Almost qualifies...

...as a view of the East River!
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R.I.P. Boot!

You served me well, Asolo A527! I'll check to see if you can be re-soled, but it looks like the end of the trail for you.

*tear drips down cheek*

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Getting in the hike!

Before the rain comes, I GOTTA get my hike in.
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correlation [NOT EQUALS] causation

When you read a news report about this paper in the American Journal of Public Health entitled Health Insurance and Mortality in US Adults, take a deep breath and remember that journalists do not understand that

correlation does not equal causation.

What you will no doubt see in the media is this:

[MSNBC]: New data show that insuring people will save thousands of lives!

[Fox News]: Ridiculous! Silly liberals. The uninsured tend to be people who pick their noses, and nose-picking is what causes death--not the lack of insurance!

(Nose-picking is just an example here--fill in whatever third factor you like.)

The authors do appear to understand the distinction between correlation and causation, and use careful wording.* From the abstract:

"Uninsurance is associated with mortality."

"...is associated with" is much different than "causes," but I fear that "causes" is what the journalists will say.

This isn't to say the paper is without merit. The methodology is interesting, and so is the finding. They looked at people who didn't have insurance at a single point in the past, then looked at their mortality rate in subsequent years. What makes it somewhat interesting is that:

"After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio=1.40; 95% CI=1.06, 1.84) than those with insurance."

This makes it more interesting since some obvious factors other than insurance status at the time are eliminated as explanations for the difference in death rate. Of course, there are probably lots of other factors that weren't controlled, but it is an interesting finding.

* On a personal note, I don't quite trust the authors--they've done a lot of cherry-picking in their other work. I haven't analyzed this paper, but the timing of their publication of this correlation finding is not a coincidence. They know quite well that most people will view it as a causation paper.

Charles Ward Reservation

Walked through the Charles Ward Reservation, which sits on the Andover/North Andover border. Highest point in Essex County: Holt Hill. At the top of the hill are solstice stones (not shown.) You could have seen Boston in the background, if I had moved a little to the right.

At another point in the reservation, Elephant Rock...

Not sure why!

Markets, Part III: Barriers to entry

Recall that in the first post, I used widgets to show how markets can be self-correcting and result in benefits for everyone involved, without the need for government interference. I then identified five qualities of a market that make it work well.

In the second post, I explained why informational symmetry is a problem when it comes to markets for healthcare.

Now I'm going to briefly discuss barriers to entry. High barriers to entry, if you'll recall from the first post about widgets, mean that new competition has trouble entering the market. This could mean a new competitor (such as Wally, who started Wally's Widget Emporium,) or it could just mean that existing competitors have trouble entering another portion of the market (e.g. geographical.) There are many potential barriers to entry.

Barriers to entry are, generally speaking, bad for competition--as the widget example showed. They lead to inefficiency and create the potential for exploitation. In the worst case, they permit and perpetuate monopolies. Markets for healthcare services are not unusually affected by these barriers, however--which is why this won't be a long involved post.

• Some barriers to entry serve useful purposes. One reason I can't start up my own airline is that there are lots and lots of regulations regarding equipment, training, maintenance, etc. etc. etc. That's kind of a good thing.
• Some barriers to entry we can't do much about because they are inherent to the enterprise. To become a car manufacturer (at least, one that competes with the big makers), one needs tons of expertise, tons of experience, a lot of money, etc., etc.
• Some barriers to entry are erected intentionally (though not uncontroversially). For example, governments usually impose tariffs on imports precisely for the purpose of limiting foreign competition.

The barriers we care most about--the ones we should ameliorate through government--are those that (1) inhibit competition (are 'anti-competitive') and (2) don't give us enough in return. If Microsoft bundles Internet Explorer with Windows, it's very hard for a potential browser-maker to break in--leaving us with an inferior product for much longer than would otherwise be the case! On the other hand, the bundling was, in some senses, an advantage for consumers.

There's probably nothing special about healthcare when it comes to anticompetitive practices, so I won't spend any more time on this section. There are certainly some very large insurers, and some very large hospital groups, that wield 800-lb gorilla-type power in markets. In Massachusetts, there's all sorts of consternation over the one I work in, and the Atty General keeps a close eye on its practices. Any large-scale changes in the delivery system will have to continue to allow policing of the markets.

But my project here is to explain the limitations of unfettered markets when it comes to healthcare. Okay, let me post this, so I can get on to the more interesting parts of the series!

NPR's been reading my blog!

Check out this story on Morning Edition, which proves that my blog, despite being read by only a couple of people, is influencing the healthcare debate!

Chana Joffe-Walt and David Kestenbaum talk about the "information problem" in medicine.