Topic: Health Care

Why Measles Making the News Is a Sign of Progress

A set of measles outbreaks in Washington state, New York City, and elsewhere, is making national headlines and frightening parents around the United States. Counter-intuitively, measles making the news is a sign of progress. Not long ago, measles was so common that it was simply not newsworthy. Suffering from the extremely infectious disease, which causes spotty rashes and a hacking cough, was widespread and often deadly.

It was once the case that even royalty fell victim to diseases now easily preventable with routine shots given during childhood. Measles killed the un-vaccinated King Kamehameha II of Hawaii, and his queen, Kamamalu, in the 1800s. A century prior to that, King Louis XIV of France lost his brother, son, grandson, and great-grandson to smallpox. Smallpox once claimed approximately 400,000 lives annually in Europe in the late 18th century, and in the 20th century, it caused hundreds of millions of deaths around the world. Thanks to vaccines, smallpox was eradicated in 1980.

As recently as the late 1950s and early 1960s, nearly twice as many children died from measles as from the polio disease. Thanks, once again, to vaccines, polio was eliminated from the United States in 1979.

Recent coverage by the Washington Post of the current measles outbreaks contains an amazing anecdote of a measles victim’s visit to a doctor: “the doctor, who had never seen measles, misdiagnosed the man’s fever and cough as bronchitis.” That measles is now so rare that even a trained medical doctor cannot recognize it, when just a generation ago it was a common childhood ailment, is truly a triumph of medical progress.


As recently as 1990, measles caused over 22 deaths per 100,000 people globally. Thanks to the measles vaccine and rising global vaccination rates, that figure fell to just over 1 per 100,000  people by 2016, the most recent year for which there is data. That represents a decline in measles deaths of over 95 percent.

The current uptick in measles cases is troubling. But the fact that measles cases are making the news at all is a testament to medical progress.

An Encouraging Sign for Harm Reduction Advocates

A New Hampshire high school student who is remarkably knowledgeable about the various harm reduction strategies that are underused to address the overdose crisis engaged Senator Cory Booker (D-NJ) in a discussion of the subject during a campaign stop in Littleton, NH. The video of the exchange is here.

Senator Booker, who is seeking the Democratic nomination for President in 2020, is a former mayor of Newark, NJ, a city with major drug overdose problems. He had a sophisticated conversation with the student and agreed with her on the need for safe syringe programs. At about 1:50 into the video Booker was asked if he would support needle exchange programs and safe injection sites. He responded that as mayor of Newark he established the needle exchange program in that city and “fully supports” establishing safe injection sites.

As I detail in my Policy Analysis on harm reduction, both needle exchange programs and safe injection sites have been shown for decades to reduce the spread of HIV and hepatitis, reduce overdoses, and increase the number of addicts obtaining rehab. 

While needle exchange programs are legal in the US, and are even promoted by the Surgeon General, the Centers for Disease Control and Prevention, and the American Medical Association, many states have anti-paraphernalia laws that inhibit their creation.

Safe injection sites exist in over 120 cities in Europe, Canada, and Australia, and have been in use for over 30 years. One even operates in the US clandestinely, because federal law prohibits safe injection sites in this country. Several cities are attempting to establish safe injection sites in the US, including Seattle, San Francisco, Boston, and New York. In Philadelphia, a nonprofit that includes former Pennsylvania Governor Edward Rendell on its board is attempting to establish a “Safehouse” in that city, funded entirely with private money, but is being thwarted by the Department of Justice.

While the Senator seemed to wrongly accept the mistaken narrative that the opioid manufacturers are to blame for much of the problem, it is gratifying to learn that Senator Booker has an appreciation for harm reduction in general, and needle exchange and safe injection sites in particular. And, to his credit, he has also expressed enlightened views regarding cannabis legalization

As more members of Congress join the growing ranks of mayors of major US cities in endorsing safe syringe programs, momentum will hopefully build for states to remove any remaining obstacles to needle exchange programs and for Congress to remove the federal obstacles to safe injection sites.

Is it True that 40% of Americans Can’t Handle a $400 Emergency Expense?

Governor John Hickenlooper, writing in The Wall Street Journal, repeats a misleading interpretation of one answer to a Federal Reserve poll question that is frequently used to suggest many Americans are in dire financial straits: “Forty percent of Americans in 2017 didn’t have enough savings to cover a $400 medical emergency or car repair, according to the Federal Reserve.”

But that is not the question that was asked, and it certainly is not the answer.

