....."The biggest problem with healthcare policy may be that those who design healthcare policy mostly design it for people who design healthcare policy.".....
NOW
Substitute for "healthcare" any policy designed or implemented, or both, by GOVCO (my shorthand for every level of government or "governance" (ie big business or NGOs) and you have articulated the "IRON-RULE of The Way the World Works". At least for today. Tomorrow it may stop working at the rate we're going. And then the "Graboyes Iron Rule" will wind up on the ashheap of history.
The "Graboyes Iron Rule." I like it. Catchy! How's this for a statement of the rule?: "If experts discuss any topic of public policy for long enough, the likelihood that someone will offer 'arugula' as a solution approaches 100%."
And, if I may, offer my definition of an expert: "Someone who knows more and more about less and less until he knows everything about nothing. And then proceeds to share his expertise with you."
The intellectual equivalent of Woody Allen's definition of a stockbroker: "A stockbroker is someone who invests other people's money until it is all gone.”
There's an aspect to AI image programs like Midjourney that can be frustrating or fun. That is that the programs are fairly stupid. In this article (https://graboyes.substack.com/p/chickens-and-neutrons-and-long-leggedy) scroll down to the image of a gas station at night. It came out just as I wanted it--really a rather attractive image--except that the car is parked in an impossible fashion. I thought about redoing it and then decided, "Naaah. Let's see if anyone notices." No one did. In the present article, the asphalt crew is daintily picking their way through mountains of fresh produce. But if you look closely, Midjourney put a big pile of dirt or asphalt on the table, creeping over into the vegetables.
Thanks for the amplification! I did have to go back and look for the dirt! BTW, this is another superior post, and proof that your insight and skill are durable.
Many thanks! Glad you enjoyed the dirt. Don't know your age, but in the 1960s, "Get Smart!" featured a character called "Hymie the Robot." A brilliant, empathetic machine, but unable to understand idiomatic expressions. (If Max told him, "Let's hop to it, Hymie," Hymie literally hopped to wherever they were going.) Generative AI programs remind me of Hymie.
We’re pretty much contemporaries. Get Smart, Wild Wild West and Star Trek on our brand new color TV were the rewards for good grades and chores done. Hymie was classic along with the shoe phone!
Same here. All three were fantastic shows. There was a whole lot of classic to "Get Smart." The Cone of Silence. Episodes called "Tequila Mockingbird" and "How Green Was My Valet." And everything about the wonderful Agent 99.
Robert, Excellent summation and analysis but it begs the question: what can we as physicians do about it? I have always tried to counsel and advise my patients in healthy lifestyles, healthy eating, managing stress, etc. etc. but even though I am old school, see every patient, and spend much more time with them than the average primary physician (I am a specialist), it amounts to no more than 45-60 minutes in two or three visits over several months, most of which time is devoted to the specific problem they come to me with. I don't have answers either, but to think we are going to make a dent in obesity and chronic disease by targeting the fifty-something who is obese, already diabetic, and hypertensive is a fantasy. We need to restore some common sense policies and target the next generation. Restoring outdoor recreation in schools for kids, teaching nutrition to the young, and at least making an effort to get them off of their screens would be a start. How do we restore unstructured play, such as was the norm on my own childhood. Grownups must model healthy behaviors, especially doctors (my partner is obese-imagine how effective his advice to his patients to lose weight is). I fear I am a pessimist because I know human nature craves creature comforts and it is the unusual person who goes out of their way to be uncomfortable, i.e. exercise when they don't feel like, refrain from stuffing their face when confronted with a smorgasbord of tasty food, and resist that second or third drink. Rick
I'm not a nihilist, but I'm not optimistic about medicine's capacity to greatly change human behavior. I used to have my classes read "The Fattening of America" by Eric Finkelstein and Laurie Zuckerman. I chose this book, not because it was on obesity, but rather because it's the best book I've ever read on the broader subject of what health economics is all about, how a health economist thinks, and how all of that impacts (or fails to impact) policy and behavior. He does a deep dive into why obesity numbers have risen so rapidly for the past 30-40 years. He then goes one by one through the policy and behavioral modification options. He ultimately concludes that none of these well-intended attempts will make much of a difference. The problem, as he explains, is that most obesity is "rational obesity." The individual knows why he's obese, knows the dangers of being obese, knows how to lose weight, but simply has higher priorities. He uses his uncle as an exemplar--the uncle, who once was slim, is a wealthy, workaholic attorney who loves Italian food and hates exercise. Finkelstein discusses the what it would have taken for his uncle to remain thin and concludes that virtually nothing would have persuaded him to follow that path.
And, as I stressed to my students, our calorie imbalance isn't that big. 50 years ago, calories consumed-minus-calories burned was close to zero, so the population only put on a little weight as they aged. Today, a gap opened up--more calories consumed, fewer calories burned. But that gap only amounts to 100 calories a day or less. But that is enough to fuel the whole crisis, if it is a crisis.
Finkelstein also notes that with advances in modern medicine, obese people today have many biometrics that are better than thin people had 50 years ago. And I'll note that Finkelstein is a crusader against obesity. He just thinks (or at least thought when he wrote the book) that obesity is an individual choice, and it will cease to be a problem when people change their individual priorities. He regrets that that's the case. If I remember correctly, the one thing he thought might help (for complex reasons) was reducing corn subsidies--but we know how that idea plays in the Iowa Caucuses. (And, in fact, arugula first arose as a policy meme in Iowa in 2008.)
After working in Home health as a physical therapist for 10 years you come to realize that Yes you have very little sway over what you can do to change a person’s overall health.
For the policy wonks, I would recommend they spend a year doing just home health visits. They would see the limitations of the mentioned policies. Gym memberships, tax credits, yoga breaks and even 100% governmental subsidized arugula distribution to all citizens won’t help. The variables are too numerous and behaviors are too in bedded.
Specific issues can be addressed for an immediate health problem. But the fact that I saw people on a frequent basis for the same problem confirms the inability for most people to change even with repeated education.
Great post. Here's something related from Florence Nightingale: "To patients enduring every day for years from every friend or acquaintance, either by letter or viva voce, some torment of this kind, I would suggest the same answer. It would indeed be spared, if such friends and acquaintances would but consider for one moment, that it is probable the patient has heard such advice at least fifty times before, and that, had it been practicable, it would have been practised long ago."
> The biggest problem with healthcare policy may be that those who design healthcare policy mostly design it for people who design healthcare policy.
See also: open-source software. With a very few notable exceptions such as web browsers, almost all of it is built by software developers to solve their own very specific needs, which is why it's often a poor fit for things the general public wants to do.
