The significant differences in preventive care suggest that greater differences in health might emerge in later waves of the study.
  
  
• Mental health is also health, and significant differences in depression should not be dismissed as unimportant. Financial hardship also matters, and its absence may be related to the lower incidence of depression in the Medicaid group.
  
  
• There is no comparable study of the health effects of private health insurance, so these data should not be used to infer that Medicaid is any more expensive or less effective than private insurance.
  
  

Let's do a thought experiment. Suppose you had a private health insurance policy, researchers did a study to evaluate its health effects that was comparable in size, duration and design to the Oregon study, and obtained identical results. That is, the policy holders' health was better, but not significantly better than people without insurance. Would you cancel your policy? One of the reasons people buy health insurance may be that they think it will make them healthier, but it is my guess that the primary reason people in this country buy health insurance is to guard against the financial consequences of catastrophic illness.

You may also be interested in reading:

Tom Corbett to PA's Working Poor: “Drop Dead!” Part 1. Medicaid improves Health and Saves Lives.

Tom Corbett to PA's Working Poor: “Drop Dead!” Part 3. What Medicaid Expansion Would Mean to Pennsylvania

Medicaid Expansion Update

The Mourning After Drama Continues

At the end of our last episode, 24 days ago, U. S. District Judge Edward Korman had overturned the Obama administration's decision to deny girls under 17 access to morning after birth control pills without a prescription. The judge correctly noted that the age restriction contradicted the unanimous recommendation of the scientific advisory board of the Food and Drug Administration, which was in turn based on studies showing that adolescents had no difficulty understanding how to use the pills, called Plan B One-Step. The judge gave the Obama adminstration until May 6 to make the pills available over the counter to women of all ages.

Yesterday, the Obama administration attempted to compromise. They announced a change in the age limit. The pill will now be available without a prescription to girls 15 and over, provided they can prove their age. In addition, drug stores will be allowed to display Plan B on their shelves, rather than keeping it under the counter with the pornography. But this decision has at least two problems.

• Girls 15 and over must produce identification to prove their age. (The package will actually prompt the cashier to verify the customer's age.) For most people, this is a driver's license, but many teenage girls will not have a driver's license because they are too young, their family is poor, or they live in an urban area. The fallbacks are birth certificates and passports, but producing them would probably require parental help and might cause a delay of more than 72 hours after intercourse which would make the pill ineffective.

• The result of this decision is to increase the likelihood of an unwanted pregnancy, but only for girls 14 and under. This is awkward from both a moral and a social policy perspective. If we assume that unplanned pregnancy is the result of an unwise decision, it's not clear that younger girls should be punished more for their poor judgment than older girls. It's also pretty obvious that the younger the girl, the greater the disaster an unwanted pregnancy is for her personally, her child, and the society at large.

Strangely, the Obama administration announced that this regulatory change was not a response to Judge Korman's ruling. (Why do governments make such preposterous statements?) They also did not announce whether they would appeal the decision. I guess it's now up to the judge to decide whether he will accept these new rules. The Center for Reproductive Rights, which filed the lawsuit, has announced that they will continue to fight against any age restrictions on morning after contraception.

Stay tuned.

Update (5/2):  The Obama administration has appealed Judge Korman's decision that must be made available to all females regardless of age.

You may also be interested in reading:

Sixteen Months After the Mourning After

The Mourning After

Tom Corbett: Conspiracy Theorist

Governor Tom Corbett traveled to Washington yesterday to participate, along with Governors Paul LePage of Maine and Scott Walker of Wisconsin, in a Small Business Summit sponsored by the U. S. Chamber of Commerce. Not surprisingly, the three Republican governors expressed a negative view of the Affordable Care Act (ACA).

The ACA requires firms with 50 or more employees to provide health care coverage for their workers or pay a fine. Gov. LePage stated that he is actively encouraging Maine businesses to break the law in the hope that the ACA will fail. “I tell Maine businesses to pay the penalty,” he said. “It would be cheaper by just writing a check for the penalty and then let Obamacare fall on its own weight.” Gov. Corbett was more circumspect. He said he didn't have to encourage Pennsylvania businessmen to defy the law, as they had already arrived at that decision on their own.

Gov. Tom Corbett

The Governor went on to suggest that the ACA was designed to fail, the motive being to pave the way for a single payer health care system. “I see the whole thing collapsing and, potentially, in the long run that may have been the plan,” he opined. “I'm a prosecutor. I believe in conspiracies.”

