Social Psychologists Set an Example

Sandra Bem, a feminist social psychologist and the author of gender schema theory, died May 20 at her home in Ithaca, NY, at age 69. Her husband, Daryl Bem, is also a prominent social psychologist. The following is the relevant section of her obituary.

The cause of death was suicide.

When she was diagnosed four years ago with Alzheimer's, she said she would end her life while she still could when the disease became too debilitating to continue.

After years of expensive medical treatments, she stopped all care six months ago and decided it was time to die.

She bought a copy of “The Peaceful Pill Handbook” and chose to take her life with pentobarbital.

The family held a service for her two days before her death.

“Instead of a funeral service, the family met with her last Sunday, a group gathering where we all shared our memories of her and our thoughts and feelings,” said her husband, Darly Bem, 75, also a nationally recognized psychologist. “Everyone was aware that Tuesday was the deadline.”

After spending her last day with Daryl, during which the couple went for a long walk, watched a movie and had dinner, Sandra took the drug at about 7 p.m. Tuesday and died in her sleep.

Thanks are due to the Pittsburgh Post-Gazette for having the courage to publish this information. I suspect some readers were not pleased.

Health Insurance and Mortality, Part 2

Please read Part 1 of this post before continuing.

Not surprisingly, there have been several criticisms of the Sommers, Long and Baicker study. Here are the main ones I've been able to identify so far, and my comments on each.

• It's too good to be true. The New York Times reports that experts are “skeptical of the magnitude and suddenness of the decline” in mortality. According to Dr. Joseph Antos, a health economist at the American Enterprise Institute, “Health care is a much more involved process—you don't just sign up and suddenly get well.” This objection, of course, does not explain the results. These researchers may be overlooking the fact that being without health insurance is a psychological stressor, the removal of which may have immediate health benefits.

• The results contradict those of the Oregon Medicaid study. A 2013 study by Baicker, et al., examined the effects of Medicaid expansion in Oregon using a randomized control group design. (The opportunity to sign up for Medicaid was determined by lottery.) Although this study found economic and psychological benefits of Medicaid, its effects on objective measures of health were disappointing. Blood pressure, cholesterol and blood sugar levels were all lower in the Medicaid group, but the differences were not statistically significant. However, the Oregon study's sample size was too small to detect medically important health benefits. The Massachusetts study has many more particpants. If the same percentage decline in mortality observed in the Massachusetts study had been seen in Oregon, it too would not have been statistically significant. The two studies are not inconsistent. An important strength of the Massachusetts study is its larger sample size. Furthermore, it measured the effects of the entire health reform package, not just Medicaid expansion.

• It costs too much. Using the Sommers, et al., data, Cannon calculated that it cost Massachusetts $4 million per life saved. He argues that this is not cost effective. However, this assumes that the only benefit people received from Romneycare was when it saved their lives. It ignores the many health and quality of life benefits people receive from medical treatments for non-life-threatening illnesses and injuries. What is the value of a knee or hip replacement that allows a person to walk free of pain for 20 years? How do you measure the benefits to a family of avoiding bankruptcy and the loss of their home?

• Massachusetts is different from other states. Massachusetts is “whiter and more affluent” than most other states, but the matched comparison groups control for race and income. It could be argued that Massachusetts has a more effective health care system (more doctors, better-equipped hospitals) than other states. However, a convincing alternative explanation must explain not just lower mortality in Massachusetts, but all the results. Why did the mortality rate change from 2001-2005 to 2007-2010? Wouldn't a better health care system be expected to help people over 65 as well? As Sommers, et al., state in their conclusion:

Although we cannot rule out unmeasured confounders, it is challenging to identify factors other than health care reform that might have produced this pattern of results: a declining mortality rate in Massachusetts since 2007 not present in similar counties elsewhere in the country, primarily for health care-amenable causes of death in adults aged 20 to 64 years (but not elderly adults), concentrated among poor and uninsured areas and not explained by changes in poverty or unemployment rates.

Of course, health insurance is useless if there are no doctors or hospitals in your area. The quality of the health system may have interacted with health care reform to produce a better result in Massachusetts than would be expected in other states. This does not explain away the results, but it may limit our ability to generalize from them.