One modestly-cynical-but-also-accurate understanding of large, successful open-source software projects is that they are a mechanism through which tech companies can collaborate on — and share the cost of — important software infrastructure that's not part of those companies' "special sauce." One super-important feature is that such public collaboration avoids adverse consequences anti-trust-wise. At least so far.
The vast majority of changes contributed to the big successful open-source projects are produced by employees of tech firms *as part (or all!) of their full-time job*. This fraction decreases for smaller and/or less-successful projects all the way down to near-zero for "hobby projects."
I recently had the opportunity to advise a younger, healthy family member just starting out in life who needed to purchase health insurance. Before this, I never had much reason to really think about health insurance other than picking from the menu of choices offered by a corporate employer. My experience validates your thesis to a "T."
Putting aside employer sponsored plans, health plans fall into two broad groups.
The first is the "Obamacare Compliant" plans. These are characterized by high deductibles, high coverage limits, and higher premiums. They make a lot of sense for higher earners who aren't terribly concerned about going out of pocket to cover routine needs like their kids' strep throat. Their high coverage limits provide a backstop in case things really go off the rails for something like a cancer diagnosis or a kidney transplant. It would also seem that these plans great sense from a health care system cost containment standpoint. Not coincidentally, these structures fit the needs of the kind of people that develop health care policy. One might call them "Rich People" plans.
The second are what I will call "Normal People" plans, for lack of a better term. These plans are characterized by lower deductibles, lower coverage limits, and lower premiums. They make a lot of sense for someone who might otherwise have to choose between having their sprained ankle looked at or making their next car payment. Normal People plans provide a day-to-day backstop for people don't have wealth to protect in the case of a catastrophic event. This second type of plan is actually illegal in a number of states.
My family member would have opted for the second type of plan. Had I been in their position, I would have done the same. But knowing that I was going to be the bankroll in any event, I opted for the first type.
I can kind of understand why some states prohibit the #2 plan. The person who chooses it is kind of making a bet, that he *won't* get cancer or need a kidney transplant, and is therefore willing to forego coverage for it. But other law and custom tends to prohibit the healthcare system from profiting by taking the other side of that bet. That is, if the young healthy person *does* unfortunately get cancer or need a transplant, the healthcare system is not permitted to say sorry you lost your bet, no $250,000 treatment for you, you'll have to come up with the cash by some miracle or die. So the person *does* get treatment, but the costs end up on the state, and not surprisingly the state says we don't want any part of this racket. If you know someone who works in the ER of a big urban hospital, they can tell you of the astonishing amount of very expensive healthcare that gets absorbed by uninsured people who have no hope of ever paying. When it's a public hospital, that comes out of the taxpayer, and when it's private, it gets paid by the people who *do* have insurance, and fork out $200 for an Advil in the hospital after elective surgery.
Personally, I'm all for allowing people to make the bets they choose. I think a young person *should* be allowed to decline coverage for transplants, neurosurgery, bypass, IVF, et cetera, on the grounds that he estimates his personal risk is low enough to be acceptable. But then, the flip side of that *must* be that we harden our hearts in the cases where that estimate was badly mistaken, and decline to compel the medical community to assist without payment in those cases. People must be allowed to die of completely treatable conditions, just because they lack the money to pay, if they have deliberately chosen to not insure against them.
I feel like a large part of the anguish of this debate stems from two great social myths, which are delusional:
(1) We steadfastly decline to believe the actual lifetime cost of medical care. We have a vague idea that it might demand 5% of our lifetime incomes, but surely not much more, when the reality is probably that it requires something like 20% of the average lifetime earnings to pay for the average lifetime medical care costs. (I base that WAG on the fact that about 20% of GDP is healthcare spending.) We cling to delusionary hopes of immortality, that if we only eat right, take this and that supplement, do this or that juice cleanse, get checkups in a regular way, we will escape the terrible expensive diseases that kill people, and just sail on forever. Or maybe, if pressed, we'll admit the ambition is *just" to live into our 90s with little in the way of expensive invasive care, and pop off quietly from a painless stroke in our sleep. The entire debate might be a little less hysterical and rage-filled if we all just accepted that, yeah, if you want First World first-rate medical care all your life, then you will need to set aside 1 of every 5 dollars you ever earn to pay for it. (Of course, you already have to set aside 1 of every 5 dollars to pay for the government, so before we even get into things like retirement savings, or savings for the kids' college, you're down to 3 of every 5 dollars you ever earn. This is discouraging.)
(2) We continue to believe in this area, as in many others, that there exists some stratum of tappable wealth among a minority of us that could be expropriated to ease all our burdens. Why not tax Bill Gates a mere 10% of his fabulous wealth to help us out? Or a mere 1% of Amazon's annual revenue stream? But here again we display our innumeracy. According to Forbest the 400 richest Americans have an aggregate wealth of $4.5 trillion, which sounds amazing, and would be, on a personal level. But it is virtually nothing on a national scale. If you taxed away 10% of that wealth, it would reduce the *deficit* of the Federal government ($4.6 billion/day) for a smidge over 3 months. You would have to confiscate 40% of that wealth just to close the gap between Federal spending and Federal income taxes for 1 year. (And then what do you do the next year?) Or consider Walmart, the largest company in the world by revenue. They haul in $600 billion a year, which sound fabulous -- but US healthcare spending is of the order of $4 trillion a year, which means a 1% tax on Walmart would cover healthcare spending for half a day.
It's certainly true that the richest people and largest companies are indeed very rich -- but that wealth pyramid is very narrow at the top, and the aggregate income doesn't actually represent a rich vein of tappable wealth (even leaving aside the negative motivational effects trying to steal it for the commonweal would have). And again, I feel like our discussions would be less hysterical if we all accepted the fact that there *is* no magic wealth source Somewhere Else to pay for the expensive time of highly skilled people that we all, individually, wish to be able to command when we are hurt or sick.
Can we reduce the cost of healthcare, by efficiency improvements? Certainly that must be the case. But I find it highly doubtful that we can reduce it by the factors of 75-90% that would be necessary to bring the actual cost in line with our (flawed) intuitions about how much it ought to cost.
Oct 22, 2023·edited Oct 22, 2023Liked by Robert F. Graboyes
Great comment!
You make the case for Rich People Plans from the perspective of somebody who is responsible for managing the state’s health care budget. Not that there’s anything wrong with that.
I would submit that the perspective of a generally healthy Normal Person is quite a bit different. The rare bad luck of getting hit by a runaway truck pales in comparison to the reality of having kids who need new shoes. My recent experience advising a family member helped me see, and actually feel, this perspective.