A lot of us probably wish the Governor's speculation were correct. However, I've completed five weeks of an eight-week course, “Health Policy and the Affordable Care Act,” taught by Dr. Ezekiel Emanuel, one of the architects of the ACA, now teaching at the University of Pennsylvania. If Dr. Emanuel is typical of the policy makers who wrote the bill—and I believe he is—they were a lot more interested in saving money than saving lives. Of course, they expect it to do both, but he emphasizes the fact that only two of the ten titles in the act deal with expanding access to health care. The majority of the bill is about improving efficiency and lowering cost. It is clear from his lectures that he expects the ACA to be successful, and that he has no interest whatsoever in moving the country to a single payer health care system.

In one respect, I agree with Gov. Corbett. I believe in some conspiracies, too. For example, I believe there was a conspiracy to delay the Jerry Sandusky indictment until after the 2010 gubernatorial election.

You may also be interested in reading:

Medicaid Expansion Update

Tom Corbett to PA's Working Poor: “Drop Dead!” Part 3. What Medicaid Expansion Would Mean to Pennsylvania.

Who Pays?

Sixteen Months After the Mourning After

The second-ever post on my new attempt at blogging was a Bronx cheer for the Obama administration's decision to overrule the unanimous recommendation of the scientific advisory board of the Food and Drug Administration and refuse to allow Plan B One-Step, the morning after contraceptive, to be sold to girls under 17 without a prescription. The decision was announced by Health and Human Services Secretary Kathleen Sebelius, but President Obama publicly supported the move, describing it as “common sense” (which, of course, trumps science every time).

Yesterday, Federal Judge Edward Korman of the Eastern District of New York overturned Sebelius's decision, ruling that the morning after pill must be made available over the counter to girls of all ages. In a sharply-worded decision, he said, “(T)he secretary's action was politically motivated, scientifically unjustified, and contrary to agency precedent.”

The petition to make the morning-after pill universally available was orginally filed in 2001. Judge Korman accused both the Bush and Obama administrations of acting in “bad faith” by delaying action on the petitition for over a decade. “Indeed, it could be accurately described as an administrative agency filibister,” he said.

Needless to say, the judge's decision was applauded by women's groups and criticized by the religious right. However, the prize for the most illogical response goes to the Catholic Church. A spokeswoman for the U. S. Conference of Catholic Bishops claimed, “Plan B does not prevent or treat any disease, but makes young adolescent girls more available to sexual predators.” How's that again? 

Press Secretary Jay Carney said yesterday that the President still supports Secretary Sebelius's decision. The Justice Department must now decide whether to appeal. The ball is in your court, Mr. Black Republican.

Phil Spector: Actual Innocence?

I was never a big fan of Phil Spector's music, although I ultimately came to appreciate his work with the Righteous Brothers and Ike and Tina Turner. I was aware of Spector's reputation for egotism and erratic behavior long before he was charged with the murder of Lana Clarkson. I usually skip over newspaper reports of celebrity trials. For all these reasons, I didn't pay much attention to the Spector trials as they occurred. Since he had the best legal representation money could buy, I assumed he was guilty. But after seeing writer-director David Mamet's fictionalized reconstruction of his first trial, Phil Spector, and the documentary on which it was partially based, The Agony and the Ecstasy of Phil Spector, directed by Vikram Jayanti, I'm beginning to take seriously the possibility that he is actually innocent of the murder.

As you may know, actress Lana Clarkson was shot in the mouth with one of Spector's pistols while seated in his living room. After the fatal shot, Spector emerged from the room holding the gun and, according to his chauffeur, said, “I think I just killed someone.” At issue is whether Ms. Clarkson shot herself or whether Spector shot her.

I consider myself a member of the Sherlock Holmes school of criminal investigation. The physical evidence is by far the most important consideration. Eyewitness testimony can be biased or simply mistaken. Speculation about motives or states of mind is hopelessly subjective. Evidence of the defendant's past behavior is often irrelevant to the present case. What matters are the physical traces of behavior that can be preserved and analyzed. There are several problems with the case against Spector:

• First and foremost is the lack of blood on Spector's clothing. For Spector to have shot her, he must have been standing within two feet of her. When someone is shot in the mouth, a large volume of blood and brain tissue is expelled through the open mouth, totally saturating anything in its path. Yet Spector's white sport coat (and the rest of his clothing) is totally free of blood with the exception of what appear to be a couple of fingerprints, which could have occurred (by his account) after he picked up the gun. The prosecution seems to have had no convincing explanation for this lack of blood. It has been speculated that Ms. Clarkson was holding her hands in front of her face to ward off his attack, but if you place your hands in this defensive position, you'll see that there is plenty of opportunity for blood to escape around and between your hands and fingers.
  