The question was about how people would choose to pay a $400 “emergency expense” — not whether or not they could pay it out of savings (or checking) if they wanted to.  Respondents were also free to choose more than one way of paying the extra $400 (“please selects all that apply”), so the answers add up 143% rather than 100%.  Even if 100% said they could pay an extra $400 with cash, there could still be more than 40% who would choose a different method.

It turns out that 86% would pay cash or charge it and then pay off the bill at the next statement (many consumers autopay credit card bills from checking accounts).   Some (11%) said they might borrow some or all of it from a friend or family member, but that probably means a spouse or parent in most cases (respondents included full-time students).

Report on the Economic Well-Being of U.S. Households (SHED)

A related follow-up question asked if a $400 “emergency expense” would prevent paying all other bills in full an on time, and 85% said it would not.

Question EF5B. How would a $400 emergency expense that you had to pay impact your ability to pay your other bills this month

Response Percent
I would still be able to pay all of my other bills in full 85
I could not pay some other bills or would only make a partial payment on some of them 14
Refused 1

Note: Number of unweighted respondents = 9,670.

There are many credible ways to measure economic well-being (such as real after-tax income and/or wealth), but giving a few thousand people a multiple-choice exam about how they might prefer to pay an unexpected $400 expense is not one of them.

Statistical Ambiguity Should Never Be Glossed Over

The New York Times’ “Upshot” blog is an admirable attempt to inject the public policy debate with data-driven insights. Too often, we are treated in the Opinion pages to gauzy, impressionistic arguments left empirically adrift. 

One such article, by the NYT’s healthcare specialist Margot Sanger-Katz, has been frequently cited and tweeted about since its publication in 2016. It is titled “How Expanding Medicaid Can Lower Insurance Premiums For All.” Just today, the Upshot twitter account retweeted the following, by Democratic leader of the Wisconsin State Assembly, Gordon Hintz: 

Both the title of the piece, and the framing of the tweet, suggest a causal relationship between the ACA’s Medicaid expansion and average private health plan premiums.

The article presents us with the following:

new study published by in-house researchers at the Department of Health and Human Services compared places that have expanded their Medicaid programs as part of Obamacare with neighboring places that have not. They found that, in 2015, insurance in the marketplace for middle-income people cost less in the places that had expanded Medicaid.

By comparing counties across state borders, and adjusting for several differences between them, the researchers calculated that expanding Medicaid meant marketplace premiums that were 7 percent lower.

Red Flag #1: This study was conducted, as noted, by HHS researchers. This is certainly not disqualifying per se, but it should cause us to readjust our priors. While peer-review has many, many problems as a vetting mechanism for quality, at least it’s vetting mechanism. Moreover, generally speaking, more prestigious journals do tend to demand more scrupulous econometric work.

It’s worth noting that before we even dive into the methodology, the study itself admits that whatever causal effect is at play here, the likely mechanism is that newly eligible Medicaid enrollees in states that expanded Medicaid are lower-income and therefore in poorer health than those individuals earning in excess of 133% of the poverty line. This means that sicker-than-average individuals transfer from private insurance to Medicaid, which lowers the overall private risk pool, and thereby lowers premiums. Katz’ summary is correct when she carefully writes: “Expansion of Medicaid could lower insurance prices for everyone else.” Indeed, it does lower insurance prices. But Medicaid doesn’t dragoon healthcare providers into working for free. Someone still pays for these new enrollees, and that someone turns out to be taxpayers. This article does not demonstrate that there’s a free lunch from Medicaid expansion. Conversely, “Because the states that didn’t expand had more sick people in their middle-class insurance pool, prices went up for everyone, the paper argues.” But, ceteris paribus, these states (and/or the federal government, depending on the fiscal cost sharing) would need to charge lower taxes (a price, afterall) for the same remaining mix of transfers and services.

Yet the foregoing discussion assumes that the causal mechanism can be defensibly inferred from the HHS’ statistical analysis. Let’s take a gander.

While the study provides 13 different specifications, the primary model of interest is #12 in Table A3. We can see that between matched counties on either side of a border that divides a non-expansion vs. an expansion state, the average age-adjusted “silver-rated” private insurance plan was $15 lower than its matched non-expansion county, or roughly 7% of the average premium. Moreover, this variable is significant at the 0.01 level.