None of us want the Normal Person who rolled snake eyes to bleed out in the ditch. The challenge is finding the right balance between paying for new shoes and covering tail cases like the runaway truck. Covering routine events like strep throat is more like cost smoothing; spreading the risk of truck accidents functions more like actual insurance. For young healthy people, anyway. Seems that we, as a society, should be able to find a way to cover the tail.
Also agree completely about the nominal 20%. But that’s an average. For a Rich Person, it’s less than 20%; for a Normal Person, its obviously more. (BTW, I meant to mention in my previous comment that the situation is even crazier when you’re trying to navigate the donut hole where somebody makes too much to qualify for an Obamacare subsidy and not enough to cover medical bills that a Rich Person would consider middling. That’s when it’s really nice to have the metaphorical rich uncle).
Plus, the costs are time skewed – most of that 20% is incurred in the last year or two of life. So there’s this whole intergenerational component where junior is subsidizing grandma. Not that any of us feel good about sending grandma out on the ice floe.
20% isn’t sustainable over the long term. As you point out, there aren’t enough rich people to pay for all of this stuff. Like that soccer team whose plane crashed in the Andes, some truly horrifying ideas can start to seem rational, and then necessary. Medial Assistance In Dying (MAID) in Canada, anyone?
My guess is that nothing I said above is especially original, except that actually experiencing the Normal Person perspective in real life was really valuable.
One last point. The government dominates the health care sector from end-to-end. All the way from funding basic research, to medical education, to device and therapy approvals, to credentialling, to reimbursement and payment. On its face, pervasive government involvement seems reasonable, and even foundational.
Harder to see is that pervasive regulation stifles innovation, protects incumbents, and drives up cost (there may even be a parable from a 19th century French economist that is on point).
A great example is the HIPAA privacy law. What kind of troglodyte could possibly be against patient privacy? Yet complicated privacy regs impede innovation by new entrants who are forced to choose between funding fundamental innovation and compliance consultants. Did you know that some health care providers still use fax machines in order to comply with HIPAA regulations? In the third decade of the 21st century.
If we really want to reduce health care costs, fundamental structural reform of our health care system might be a good place to start.
Love this Substack! Our host is one of the few people that can expound at great depth on an incredible range of topics. Thank you!!!!
Oct 23, 2023·edited Oct 23, 2023Liked by Robert F. Graboyes
Thanks for the interesting and thoughtful response. One thought about the Normal Person, however: suppose that perspective is overoptimistic? That is, what if the Normal Person habitually seriously underestimates the probability of a long tail event? Two reasons to think they might: (1) it seems like human nature, especially among the young[1]. We all know it's not untypical for young men to act as if they're invulnerable, take risks at which the more experienced man shakes his head in wonder, et cetera; and (2) if the probability *were* super low, then in a truly free market, the cost to insure against those risks should be pretty low. If the difference between the Normal Person plan and the Rich Person plan is significant -- and the difference in coverage is largely for catastrophic events -- that would seem to imply that the risk of catastrophic events is not as rare as one might hope.
Of course, the only data-drive point here (the second) *assumes* that the cost of catastrophic insurance accurately represents the probability times cost of such an event. There are a lot of reasons why it might not -- if nothing else, as you point out, the clumsy hand of government lies heavily on the whole business, and that might badly distort the correlation of price and risk for which one might hope. One wishes there were some way to know -- as an empiricist, and one who always favors the unvarnished truth over any amount of comforting stories, it would be wonderful if there existed some excellent dataset in which one could look up all the statistics of importance: what are my chances of X and Y happening, given assorted factors? How would they change if I modified A and B? As it is, one is reduced to trolling the Internet and trying to winnow the tiny bits of real data from the overwhelming torrent of bullshit, just-so stories, hucksterism and salesmanship, ax grinding, and plain error. I'd be OK if the CDC got an extra $1 billion a year just to assemble all the data and publish it.
I entirely agree with you that regulation stifles innovation and protects the established players, in this case enormous insurance companies for the most part. This is a great pity. I recall someone once pointing out that in the one area of medicine that least regulated -- elective cosmetic surgery -- price competion is fierce and creative economies abundant, prices are transparent and strongly connected to the actual cost of the service.
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[1] I'm reminded of the story that supposedly 85% of us (or something like that) consider ourselves "above average" drivers ha ha.
I should toss in that one of the big arguments for the Affordable Care Act was the EEEnormous burden foisted upon us paying customers by the uninsured. If I recall correctly, uncompensated care actually amounted to only around 2.5% of overall healthcare expenditures. Much of the expansion in the insurance rolls has come from expanding Medicaid eligibility. So now, the costs of those patients is borne by taxpayers paying into an account marked “Medicaid,” whereas previously, these costs were borne by taxpayers paying into an account marked “uncompensated care.”
An apt example of what Prof. Graboyes refers to would be the Healthy, Hunger-Free Kids Act of 2010. Its object was to improve the standards of lunches and breakfasts served in government schools. In particular, it required more fresh fruit and vegetables. The Act was largely designed by Michelle Obama and passed by the Congress, none of whom eat in school cafeterias. By 2014, a study by the Harvard School of Public Health reported that students under the program threw away 60% of the vegetables and 40% of the fruit.
Oct 17, 2023·edited Oct 17, 2023Liked by Robert F. Graboyes
As a retired ESL teacher in FFX county I can attest to that. First of all we provide the kids with choices, usually the salad and fruits are what they do not choose. I can honestly say I wouldn't eat the salad either- it was always looking dead on the plate. They go for the starchy main dishes of spaghetti, pizza, fried chicken , burritos, etc. as well as the cookies or ice cream, and chocolate milk over white, both of these drinks having aspartame added which has been noted as a substance that stores in the body and adds to the weight children gain.( adults as well) Many of these kids go home to their native diets which also contain starchy foods, and sweets. School lunches are the worst food ever, but cheap to process and supposedly meet the current requirements in a school lunch.
We will never go back to the days of my elementary youth when the cafeteria ladies made the food for us, yeast rolls, vegetable soup, nutritious and satisfying.
I think it was president Reagan who reshaped the school food program to a cheaper more plentiful model that was the beginning of the downfall of decent food for kids. Another problem would also be the financial status of the area school system and the money they could afford to pay out for school lunches even when food was being made. I taught in Rockingham country for one year, ( 1970's) in 3 different schools as a music teacher. I saw a distinct difference in the food planned and served to the kids in those schools, and how those choices reflected the economic status of the folks living in those areas.