  
• The angle of entry of the bullet is inconsistent with the prosecution case. The path of the bullet is slightly upward, which is consistent with the possibility that she shot herself. If Spector had been standing in front of her, as the prosecution claims, the path of the bullet would have been downward. I suppose he could have been kneeling, but no one is claiming that.
  
  
• The defense has offered a plausible explanation of the physical evidence which suggests that she shot herself by accident while she was drunk and fooling around with the gun. Spector claims that he entered the room, saw her with the gun in her mouth, and shouted something like, “What the hell are you doing? Stop!” According to Mamet, the defense tested several participants, having them hold a similar gun in their mouths and startling them using the same language. In the majority of cases, they pulled the trigger while removing the guns from their mouths. Removing a gun from your mouth is an awkward movement. Try it and you'll see how your finger could accidentally press against the trigger as you pull the gun away from your face.
  
  

• Spector claims that the chauffeur misunderstood him and that what he actually said was, “I think I'd better call someone.” The chauffeur was a Brazilian immigrant whose command of English was not that good. Admittedly, if he didn't shoot her, picking up the gun was a stupid thing for Spector to do, but it could be attributed to  the shock of what (he claims) he just witnessed.

Mamet's argument is that most of the jurors ignored the physical evidence because they didn't like Spector, largely due pretrial publicity and his unusual appearance. Their dislike was exacerbated by the judge's controversial decision to allow five women to testify that Spector had previously threatened them with guns if they did not comply with his sexual advances. This was justified on the grounds that it established a pattern of behavior on Spector's part, but it is obviously weak evidence of his guilt in the Clarkson case. Mamet's screenplay also claims that his lawyer, Linda Kenney Baden, planned to have him tell his side of the story, rehearsed his testimony, but then changed her mind since his response to cross-examination was unpredictable. The documentary doesn't shed light on her legal strategy, since Spector was interviewed before the first trial.

The first trial ended in a hung jury. Two jurors held out for acquittal. This encouraged the prosecution to retry him. I'm not sure what happened during the second trial, but it seems likely that he had a less competent defense attorney. He was convicted and is serving a sentence of 19 years to life. In 19 years, he will be 88.

If you decide to watch one of these films, I actually recommend Mamet's account—on HBO this month—in spite of the fact that Al Pacino portrays Spector as more eccentric than he actually was, at least during Jayanti's interview. Here's a “Making of” feature.

The Jayanti documentary is primarily about his past life and contributions to popular music. It is available in full on You Tube.

Book Review: Failed Evidence, by David Harris

Failed Evidence: Why Law Enforcement Resists Science, by David Harris, Professor of Law at the University of Pittsburgh, concerns one of the recurrent themes of this blog—the fact that sound social science research seldom has much effect on public policy. (Check out his seven short videos dealing with main themes of the book.)

Our legal system should be undergoing a crisis of confidence as we continue to discover the number of innocent people who have been sent to jail. DNA evidence has resulted in over 300 exonerations so far, but DNA is only available in 5% of criminal cases, suggesting that we are seeing only the tip of the iceberg. Dr. Harris reviews research which casts doubt on current practices in the three areas that account for the greatest percentage of exonerations: incorrect eyewitness identifications, inaccurate forensic testing, and false confessions.

In all three areas, current practices are deeply flawed, and research suggests straightforward remedies that would greatly decrease errors. Eyewitnesses are usually shown lineups and photospreads using procedures that encourage them to pick the suspect who most closely resembles the perpetrator. The administrator knows which person is suspected and gives positive feedback if the suspect is chosen, which increases the eyewitness's certainty. Forensic tests, i.e., identification of fingerprints, firearms, hair and blood samples, etc., are inherently subjective. The reliability that is sometimes claimed for them occurs only when the second examiner is told in advance of the first one's results. False confessions occur because police question suspects for long periods of time under extreme pressure, and are permitted to lie about evidence. This produces fatigue and confusion, and some innocent suspects confess only to put an end to this painful situation. Because the idea that an innocent person might confess is counterintuitive, I've included this 10 minute video from Saul Kassin which gives further explanation of how it occurs.