But this finding hinges crucially on the many, discrete methodological choices made by the researchers, any one of which could fundamentally change the results. Taking a quick glance at the other control variables:

  • The coefficients are not standardized, and nowhere in the study is the unit of measurement for any of these variables revealed. For instance, the effect size of Percentage of Adults Who Are Current Smokers, 2015 is 129.7. This means it cannot be measured in percent terms- so what is the unit of measurement? A number per 1,000 residents? Similarly, Hospital Beds Per Capita 2012 has a whopping -977.8 coefficient, Primary Care Physicians Per Capita 2013 clocks in at -4,001, but Physicians Per Capita 2013 has a positive effect of 860.7. This would all be much easier to suss out if the study ever explained what units we’re dealing with.
  • There is almost certainly a multicollinearity issue, the last two variables I cited alone should suffice to raise that worry.
  • This wouldn’t be as big of an issue if the paper actually varied the control variables across the 13 models. Instead, it varies the observations, but applies the same battery of controls to each subset. How do we know if this effect is robust to different control variables?
  • While the border-matching design does do a good job of controlling for regional variations in relevant demographics, it does not account for interstate differences that could affect premiums other than Medicaid expansion. For instance, private health insurance companies in different states face potentially very different state-level taxes, minimum wages, essential fringe benefits that they need to pay to their employees, etc. Different operating costs affected by state-level variables will undoubtedly affect premiums. Such interstate differences need to be comprehensively accounted for in any non-experimental or quasi-experimental research design. 
  • The very same left-leaning economists and public health experts who sing the praises of the ACA’s Medicaid expansion would be very discomfitted by some of the un-touted findings in this very same study. The much-lamented rise in concentration among firms in the U.S. economy, including hospitals, has no effect on private sector premiums. Presumably, in states where the hospital sector was excessively concentrated, hospitals would be able to wield this market power and extract larger reimbursements from health insurers, who would pass these costs along to beneficiaries. The Model 12 specification shows no significant effect of hospital HHI, and the only significant effect appears in Model 9, where the dummy Hospital HHI < 2500 (that is, less concentrated) has a positive effect on premiums that is 3x larger than the negative effect of Medicaid.

All in all, Katz’ boilerplate “adjusting for several differences between them” is insufficiently nuanced, especially if we’re meant to actually make public policy changes on the basis of the evidence presented.   





The Secret Safe Injection Facility That Is Saving American Lives

I have written herehere, and here about efforts by a nonprofit in Philadelphia named “Safehouse” to establish a Safe Injection Facility in the neighborhood of Kensington, where IV drug use is rampant and out in the open, and overdoses are soaring. That effort is being impeded by threats from the Department of Justice that it will enforce federal law prohibiting such sites. The specific law at issue is known as the “Crack House Statute,” passed in the 1980s. Leaders in other major US cities who also want to set up Safe Injection Facilities, including SeattleSan FranciscoNew York, and Boston, are closely monitoring the situation before proceeding with their own plans.

In my Policy Analysis on harm reduction I wrote of the impressive results that Safe Injection Facilities (also called “safe consumption sites” and “overdose prevention sites”) have had throughout much of the developed world since the 1980s. Now in operation in over 120 cities in Europe, Canada, and Australia, these facilities have dramatically reduced the spread of HIV, hepatitis, and other blood-borne diseases, dramatically reduced overdose deaths, and have brought many addicts into rehab programs. Darwin Fisher, the Program Coordinator of “Insite” in Vancouver, BC, the oldest Safe Injection Facility in North America (since 2003), gave an impressive presentation of how that facility has worked to save lives at Cato’s conference on harm reduction last March. You can see that presentation here.

The Policy Analysis also mentioned a Safe Injection Facility secretly operating in the US since 2014, notwithstanding the federal prohibition. A 2017 paper in the American Journal of Preventive Medicine that kept the name and location of the site confidential, reported it was well-accepted by the community, had at least four documented overdose reversals, and had no deaths associated with its operation. Dr. Barrot Lambdin, a senior epidemiologist with RTI International, an independent non-profit research institute in North Carolina, gave a data update on this secret Safe Injection Facility at an international conference on harm reduction held in Porto, Portugal on April 29, 2019. He did not disclose the name or location of the facility. 

One objection raised by residents of communities where these sites are proposed is that they don’t want to see IV drug users on the streets of their neighborhoods. But proponents respond that Safe Injection Facilities actually bring such people indoors, injecting their drugs out of the view of the community. Dr. Lambdin reported that since the facility’s opening in September 2014, nearly 8,400 public injections were prevented. 

Dr. Lambdin also reported the number of overdose reversals has now increased to 26.

Because the site is illegal, it is only able to operate part time—five or six days a week for eight or ten hours a day. And it accepts participants by invitation only. The surrounding community has cooperated by helping the facility maintain secrecy.