Now something we will never do, not our culture-- since my husband is French and my son went to the European school for a few years, .. they lived and ate by European customs. Large meal in the middle of the day. .. My husband came home everyday to a hot meal for lunch, made by his mother, a 2 hour break, back at school at 2PM. He walked to and from school. Then back to school until 4 or 5 PM depending upon higher grade level. Of course this is not our custom, but the food was great! My son did not experience that at the EU school. They had a cafeteria where they were served food on plates at a table, and the food was passed around. ...of course good food you'd never see here. And the kids served themselves. LOLOL! This was not the best practice because there were always some folks who took more than they should have. The point I am making is that they ate decent food. And the walking most of them did offset any bad calories they may have eaten. However, the food was not the cheapest, but cooked that day, not sent in gov't packaging to the schools, and was nutritious.
So even though I have great respect for Mrs. Obama's better food, exercise heath plan, I saw that it made little difference in what children ate at lunch time in the USA. I've seen fruit/veggie plates with a pot of sherbet in the middle thrown away, the sherbet eaten and a cookie to go along with it as an extra for the lunch.
Starchy foods are filling, but add to weight issues, desserts are preferred over wilted lettuce and tomato, even fruits if they aren't canned. Most people in this country eat more starches than they do fruits, veggies, and lean meats because they can't afford higher quality foods. And that is a huge number of folks, along with folks who come from cultures with starchy foods and desserts. Our junk food products just add to the mix. I'm sure the percentage of people in the USA who exercise regularly through sports, dance, or just walking and who know how to eat well, practicing it regularly , is lower than most of the population.
It's all the grains and carbs and ultraprocessed oils. We raise people like my uncle's hogs. He wouldn't touch corn or as he called it 'pig food'. We've raised a nation of hogs.
As an internist/pediatrician who largely deals with uninsured/underinsured people, I want to comment about my 21 years of experience with the “asphalt crew” types. I do a lot of DOT physicals. My income is considerably lower than that of my colleagues as I am self employed by choice and thus NOT personally receiving the health related benefits mentioned in your article.
First, only giving advice which I am personally able to follow has made me focus on what is practical. Taking as much self control out of the equation as possible is a good starting point. My top dietary recommendation is “only use the small plate and the small bowl.” I am glad to report that this is something which has been effective for gradual weight loss in a surprisingly high proportion of my clientele. Those who adopt this lose weight typically at a rate of 2-5 lbs. per year, and keep it off. My second dietary suggestion is to avoid calories in beverage form. The chronic soda drinkers who switch to water typically lose about 10lbs. in the first year.
Second, not all health problems are caused by lifestyle. You can’t control your heredity and it appears that which bacteria reside in your gut has an outsized impact on health risks. I have seen people smoke and drink their way into their 80s, and nonsmokers develop heart disease in their thirties.
Third, the role of oral health in disease prevalence is largely ignored, but something with the potential to have an enormous impact. It’s expensive to care for teeth out of pocket if you’re in need of professional help. This is an issue for most people who lack dental benefits, as well as those who have them but can’t use them due to work hours or distance constraints.
Ultimately we need to stop looking for utoipia in health care, and focus on doing what we can. I see plenty of people who cannot be helped. It’s frustrating but health care policy wonks need to factor that in. I get tired of people who aren’t in the trenches pontificating about this stuff.
There’s plenty of room in the trenches, though, for anyone who wants to jump in. Ivory towers are so confining…
There is a grocery store in my area that is in a part of the county with houses that sell at the cheapest for $5 million or so. The store sells wonderful stuff, fresh wild line-caught king salmon, no doubt flown in this morning from Iceland, for $35/pound, or exquisite chocolates made by elves in Swiss mountainside villages at $5 per quarter ounce, et cetera. Whenever I go there (which is not often), I notice that nobody in the store is overweight, which is quite a contrast from the middle class store to which I usually go. It's uncanny. And I wonder, is it the chicken or the egg? Are these people slim because they're wealthy and can afford the time, effort, and money to take care of their bodies? Or are they rich because they have the kind of self-discipline and forethought that keeps people from getting fat and out of shape as they get older?
I’ve wondered the same. Years back, I mentioned to my mother that we had a fantastic butcher’s shop near us in the DC area. She was slim and very weight-conscious and responded that one could grow quite obese from the assortment of meats I listed off. I said that, no, you could stand in the place all day long and never see an obese customer come in. In contrast, the low-cost, small-town grocery where she shopped had few customers who weren’t.
The story (advance apologies if you've read it) is the continuation of the story of Theseus that Renault began in "The King Must Die" (and both are outstanding books btw). As you know, the story of Theseus is ultimately tragic. An older Theseus is musing on how he came to that end -- was it fate? Or was it his decisions? Hence the somewhat bitter but resigned quote.
In this case, we were discussing whether people are healthier because they are rich (with wealth playing the role of fate in the analogy) or are rich and healthier because they make better choices. I threw the quote in because it's a question that in a more general way humanity has been debating at least since Sophocles (e.g. was Oedipus doomed from the start, or could he have made better decisions)?
I had not known of Renault, but she seems fascinating. While I'm reasonably knowledgeable about Greek mythology, I did not know much about Theseus. Your point is excellent. And that question long preceded the Greeks. Exodus 9:12 says that "The Lord hardened Pharaoh's heart, so that he would not let the children of Israel go." This has spawned a long theological debate over whether Pharaoh's self-destructive command was his own decision or whether he was merely a pawn of God.
It is the self-discipline and forethought, reinforced by social norms. In "Bonfire of the Vanities", Tom Wolfe described the "social X-ray", a wealthy woman thin to the point of scrawny so she can fit into designer clothing. Look at a group picture of executives of a large corporation. Few or none are fat because a trim, fit executive is much more likely than a fatty to get promoted.
Excellent observation! People often say that (1) data indicate that obese people are less productive, so (2) It in the employer's interest to fight obesity among their employees. There are multiple problems with that chain of reasoning. First, it's not clear that employers--including the military--have any real capacity to reduce obesity among employees. Second, to the extent that employers can nudge obese employees to lose weight, the cost of doing so likely exceeds gains from productivity. Third, even in the unlikely possibility that the cost of thinning down an employee is less than the productivity gains of doing so, it's likely that the employee will have moved on to another employer. Fourth, as you suggest the thin/high-performing relationship may be an instance of correlation, not causality. And fifth, it is likely that employers have already priced the reduced productivity into the employee's compensation.
I believe this was also a strong theme running through "The Bell Curve" by Murray and Herrnstein, with respect to the justice system, that is, that the justice system is designed by people (lawyers, legislators, judges) to work for people like themselves -- who, of course, are almost never its "clients." Consequently, for the people who actually become enmeshed in it, its systems of motivations and its general machinery are baffling, ineffective, in turn laughable and horrific, and its outcomes far more mediocre than the theory of its designers would suggest. I found this a very persuasive point of view. It doesn't surprise me at all that it should apply to the socialized aspects of medicine -- or old age medical care and pensions, while we're at it.