• More research is needed. This cliché is, of course, trivially true. However, it is unrealistic to expect definitive studies of effects of the Affordable Care Act (ACA), since it is being implemented simultaneously in all 50 states. There are no experimental and control groups, only before and after comparisons, the results of which can easily be dismissed as caused by other changes taking place in society at the same time. About the best we can expect will be comparisons between states that do or do not expand Medicaid. (Pennsylvanians will be happy to know that, thanks to Governor Tom Corbett and our legislature, future researchers will be counting the number of excess deaths in our state.) However, states that are not expanding Medicaid are already known to differ both economically and politically from other states. And while Medicaid expansion is an important provision of the ACA, it is only a part of it.

In short, the Sommers, et al., study may be the best that is available for the foreseeable future. Even conservative critics of health care reform are granting it grudging respect.  Megan McArdle stated, "(A)fter yesterday's report, I've revised the probability of 'huge benefits' [from health care reform] upward, and you should do the same."

You may also be interested in reading:

Health Insurance and Mortality, Part 1

Big News From Oregon:  Not All of It Good

The Coverage Gap:  The Real Failure of Obamacare

Romneycare:  The Bottom Line

Health Insurance and Mortality, Part 1

In 2006, Massachusetts implemented the country's first comprehensive health care reform (“Romneycare”). It made health insurance mandatory for nearly all citizens, expanded Medicaid to cover people earning up to 150% of the federal poverty level (FPL), and provided health insurance subsidies for people with incomes up to 300% of FPL. It became the structural model for the Affordable Care Act (ACA). A previous study showed that Massachusetts residents reported themselves to be in better health following the implementation of Romneycare. A new study out this week shows that health care reform significantly reduced the mortality rate in Massachusetts compared to nearby states. This is the bottom line in health care research. It's good news not only for the ACA, but for single payer advocates as well, since single payer would further expand the number of people covered by health insurance and would presumably reduce the red tape and out-of-pocket costs that keep some people from using health care.

The study, by Drs. Ben Sommers, Sharon Long, and Katherine Baicker, is a quasi-experimental design. It lacks an important feature of true experiments—random assignmnent of participants to conditions—but attempts to compensate for this by using a matched comparison group that controls for most plausible alternative explanations. In this case, the experimental group was the citizens of Massachusetts. Each county in Massachusetts was matched with a comparison county drawn from a nearby state. The counties were matched for age distribution, race and ethnicity, poverty, income, unemployment, lack of health insurance, and their existing mortality rate. The authors compared the mortality rates of adults under 65 from 2001-2005 (prereform) to 2007-2010 (postreform). Here are the results.

• Mortality in Massachusetts declined 2.9% relative to the comparison group. This is equivalent to 8.2 deaths per 100,000 people, or one death prevented for every 830 people who obtain health insurance. The New York Times calculates that a national 2.9% decline in mortality among adults under 65 would translate to about 17,000 lives saved per year. Harold Pollack claims that the number is as high as 24,000 per year.
• Mortality “amenable to health care,” i.e., from causes such as cancer, heart disease and diabetes, declined 4.5% relative to the control group. Mortality from causes not amenable to health care, i.e., auto accidents, was unchanged. See the chart below.
  
  

• Mortality among people over 65 was unaffected. This is to be expected, since senior citizens already had Medicare.
• Reductions in the mortality rate were greatest among counties with the lowest incomes and the lowest rates of insurance coverage prior to reform.
• As you would expect, the study also found significant increases in insurance coverage, access to medical care, and self-reported health in Massachusetts compared to the comparison group.

As health care expert Austin Frakt has noted, this study constitutes the strongest evidence yet that having health insurance can save your life. Nevertheless, the study is not without its critics. I will look at some of those criticisms in Part 2 of this post.

You may also be interested in reading:

Health Insurance and Mortality, Part 2

Big News From Oregon:  Not All of It Good

The Coverage Gap:  The Real Failure of Obamacare

Romneycare:  The Bottom Line

A Nous la Liberte

Each week, Dr. Aaron Carroll, one of the bloggers at The Incidental Economist, releases a 5-10 min video called "Health Care Triage," in which he discusses current issues in health. This week's installment will be of special interest to single payer advocates, since it concerns the French health care system, which he considers the best in the world. You may not know whether to laugh or cry.