So here is an example of a Safe Injection Facility saving lives, and well-accepted by the surrounding neighborhood, in spite of federal impediments. Imagine how many more lives it could save if it could operate around the clock, out in the open, and advertise for walk-ins. Imagine how many hundreds or even thousands of lives would be saved if the “Crack House Statute’ was repealed.

As Seattle Reels From An HIV Outbreak, Safe Consumption Sites Make More and More Sense

The US Centers for Disease Control and Prevention’s latest Morbidity and Mortality Weekly Report (MMWR) alarmingly reports a 286 percent increase in cases of HIV among heterosexual persons injecting drugs in King County, Washington from 2017 and mid-November 2018. The report recalls a similar outbreak for similar reasons in rural Indiana that took place between 2011 and 2014, and ultimately led the state to enact legislation permitting needle-exchange programs to operate there. 

As I explain in my policy analysis on harm reduction strategies, needle exchange programs have a more than 40 year track record reducing the spread of HIV, hepatitis, and other blood-borne diseases, and are endorsed by the CDC and the Surgeon General, but are prohibited in many states by local anti-paraphernalia laws. But such laws are not the problem in the state of Washington. Needle exchange programs have operated legally there for years.

Safe Consumption Sites have been shown to be even more effective in reducing the spread of HIV and hepatitis, as well as preventing overdoses. The nearby city of Vancouver, BC has found they dramatically reduced cases of HIV as well as overdoses since 2003.

Recognizing this, the Seattle city council voted in 2017 to permit the establishment of two safe consumption sites, which are obstructed by federal law, in particular the so-called “Crack House Statute” passed in the 1980s, which makes it a felony to “knowingly open, lease, rent, use, or maintain any place for the purpose of manufacturing, distributing, or using any controlled substance.” A non-profit group in Philadelphia is attempting to set up a “Safe House” there, and has already been met with the threat of prosecution from the Department of Justice. Former Pennsylvania Governor Edward G. Rendell, a principal of that non-profit, spoke about this at a recent conference on harm reduction held at the Cato Institute.

With safe consumption sites working in more than 120 major cities throughout the developed world, including several in neighboring Canada—and with outbreaks of HIV developing across the US—lawmakers who claim to be deeply concerned about the plague of disease and overdoses afflicting the country should put their money where their mouth is and repeal the outdated “Crack House Statute” so cities and towns can get to work saving lives. 


Latest Opioid “Sting” Again Illustrates The Power of Prohibition to Corrupt

The front page of today’s Wall Street Journal reports on a federal sting operation that led to the arrest of 31 doctors, 7 pharmacists, 8 nurses, and other health care professionals including dentists for distributing more than 32 million prescription opioid pills to patients in five Appalachian region states. 

Federal prosecutors described doctors handing out pre-signed blank prescriptions in exchange for cash. In some instances, doctors provided prescriptions in return for sexual favors. One Alabama doctor allegedly recruited prostitutes to become patients and let them use drugs at his house. Dentists performed unnecessary teeth extractions on cooperative patients so they can have a legal excuse to prescribe them the opioid pills they desired. Some doctors knowingly sold prescriptions to nonmedical drug users and then billed Medicare and Medicaid for the evaluations and tests they performed as a cover.

Brian Benczkowski of the Department of Justice told reporters, “When medical professionals behave like drug dealers, the Department of Justice is going to treat them like drug dealers.” 

Mr. Benczkowski is right to consider these professionals “drug dealers.” This is just the latest and most graphic example of how prohibition fuels the so-called opioid crisis. In 2017 the DOJ arrested 412 doctors, pharmacists, and others for engaging in similar schemes in Florida. 

As I have written here, drug prohibition creates lucrative black market opportunities for people willing to sell drugs illegally. Prescription pain pills sell for a much higher price on the black market than they do legally at the pharmacy. The lure of easy money tempts corrupt doctors, dentists, nurse practitioners, and pharmacists to leverage their degrees to nefarious ends, especially because they can use the third party payment system to “double-dip:” they get paid by drug dealer middlemen for churning out and filling prescriptions which then get sold on the black market, and at the same time get reimbursed for their “services” by Medicare, Medicaid, and insurance companies.

Prohibition brings out the worst in people. It provides the corrupt and the corruptible with irresistible money-making opportunities. 

Meanwhile, desperate chronic pain patients, already the civilian casualties in the government’s war on opioids, are justified in their concern that politicians will react to the latest news with further crackdowns on opioid prescribing while more doctors will abruptly taper their chronic pain patients or abandon treating pain altogether out of fear they might risk being the next target of law enforcement wrath.

If lawmakers, policymakers, and the press want to know where to place the blame for the ugly facts revealed by this latest sting operation the answer is obvious: blame prohibition.