....."The biggest problem with healthcare policy may be that those who design healthcare policy mostly design it for people who design healthcare policy.".....
NOW
Substitute for "healthcare" any policy designed or implemented, or both, by GOVCO (my shorthand for every level of government or "governance" (ie big business or NGOs) and you have articulated the "IRON-RULE of The Way the World Works". At least for today. Tomorrow it may stop working at the rate we're going. And then the "Graboyes Iron Rule" will wind up on the ashheap of history.
But until then...
The "Graboyes Iron Rule." I like it. Catchy! How's this for a statement of the rule?: "If experts discuss any topic of public policy for long enough, the likelihood that someone will offer 'arugula' as a solution approaches 100%."
And, if I may, offer my definition of an expert: "Someone who knows more and more about less and less until he knows everything about nothing. And then proceeds to share his expertise with you."
Yes, I'm a cynic. ;-)
The intellectual equivalent of Woody Allen's definition of a stockbroker: "A stockbroker is someone who invests other people's money until it is all gone.”
"fall consensus effect"? Could this be a wrong-word error for "false consensus effect"?
Thanks! I'll fix it, dang it all.
Yep. Arugula arrives well before the asymptote runs out.
I’m beginning to warm up to this mid journey thing. The illustration is priceless.
It can be fun. It's like any artistic medium. It depends who does it. :)
There's an aspect to AI image programs like Midjourney that can be frustrating or fun. That is that the programs are fairly stupid. In this article (https://graboyes.substack.com/p/chickens-and-neutrons-and-long-leggedy) scroll down to the image of a gas station at night. It came out just as I wanted it--really a rather attractive image--except that the car is parked in an impossible fashion. I thought about redoing it and then decided, "Naaah. Let's see if anyone notices." No one did. In the present article, the asphalt crew is daintily picking their way through mountains of fresh produce. But if you look closely, Midjourney put a big pile of dirt or asphalt on the table, creeping over into the vegetables.
Thanks for the amplification! I did have to go back and look for the dirt! BTW, this is another superior post, and proof that your insight and skill are durable.
Many thanks! Glad you enjoyed the dirt. Don't know your age, but in the 1960s, "Get Smart!" featured a character called "Hymie the Robot." A brilliant, empathetic machine, but unable to understand idiomatic expressions. (If Max told him, "Let's hop to it, Hymie," Hymie literally hopped to wherever they were going.) Generative AI programs remind me of Hymie.
We’re pretty much contemporaries. Get Smart, Wild Wild West and Star Trek on our brand new color TV were the rewards for good grades and chores done. Hymie was classic along with the shoe phone!
Same here. All three were fantastic shows. There was a whole lot of classic to "Get Smart." The Cone of Silence. Episodes called "Tequila Mockingbird" and "How Green Was My Valet." And everything about the wonderful Agent 99.
We were thinking that was a generous serving of quinoa to eat with the salad!
Robert, Excellent summation and analysis but it begs the question: what can we as physicians do about it? I have always tried to counsel and advise my patients in healthy lifestyles, healthy eating, managing stress, etc. etc. but even though I am old school, see every patient, and spend much more time with them than the average primary physician (I am a specialist), it amounts to no more than 45-60 minutes in two or three visits over several months, most of which time is devoted to the specific problem they come to me with. I don't have answers either, but to think we are going to make a dent in obesity and chronic disease by targeting the fifty-something who is obese, already diabetic, and hypertensive is a fantasy. We need to restore some common sense policies and target the next generation. Restoring outdoor recreation in schools for kids, teaching nutrition to the young, and at least making an effort to get them off of their screens would be a start. How do we restore unstructured play, such as was the norm on my own childhood. Grownups must model healthy behaviors, especially doctors (my partner is obese-imagine how effective his advice to his patients to lose weight is). I fear I am a pessimist because I know human nature craves creature comforts and it is the unusual person who goes out of their way to be uncomfortable, i.e. exercise when they don't feel like, refrain from stuffing their face when confronted with a smorgasbord of tasty food, and resist that second or third drink. Rick
I'm not a nihilist, but I'm not optimistic about medicine's capacity to greatly change human behavior. I used to have my classes read "The Fattening of America" by Eric Finkelstein and Laurie Zuckerman. I chose this book, not because it was on obesity, but rather because it's the best book I've ever read on the broader subject of what health economics is all about, how a health economist thinks, and how all of that impacts (or fails to impact) policy and behavior. He does a deep dive into why obesity numbers have risen so rapidly for the past 30-40 years. He then goes one by one through the policy and behavioral modification options. He ultimately concludes that none of these well-intended attempts will make much of a difference. The problem, as he explains, is that most obesity is "rational obesity." The individual knows why he's obese, knows the dangers of being obese, knows how to lose weight, but simply has higher priorities. He uses his uncle as an exemplar--the uncle, who once was slim, is a wealthy, workaholic attorney who loves Italian food and hates exercise. Finkelstein discusses the what it would have taken for his uncle to remain thin and concludes that virtually nothing would have persuaded him to follow that path.
And, as I stressed to my students, our calorie imbalance isn't that big. 50 years ago, calories consumed-minus-calories burned was close to zero, so the population only put on a little weight as they aged. Today, a gap opened up--more calories consumed, fewer calories burned. But that gap only amounts to 100 calories a day or less. But that is enough to fuel the whole crisis, if it is a crisis.
Finkelstein also notes that with advances in modern medicine, obese people today have many biometrics that are better than thin people had 50 years ago. And I'll note that Finkelstein is a crusader against obesity. He just thinks (or at least thought when he wrote the book) that obesity is an individual choice, and it will cease to be a problem when people change their individual priorities. He regrets that that's the case. If I remember correctly, the one thing he thought might help (for complex reasons) was reducing corn subsidies--but we know how that idea plays in the Iowa Caucuses. (And, in fact, arugula first arose as a policy meme in Iowa in 2008.)
After working in Home health as a physical therapist for 10 years you come to realize that Yes you have very little sway over what you can do to change a person’s overall health.
For the policy wonks, I would recommend they spend a year doing just home health visits. They would see the limitations of the mentioned policies. Gym memberships, tax credits, yoga breaks and even 100% governmental subsidized arugula distribution to all citizens won’t help. The variables are too numerous and behaviors are too in bedded.
Specific issues can be addressed for an immediate health problem. But the fact that I saw people on a frequent basis for the same problem confirms the inability for most people to change even with repeated education.