In previous weeks, Dr. Carroll has also discussed the Canadian system--not as good as France's, but much better than ours. He often discusses empirical issues, such as whether organic food is better for your health. If you sign up, You Tube will send you an e-mail each time a new video in this series is released.

You may also be interested in reading:

Conceptualizing Health Care Policy

Team Player, Part 2

Before reading further, please check out Part 1 of this report.

On December 7, 2012, a Florida State University (FSU) student reported to Tallahassee police that she was raped the night before by an unknown assailant after an evening of drinking. The alleged rapist turned out to be FSU's star quarterback Jameis Winston, who claimed that the sex was consensual. The charges were ultimately dropped for lack of evidence. FSU went on to win the NCAA's national football championship, and Winston won the Heisman trophy as the best college football player of the year. An April 16 investgation by Walt Bogdanich of the New York Times sheds further light on this incident.

Jameis Winston (©CBS Sports)

When the young woman reported to police, she had recent bruises and semen was found on her underwear. Detective Scott Angulo was put in charge of the case, but apparently there was almost no investigation. He failed to pursue obvious leads that would have easily identified the suspect and revealed that one of two teammates who witnessed the encounter, Chris Cashner, had videotaped the event. (In this age of cell phones, apparently some students like to film one another having sex.)

On January 10, 2013, Angulo got a huge break when the victim identified her assailant by name after seeing him on campus. Even then, he waited two weeks before taking the unusual step of calling Winston on the phone to request an interview. Not surprisingly, Winston lawyered up and never did speak to the police. The police finally interviewed his two teammates (who supported his claim of innocence) on November 14, almost a full year after the fact, but by that time, the tape had been erased. They also took a DNA sample from Winston, which matched that found on the accuser's clothing. On December 5, prosecutor William Meggs dropped the charges due to lack of evidence. He acknowledged that there had been deficiencies in the investigation, saying, “They just missed all the basic fundamental stuff that you are supposed to do.”

Meanwhile, FSU appears to have violated federal law by conducting no official investigation of the incident. Telephone records show that the university was aware of the charges against Winston on January 13, 2013, when an assistant athletic director called the police to ask about the progress of the investigation. Title IX of the Equal Opportunity in Education Act requires that when a university knows about a case of student on student harrassment—obviously including alleged rape—it “must promptly investigate to determine what occurred, and then take appropriate steps to resolve the situation.” FSU refuses to discuss the case citing privacy concerns, but whatever they did (if anything) did not interfere with their successful football season.

A strange presence lurking behind the scenes is the Seminole Boosters, a nonprofit organization with $150 million in assets that finances FSU varsity athletics. Bogdanich makes two interesting points. First, Detective Angulo had done private security work for the Seminole Boosters prior to the investigation. Secondly, the Boosters paid about 25% of FSU President—now Penn State President—Eric Barron's $600,000 annual salary! (What does this tell us about his job responsibilities?)

There are obvious similarities between this incident and recent events at Penn State. Former President Graham Spanier, Coach Joe Paterno, and administrators Tim Curley and Gary Schultz are accused of covering up child molestation charges against Assistant Coach Jerry Sandusky for several years. Since then, elections to the Penn State Board of Trustees have pitted candidates representing Penn Staters for Responsible Stewardship (PS4RS), who believe Paterno and his colleagues did nothing wrong, against candidates who accept the Freeh Report and NCAA sanctions against the university and want to move on. So far, four of six PS4SR candidates have been elected. Another round of Board of Trustees elections ends on May 8.

Penn State football fans can apparently take comfort in the fact that President-Elect Barron, in a situation with echoes of the Sandusky scandal, showed a similar reluctance to pursue charges against an important member of the football program.

Yesterday's paper reports that Senator Claire McCaskill (D-MO) intends to conduct hearings on college sexual assault policies, and will invite victims, administrators and university presidents to testify. She specifically mentioned the Winston case in her remarks. The U. S. Department of Education is reviewing FSU's handling of the incident. We can only hope that President Barron will receive an invitation to this party to share his perspective with the Senators.

You may also be interested in reading:

Team Player, Part 1

Freeh at Last

Who Pays?