Dr. Harris reviews the reasons police officers give “in their own words” for their fierce resistance to such evidence and the remedies they imply: they are too expensive, that they will allow guilty people to go free, the research is less valid than their own personal experience, etc. The most perversely amusing example of police intransigence is their inconsistent reaction to DNA evidence depending on whether it implicates or exonerates the defendant. Since their objections are easily debunked, he speculates about the real reasons for resistance.

These are divided into two categories. Cognitive reasons focus on the thought processes of the individual officer. An example is cognitive dissonance, which occurs when police are told that their past behavior may have sent innocent people to jail. This possibility is vigorously denied, and they attempt to bolster the effectiveness of current practices. Institutional reasons cite the context in which police and prosecutors work. Police officers are evaluated on the basis of the number of arrests they make and prosecurors are judged by their conviction rate. There is nothing in the system that rewards either of them for doing justice by releasing an innocent person.

Dr. Harris then lists 16 recommendations for reform, i.e., videotape all police interrogations from beginning to end, and makes some suggestions for how to make these changes happen. For example, cognitive dissonance may be minimized by focusing on the future rather than past injustices. It's at this point that Dr. Harris begins pulling his punches by compromising in advance with what he believes to be implacable resistance from the law enforcement community.

For example, the following one hour presentation by Dr. Gary Wells explains the process of relative judgment, and why we should replace simultaneous lineups, which result in identification of the suspect who most resembles the perpetrator, with sequential presentations in which the witness makes an independent judgment about each suspect. A meta-analysis of relevant studies confirms that sequential lineups greatly reduce incorrect identifications. However, they also slightly reduce correct identifications, since the simultaneous lineup results in a small percentage of “lucky guesses.” The loss of those lucky guesses is interpreted by law enforcement as letting innocent people go free, which generates resistance. Unfortunately, Dr. Harris's response to this dilemma is to suggests that this recommendation—in my judgment, the most important one of all—be optional, since it is unlikely to be accepted anyway.

By the way, here is the soon-to-be-released study Dr. Wells refers to in his lecture. The upcoming Supreme Court case he mentions did not have a satisfactory outcome.

It's clear that Dr. Harris is not optimistic about the prospects for reform. (Dr. Wells is much more optimistic.) He gives many examples in which police and prosecutors, working through their professional organizationals, have easily defeated reform attempts. The primary victims, innocent people wasting away jail, have no political clout. He ends the book with a chapter in which he presents only three cases in which meaningful reform has taken place. (The Innocence Project lists other examples.) In two of these cases, a conservative politician converted to the cause of reform and was able to use his credibility as a strong advocate of law and order to make it happen. If advocates as sympathetic to police and prosecutors as Dr. Harris are unable to bring about bottom-up change through persuasion, the best hope for social scientists may be to go over their heads, either through federal legislation or court decisions, such as the Miranda ruling, which law enforcement personnel are required to obey.

The Myth of the Conservative Voter

The obvious fact that majority public opinion is unable to prevail in Washington has set off a flurry of research on why the political system is so unresponsive. The latest contribution comes from David Broockman of the University of California, Berkeley, and Christopher Skovron of the University of Michigan. They sent surveys by mail and email to all of the 2012 candidates for state legislatures in the country. The response rate was 19.5% (1907 candidates), which is about double the typical response rate for mail and email surveys. The candidates were asked to estimate what percentage of their constituents would agree with the following statements:

1. Same sex couples should be allowed to marry.
2. Implement a universal healthcare program to guarantee coverage to all Americans, regardless of income.
3. Abolish all federal welfare programs.

They were also asked their own opinions on the first two issues. A new technique called multilevel regression and poststratification (MRP) was used to estimate the attitudes of the citizens in each legislative district. It would obviously be very costly to survey the entire voting population each of the country's 6500 state legislative districts. MRP uses national survey data to determine level of agreement with the three statements based on education, race, gender, social class, religiosity and having voted for Obama. The percentage of people in each of these demographic subgroups in each legislative district is determined from the 2010 census. This generates an accurate estimate of the opinions of the people in each district. Although indirect, this method has been validated against real survey data.