Great post. Here's something related from Florence Nightingale: "To patients enduring every day for years from every friend or acquaintance, either by letter or viva voce, some torment of this kind, I would suggest the same answer. It would indeed be spared, if such friends and acquaintances would but consider for one moment, that it is probable the patient has heard such advice at least fifty times before, and that, had it been practicable, it would have been practised long ago."
> The biggest problem with healthcare policy may be that those who design healthcare policy mostly design it for people who design healthcare policy.
See also: open-source software. With a very few notable exceptions such as web browsers, almost all of it is built by software developers to solve their own very specific needs, which is why it's often a poor fit for things the general public wants to do.
Interesting comparison! Reminds me, too, of what can happen when us ordinary folks try to use tools designed for and by insiders: https://timharford.com/2021/07/the-tyranny-of-spreadsheets/
One modestly-cynical-but-also-accurate understanding of large, successful open-source software projects is that they are a mechanism through which tech companies can collaborate on — and share the cost of — important software infrastructure that's not part of those companies' "special sauce." One super-important feature is that such public collaboration avoids adverse consequences anti-trust-wise. At least so far.
The vast majority of changes contributed to the big successful open-source projects are produced by employees of tech firms *as part (or all!) of their full-time job*. This fraction decreases for smaller and/or less-successful projects all the way down to near-zero for "hobby projects."
Interesting stuff!
I recently had the opportunity to advise a younger, healthy family member just starting out in life who needed to purchase health insurance. Before this, I never had much reason to really think about health insurance other than picking from the menu of choices offered by a corporate employer. My experience validates your thesis to a "T."
Putting aside employer sponsored plans, health plans fall into two broad groups.
The first is the "Obamacare Compliant" plans. These are characterized by high deductibles, high coverage limits, and higher premiums. They make a lot of sense for higher earners who aren't terribly concerned about going out of pocket to cover routine needs like their kids' strep throat. Their high coverage limits provide a backstop in case things really go off the rails for something like a cancer diagnosis or a kidney transplant. It would also seem that these plans great sense from a health care system cost containment standpoint. Not coincidentally, these structures fit the needs of the kind of people that develop health care policy. One might call them "Rich People" plans.
The second are what I will call "Normal People" plans, for lack of a better term. These plans are characterized by lower deductibles, lower coverage limits, and lower premiums. They make a lot of sense for someone who might otherwise have to choose between having their sprained ankle looked at or making their next car payment. Normal People plans provide a day-to-day backstop for people don't have wealth to protect in the case of a catastrophic event. This second type of plan is actually illegal in a number of states.
My family member would have opted for the second type of plan. Had I been in their position, I would have done the same. But knowing that I was going to be the bankroll in any event, I opted for the first type.
A practical application of your thesis at work.
Great comments! Thanks
I can kind of understand why some states prohibit the #2 plan. The person who chooses it is kind of making a bet, that he *won't* get cancer or need a kidney transplant, and is therefore willing to forego coverage for it. But other law and custom tends to prohibit the healthcare system from profiting by taking the other side of that bet. That is, if the young healthy person *does* unfortunately get cancer or need a transplant, the healthcare system is not permitted to say sorry you lost your bet, no $250,000 treatment for you, you'll have to come up with the cash by some miracle or die. So the person *does* get treatment, but the costs end up on the state, and not surprisingly the state says we don't want any part of this racket. If you know someone who works in the ER of a big urban hospital, they can tell you of the astonishing amount of very expensive healthcare that gets absorbed by uninsured people who have no hope of ever paying. When it's a public hospital, that comes out of the taxpayer, and when it's private, it gets paid by the people who *do* have insurance, and fork out $200 for an Advil in the hospital after elective surgery.
Personally, I'm all for allowing people to make the bets they choose. I think a young person *should* be allowed to decline coverage for transplants, neurosurgery, bypass, IVF, et cetera, on the grounds that he estimates his personal risk is low enough to be acceptable. But then, the flip side of that *must* be that we harden our hearts in the cases where that estimate was badly mistaken, and decline to compel the medical community to assist without payment in those cases. People must be allowed to die of completely treatable conditions, just because they lack the money to pay, if they have deliberately chosen to not insure against them.
I feel like a large part of the anguish of this debate stems from two great social myths, which are delusional:
(1) We steadfastly decline to believe the actual lifetime cost of medical care. We have a vague idea that it might demand 5% of our lifetime incomes, but surely not much more, when the reality is probably that it requires something like 20% of the average lifetime earnings to pay for the average lifetime medical care costs. (I base that WAG on the fact that about 20% of GDP is healthcare spending.) We cling to delusionary hopes of immortality, that if we only eat right, take this and that supplement, do this or that juice cleanse, get checkups in a regular way, we will escape the terrible expensive diseases that kill people, and just sail on forever. Or maybe, if pressed, we'll admit the ambition is *just" to live into our 90s with little in the way of expensive invasive care, and pop off quietly from a painless stroke in our sleep. The entire debate might be a little less hysterical and rage-filled if we all just accepted that, yeah, if you want First World first-rate medical care all your life, then you will need to set aside 1 of every 5 dollars you ever earn to pay for it. (Of course, you already have to set aside 1 of every 5 dollars to pay for the government, so before we even get into things like retirement savings, or savings for the kids' college, you're down to 3 of every 5 dollars you ever earn. This is discouraging.)
(2) We continue to believe in this area, as in many others, that there exists some stratum of tappable wealth among a minority of us that could be expropriated to ease all our burdens. Why not tax Bill Gates a mere 10% of his fabulous wealth to help us out? Or a mere 1% of Amazon's annual revenue stream? But here again we display our innumeracy. According to Forbest the 400 richest Americans have an aggregate wealth of $4.5 trillion, which sounds amazing, and would be, on a personal level. But it is virtually nothing on a national scale. If you taxed away 10% of that wealth, it would reduce the *deficit* of the Federal government ($4.6 billion/day) for a smidge over 3 months. You would have to confiscate 40% of that wealth just to close the gap between Federal spending and Federal income taxes for 1 year. (And then what do you do the next year?) Or consider Walmart, the largest company in the world by revenue. They haul in $600 billion a year, which sound fabulous -- but US healthcare spending is of the order of $4 trillion a year, which means a 1% tax on Walmart would cover healthcare spending for half a day.
It's certainly true that the richest people and largest companies are indeed very rich -- but that wealth pyramid is very narrow at the top, and the aggregate income doesn't actually represent a rich vein of tappable wealth (even leaving aside the negative motivational effects trying to steal it for the commonweal would have). And again, I feel like our discussions would be less hysterical if we all accepted the fact that there *is* no magic wealth source Somewhere Else to pay for the expensive time of highly skilled people that we all, individually, wish to be able to command when we are hurt or sick.