Climate of Mistrust

Team Player, Part 1

Two months ago, Dr. Eric Barron, President of Florida State University (FSU), was appointed President of Penn State effective May 12. It seemed an odd choice, since FSU has a mediocre academic reputation and its integrity is tainted by two recent scandals. However, FSU won the NCAA National Football Championship last year, which may suggest what Penn State's #1 priority actually is. New information has recently emerged that raises troubling questions about the university Dr. Barron has spent the last four years governing.

FSU drew the attention of the academic community in 2011, when the Tampa Bay Times revealed that multibillionaire and conservative activist Charles Koch, through the Charles G. Koch Charitable Foundation, had made a $1.5 million donation to the FSU Economics Department in 2008 to be used to hire new faculty for a program promoting “free enterprise.” In exchange, the Foundation's representatives participated in the screening process and were given veto power over new hires for the program. Under this agreement, Koch rejected 60% of the applicants suggested by the faculty, and two new faculty members approved by Koch were hired. When the the agreement become public, it was rejected by the FSU University Senate, but university senates have no power.

Dr. Barron came to FSU in 2010. He responded to the Times story and the Senate's objections by renegotiating the agreement in a way that leaves its consequences largely unchanged. Koch's representatives no longer participate in the screening process, but the Foundation is permitted to withdraw its funding if it objects to the faculty's choices. Since this would leave FSU on the hook for their salaries, it gives them an obvious incentive to hire candidates acceptable to Koch.

It would be naïve to think that academic scholarship is unaffected by political considerations. Government and corporate grants often determine what research topics are investigated and have been shown to exert a subtle influence on research results. The Koch Foundation gives approximately $80 million per year to about 150 universities (including Penn State). However, the FSU arrangement is a particularly egregious violation of the norms of academic freedom. Economics is a highly polarized discipline with clear differences between mainstream and conservative economists. The FSU donation seems to suggest that members of the corporate class can use donations to buy their own version of economic “knowledge.” It's not surprising that they would try to do this, but disappointing that a state-owned university would allow it to happen.

The Koch-FSU controversy takes on an additional twist given that Dr. Barron is a climate scientist, while the Koch brothers, deeply involved in oil and gas production, have used their wealth to secretly promote climate change denial. The FSU Economics Department uses an introductory textbook, Economics: Private and Public Choices, by James W. Gwartney, et al. Dr. Gwartney is an FSU faculty member, and two of his three co-authors were formerly affiliated with the university. Dr. Yoram Bauman, an economist with the Sightline Institute, has given the textbook a failing grade for misrepresenting the findings of the Intergovernmental Panel on Climate Change and other climate research. It is rated second worst on this issue of 18 popular introductory economics texts.

No one is accusing Dr. Barron of being a climate change denier. Between 1986 and 2006, while he was director of the Earth System Science Center and later Dean of the College of Earth and Mineral Sciences at Penn State, he recruited Drs. Richard Alley and Michael Mann, two distinguished climate scientists. Dr. Barron's views of climate science can be heard about 21 minutes into this interview. He appears to be a climate moderate concerned with predicting the future effects of climate change but emphasizing the scientific uncertainty about what these effects will be.

When Dr. Barron reports to State College for work next month, one of his first orders of business should be to explain how he intends to ensure that the Koch Foundation's Penn State donations do not influence research and teaching at the university.

In Part 2: The Jameis Winston case.

You may also be interested in reading:

Freeh at Last

Who Pays?

Climate of Mistrust

Another Dog Whistle

After signing his landmark 1964 Civil Rights Act, President Lyndon Johnson is said to have become depressed. When asked what was troubling him, he said, “I think we just delivered the South to the Republican Party for a long time to come.” He was wrong. It was not just the South. Although Johnson won that fall, since 1964 a majority of whites have voted for the Republican candidate in every presidential election. The last column of the table shows the Republican margin of victory among white voters.

Year	Republican Candidate	Democratic Candidate	Margin
1964	Goldwater	Johnson	-29%
1968	Nixon	Humphrey	16%
1972	Nixon	McGovern	40%
1976	Ford	Carter	4%
1980	Reagan	Carter	20%
1984	Reagan	Mondale	32%
1988	Bush I	Dukakis	20%
1992	Bush I	Clinton	2%
1996	Dole	Clinton	2%
2000	Bush II	Gore	13%
2004	Bush II	Kerry	17%
2008	McCain	Obama	12%
2012	Romney	Obama	20%

In Dog Whistle Politics, Ian Haney Lopez makes a strong case for the argument that race has been the driving force in American politics since the '60s. Beginning with Nixon in 1968, the Republican Party developed a winning strategy of appealing to white voters with messages based on symbolic racism. One of the results is that the Republicans have increasingly become the “white man's party.” A new set of studies by Maureen Craig and Jennifer Richeson of Northwestern University suggests that what is now a bad situation is likely to become worse.