There were positive correlations (rs = .43 to .51) across districts between the candidates' estimates and actual opinions, but they are not very impressive, accounting for only about 20% of the variance. The interesting thing about the data is that the candidates' perceived their constituents to be about 10% more conservative on these issues than they actually were, a difference roughly equal to the average difference between voters in California and Alabama. Stated differently, 60% of citizens would have to favor a liberal policy in order for their legislators to perceive them as a majority.

The responses were analyzed separately for liberal and conservative candidates based on their own answers to political questions. These data are shown in the table above. The horizontal axis represents the actual opinions in each district, and the vertical axis is the politicians' estimates. The black line is perfect accuracy. Anthing below it means the politicians are overestimating their constituents' conservatism. The blue line is the estimates of the liberal politicians, and the red line, the estimates of the conservatives. Although both groups believed their constituents were more conservative than they actually were, the conservatives seemed to be living in another world. They were off by over 20%. Nearly half the conservative candidates believed their district was more conservative than the actual opinions of the most conservative district in the entire country.

These findings may help us understand differences in the personal style of politicians. The well-known tendency of liberal politicians not to stand up for their beliefs contrasts sharply with the overconfidence of conservatives. Both may be explained by their fundamental misperceptions of public opinion.

Candidates were surveyed again after the election, but there was no evidence that they had learned anything. They were no more accurate than before, and their accuracy was unrelated to any of the activities they reported during the campaign, i.e., time spent talking with voters.

The first question about these data is their generalizability. The study should be replicated using federal and local as well as state candidates, and with a wider variety of issues. However, the differences are quite large, so I assume these findings are robust. How can they be explained? Broockman and Skovron do not speculate other than to suggest that political elites are not motivated to learn the attitudes of the people they represent.

Before giving them a political spin, we must be sure these errors are unique to politicians. It's possible that a random sample of the population might make errors of a similar magnitude and direction. If so, the data represent cultural influences to which we are all exposed. For example, the corporate media present an almost unrelentingly conservative view of the American public opinion, insisting that this is a “center-right” nation and referring to right-wing politicians as “moderates.” These data may reflect back what the media inaccurately tell us. The liberal-conservative difference may mean that the media outlets preferred by conservatives are even less accurate than those preferred by liberals.

Suppose the general public does not make errors that are comparable to these candidates—that is, these biases are unique to politicians. If these politicians are themselves more conservative than the general public, there might be a false consensus effect. False consensus refers to the tendency to assume that other people's opinions are more similar to our own than they actually are, to project our own beliefs onto others. There is reason to believe that political candidates are more conservative than the people they seek to represent, since so much money is required to run for office—either their own money or funds obtained from wealthy donors.

This shades into a second possibility, which we might call the “loudest voices” hypothesis. When considering this hypothesis, remember that money talks too. In fact, the Supremes have ruled that money is speech.

Suppose there are two types of political issues, economic and social. Economic issues are those issues that have major economic consequences, even they are sometimes debated using non-economic arguments. Therefore, they include not just taxation and public spending, but issues like climate change, health care, and foreign policy, including debates over war and peace. In the present study, health care and welfare are economic issues.

When the issue is economic, the loudest voices politicians are exposed to are those of campaign donors, whose views are well to the right of the general public. In fact, politicians may spend much of their time inside a bubble filled with rich contributors and corporate lobbyists. If you spend most of your time talking to these people, you are not likely to arrive at an accurate perception of what the general public thinks.

Social issues are those that have only minor economic consequences, such as abortion, gay rights and gun control. Although they are sometimes called “sideshow issues,” they are as important to some people as economic issues. For example, if you are pregnant, whether you have access to a safe, legal abortion is a matter of life and death. Social issues are represented in this study by gay marriage.

When the issue is social, political pressure comes primarily from grassroots organizations. Sadly, the loudest voices the politicians hear almost invariably come from the right. Conservatives are better organized, perhaps because they hold their attitudes with greater strength. Of course, what we call “grassroots” is sometimes actually astroturf. These groups receive financial and logistical help from the wealthy, since rich people know that they benefit when conservative candidates are elected.

Therefore, the loudest voices hypothesis suggests that, regardless of whether the issue is economic or social, the candidates hear mainly conservative voices. This is especially true of candidates who are themselves to the right of center. You can get a pretty distorted view of public opinion that way. Ask Mitt Romney.