Can we reduce the cost of healthcare, by efficiency improvements? Certainly that must be the case. But I find it highly doubtful that we can reduce it by the factors of 75-90% that would be necessary to bring the actual cost in line with our (flawed) intuitions about how much it ought to cost.
Great comment!
You make the case for Rich People Plans from the perspective of somebody who is responsible for managing the state’s health care budget. Not that there’s anything wrong with that.
I would submit that the perspective of a generally healthy Normal Person is quite a bit different. The rare bad luck of getting hit by a runaway truck pales in comparison to the reality of having kids who need new shoes. My recent experience advising a family member helped me see, and actually feel, this perspective.
None of us want the Normal Person who rolled snake eyes to bleed out in the ditch. The challenge is finding the right balance between paying for new shoes and covering tail cases like the runaway truck. Covering routine events like strep throat is more like cost smoothing; spreading the risk of truck accidents functions more like actual insurance. For young healthy people, anyway. Seems that we, as a society, should be able to find a way to cover the tail.
Also agree completely about the nominal 20%. But that’s an average. For a Rich Person, it’s less than 20%; for a Normal Person, its obviously more. (BTW, I meant to mention in my previous comment that the situation is even crazier when you’re trying to navigate the donut hole where somebody makes too much to qualify for an Obamacare subsidy and not enough to cover medical bills that a Rich Person would consider middling. That’s when it’s really nice to have the metaphorical rich uncle).
Plus, the costs are time skewed – most of that 20% is incurred in the last year or two of life. So there’s this whole intergenerational component where junior is subsidizing grandma. Not that any of us feel good about sending grandma out on the ice floe.
20% isn’t sustainable over the long term. As you point out, there aren’t enough rich people to pay for all of this stuff. Like that soccer team whose plane crashed in the Andes, some truly horrifying ideas can start to seem rational, and then necessary. Medial Assistance In Dying (MAID) in Canada, anyone?
My guess is that nothing I said above is especially original, except that actually experiencing the Normal Person perspective in real life was really valuable.
One last point. The government dominates the health care sector from end-to-end. All the way from funding basic research, to medical education, to device and therapy approvals, to credentialling, to reimbursement and payment. On its face, pervasive government involvement seems reasonable, and even foundational.
Harder to see is that pervasive regulation stifles innovation, protects incumbents, and drives up cost (there may even be a parable from a 19th century French economist that is on point).
A great example is the HIPAA privacy law. What kind of troglodyte could possibly be against patient privacy? Yet complicated privacy regs impede innovation by new entrants who are forced to choose between funding fundamental innovation and compliance consultants. Did you know that some health care providers still use fax machines in order to comply with HIPAA regulations? In the third decade of the 21st century.
If we really want to reduce health care costs, fundamental structural reform of our health care system might be a good place to start.
Love this Substack! Our host is one of the few people that can expound at great depth on an incredible range of topics. Thank you!!!!
Thanks for the interesting and thoughtful response. One thought about the Normal Person, however: suppose that perspective is overoptimistic? That is, what if the Normal Person habitually seriously underestimates the probability of a long tail event? Two reasons to think they might: (1) it seems like human nature, especially among the young[1]. We all know it's not untypical for young men to act as if they're invulnerable, take risks at which the more experienced man shakes his head in wonder, et cetera; and (2) if the probability *were* super low, then in a truly free market, the cost to insure against those risks should be pretty low. If the difference between the Normal Person plan and the Rich Person plan is significant -- and the difference in coverage is largely for catastrophic events -- that would seem to imply that the risk of catastrophic events is not as rare as one might hope.
Of course, the only data-drive point here (the second) *assumes* that the cost of catastrophic insurance accurately represents the probability times cost of such an event. There are a lot of reasons why it might not -- if nothing else, as you point out, the clumsy hand of government lies heavily on the whole business, and that might badly distort the correlation of price and risk for which one might hope. One wishes there were some way to know -- as an empiricist, and one who always favors the unvarnished truth over any amount of comforting stories, it would be wonderful if there existed some excellent dataset in which one could look up all the statistics of importance: what are my chances of X and Y happening, given assorted factors? How would they change if I modified A and B? As it is, one is reduced to trolling the Internet and trying to winnow the tiny bits of real data from the overwhelming torrent of bullshit, just-so stories, hucksterism and salesmanship, ax grinding, and plain error. I'd be OK if the CDC got an extra $1 billion a year just to assemble all the data and publish it.
I entirely agree with you that regulation stifles innovation and protects the established players, in this case enormous insurance companies for the most part. This is a great pity. I recall someone once pointing out that in the one area of medicine that least regulated -- elective cosmetic surgery -- price competion is fierce and creative economies abundant, prices are transparent and strongly connected to the actual cost of the service.
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[1] I'm reminded of the story that supposedly 85% of us (or something like that) consider ourselves "above average" drivers ha ha.
I should toss in that one of the big arguments for the Affordable Care Act was the EEEnormous burden foisted upon us paying customers by the uninsured. If I recall correctly, uncompensated care actually amounted to only around 2.5% of overall healthcare expenditures. Much of the expansion in the insurance rolls has come from expanding Medicaid eligibility. So now, the costs of those patients is borne by taxpayers paying into an account marked “Medicaid,” whereas previously, these costs were borne by taxpayers paying into an account marked “uncompensated care.”
David Burge (a.k.a. Iowahawk) did a great column on point #2 back around 2011. The article is republished here: "How to Feed Your Family on $10 Billion a Day": https://www.atlassociety.org/post/how-to-feed-your-family-on-10-billion-a-day. You can watch an entertaining video of it here: https://www.youtube.com/watch?v=661pi6K-8WQ.
Thanks, harshly amusing in the inimitable Iowahawk style!
An apt example of what Prof. Graboyes refers to would be the Healthy, Hunger-Free Kids Act of 2010. Its object was to improve the standards of lunches and breakfasts served in government schools. In particular, it required more fresh fruit and vegetables. The Act was largely designed by Michelle Obama and passed by the Congress, none of whom eat in school cafeterias. By 2014, a study by the Harvard School of Public Health reported that students under the program threw away 60% of the vegetables and 40% of the fruit.
Yup. I've been having an offline conversation about that all morning, and I'll likely write about it soon.