The Census Bureau projects that by 2042, the US will become a majority-minority nation. That is, more than 50% of Americans will be non-whites. The authors hypothesized that this information is threatening to white voters, and making it salient will cause them to shift toward a more conservative ideology and become more likely to vote Republican. The information is, in effect, a dog whistle, that Republicans will be able to use to their advantage in future elections.

This is not the first time that threats have been shown to lead to conservative shifts. For example, American political opinion moved sharply in the conservative direction following the 9/11 attacks. In controlled experiments, proponents of terror management theory have shown that asking participants to think about their own death leads to conservative shifts in social and political attitudes and increased support for then-President George W. Bush.

The Craig and Richeson article presents three increasingly impressive experiments. The first is an internet study of a random sample of white Independent voters—that is, voters not affiliated with either the Republican or Democratic Party—living in the Western US. California is already a majority-minority state, and in one condition, respondents were informed of this fact. In the control condition, they were told that Hispanics had become roughly equal in number to blacks in the US. Participants were then asked to indicate the extent to which they leaned toward one of the two major parties, and to rate their political attitudes on a 5-point scale from “very liberal” to “very conservative.” The results of the political leaning question are shown below.

People informed of the majority-minority status of California also rated their political attitudes as significantly more conservative than the control group.

A second experiment used a random sample of white American adults from all regions and political parties. Some of the participants—the racial shift condition—were told that America would become a majority-minority nation in 2042, while those in the control group were given information about geographic mobility. Attitudes were measures toward five social policies, such as immigration and health care reform. The authors proposed that the conservative shift was mediated by group status threat. This was measured by two questions about whether the American way of life is threatened, and whether conditions in the US are getting better or worse. Three other potential mediators of the conservative shift were measured, but, as expected, none of them panned out.

As in study 1, the participants in the racial shift condition shifted in the conservative direction on the five attitudes and those in the control group did not. Those in the racial shift condition also showed greater evidence of group status threat, and, as predicted, group status threat mediated the relationship between the racial shift information and political conservatism. (See my earlier post explaining how mediation is inferred.)

Finally, if the conservative shift is mediated by group status threat, then providing participants with information that mitigates that threat should reduce the size of the shift. Their third experiment had three conditions. Some participants were given the racial shift information. The control group was again told about geographic mobility. And finally, there was an assuaged-threat condition. Two sentences were added to the racial shift information reassuring the respondents that, despite the majority-minority shift, white privilege would be maintained. Specifically, “white Americans are expected to continue to have higher average incomes and wealth compared to other racial groups.” Some new social policy questions were also added.

As expected, only the racial shift group showed a conservative shift on the social policy questions. The participants in the assuaged-threat condition did not differ from the control group.

It should be noted the authors divided their social policy questions into those they thought were race-related, i.e., immigration, and those they thought were not, i.e., health care reform. The size of the conservative shift was the same on both sets of questions. This result would not surprise Lopez, since he maintains that virtually all domestic political issues have been racialized. For example, the term “Obamacare” is a dog whistle meant to persuade white voters—incorrectly, of course—that their heard-earned money is being taken by the government and given to “Obama's people”—undeserving minority citizens.

The Craig and Richeson article may help Republicans to identify another reliable dog whistle, although Pat Buchanan called it to their attention years ago. The majority-minority shift is sometimes said to foretell the demise of the Republican Party. However, in the short run, it is likely to increase the racial polarization of the two parties, and it may help Republicans temporarily by increasing their appeal to white voters. Lopez suggests that whether the Republican Party can remain viable in the long run may depend on their ability to persuade some non-whites, i.e., Asian-Americans and light-skinned Hispanics, to redefine themselves as “white.”

You may also be interested in reading:

Dog Whistle Politics

The Singer, Not the Song

Old-Fashioned Racism