As a retired ESL teacher in FFX county I can attest to that. First of all we provide the kids with choices, usually the salad and fruits are what they do not choose. I can honestly say I wouldn't eat the salad either- it was always looking dead on the plate. They go for the starchy main dishes of spaghetti, pizza, fried chicken , burritos, etc. as well as the cookies or ice cream, and chocolate milk over white, both of these drinks having aspartame added which has been noted as a substance that stores in the body and adds to the weight children gain.( adults as well) Many of these kids go home to their native diets which also contain starchy foods, and sweets. School lunches are the worst food ever, but cheap to process and supposedly meet the current requirements in a school lunch.
We will never go back to the days of my elementary youth when the cafeteria ladies made the food for us, yeast rolls, vegetable soup, nutritious and satisfying.
I think it was president Reagan who reshaped the school food program to a cheaper more plentiful model that was the beginning of the downfall of decent food for kids. Another problem would also be the financial status of the area school system and the money they could afford to pay out for school lunches even when food was being made. I taught in Rockingham country for one year, ( 1970's) in 3 different schools as a music teacher. I saw a distinct difference in the food planned and served to the kids in those schools, and how those choices reflected the economic status of the folks living in those areas.
Now something we will never do, not our culture-- since my husband is French and my son went to the European school for a few years, .. they lived and ate by European customs. Large meal in the middle of the day. .. My husband came home everyday to a hot meal for lunch, made by his mother, a 2 hour break, back at school at 2PM. He walked to and from school. Then back to school until 4 or 5 PM depending upon higher grade level. Of course this is not our custom, but the food was great! My son did not experience that at the EU school. They had a cafeteria where they were served food on plates at a table, and the food was passed around. ...of course good food you'd never see here. And the kids served themselves. LOLOL! This was not the best practice because there were always some folks who took more than they should have. The point I am making is that they ate decent food. And the walking most of them did offset any bad calories they may have eaten. However, the food was not the cheapest, but cooked that day, not sent in gov't packaging to the schools, and was nutritious.
So even though I have great respect for Mrs. Obama's better food, exercise heath plan, I saw that it made little difference in what children ate at lunch time in the USA. I've seen fruit/veggie plates with a pot of sherbet in the middle thrown away, the sherbet eaten and a cookie to go along with it as an extra for the lunch.
Starchy foods are filling, but add to weight issues, desserts are preferred over wilted lettuce and tomato, even fruits if they aren't canned. Most people in this country eat more starches than they do fruits, veggies, and lean meats because they can't afford higher quality foods. And that is a huge number of folks, along with folks who come from cultures with starchy foods and desserts. Our junk food products just add to the mix. I'm sure the percentage of people in the USA who exercise regularly through sports, dance, or just walking and who know how to eat well, practicing it regularly , is lower than most of the population.
Thanks for all the great first-hand info!
Metabolic researchers at this Swiss Re conference share recent research on the metabolic origin of most chronic disease. https://www.swissre.com/institute/conferences/fixing-metabolic-health.html
It's all the grains and carbs and ultraprocessed oils. We raise people like my uncle's hogs. He wouldn't touch corn or as he called it 'pig food'. We've raised a nation of hogs.
Corn subsidies are definitely a factor.
As an internist/pediatrician who largely deals with uninsured/underinsured people, I want to comment about my 21 years of experience with the “asphalt crew” types. I do a lot of DOT physicals. My income is considerably lower than that of my colleagues as I am self employed by choice and thus NOT personally receiving the health related benefits mentioned in your article.
First, only giving advice which I am personally able to follow has made me focus on what is practical. Taking as much self control out of the equation as possible is a good starting point. My top dietary recommendation is “only use the small plate and the small bowl.” I am glad to report that this is something which has been effective for gradual weight loss in a surprisingly high proportion of my clientele. Those who adopt this lose weight typically at a rate of 2-5 lbs. per year, and keep it off. My second dietary suggestion is to avoid calories in beverage form. The chronic soda drinkers who switch to water typically lose about 10lbs. in the first year.
Second, not all health problems are caused by lifestyle. You can’t control your heredity and it appears that which bacteria reside in your gut has an outsized impact on health risks. I have seen people smoke and drink their way into their 80s, and nonsmokers develop heart disease in their thirties.
Third, the role of oral health in disease prevalence is largely ignored, but something with the potential to have an enormous impact. It’s expensive to care for teeth out of pocket if you’re in need of professional help. This is an issue for most people who lack dental benefits, as well as those who have them but can’t use them due to work hours or distance constraints.
Ultimately we need to stop looking for utoipia in health care, and focus on doing what we can. I see plenty of people who cannot be helped. It’s frustrating but health care policy wonks need to factor that in. I get tired of people who aren’t in the trenches pontificating about this stuff.
There’s plenty of room in the trenches, though, for anyone who wants to jump in. Ivory towers are so confining…
Great comments, all.
Yup. Best predictor of health outcomes is zip code.
In Britain and Canada, it's called "the postal code lottery."
There is a grocery store in my area that is in a part of the county with houses that sell at the cheapest for $5 million or so. The store sells wonderful stuff, fresh wild line-caught king salmon, no doubt flown in this morning from Iceland, for $35/pound, or exquisite chocolates made by elves in Swiss mountainside villages at $5 per quarter ounce, et cetera. Whenever I go there (which is not often), I notice that nobody in the store is overweight, which is quite a contrast from the middle class store to which I usually go. It's uncanny. And I wonder, is it the chicken or the egg? Are these people slim because they're wealthy and can afford the time, effort, and money to take care of their bodies? Or are they rich because they have the kind of self-discipline and forethought that keeps people from getting fat and out of shape as they get older?
I’ve wondered the same. Years back, I mentioned to my mother that we had a fantastic butcher’s shop near us in the DC area. She was slim and very weight-conscious and responded that one could grow quite obese from the assortment of meats I listed off. I said that, no, you could stand in the place all day long and never see an obese customer come in. In contrast, the low-cost, small-town grocery where she shopped had few customers who weren’t.
"Fate and will, will and fate, like earth and sky bringing forth the grain together; and which the bread tastes of, no man knows."
(from "The Bull From the Sea," Mary Renault, 1962)
Beautiful. But now I have to figure out what you’re saying. :)
The story (advance apologies if you've read it) is the continuation of the story of Theseus that Renault began in "The King Must Die" (and both are outstanding books btw). As you know, the story of Theseus is ultimately tragic. An older Theseus is musing on how he came to that end -- was it fate? Or was it his decisions? Hence the somewhat bitter but resigned quote.
In this case, we were discussing whether people are healthier because they are rich (with wealth playing the role of fate in the analogy) or are rich and healthier because they make better choices. I threw the quote in because it's a question that in a more general way humanity has been debating at least since Sophocles (e.g. was Oedipus doomed from the start, or could he have made better decisions)?
I had not known of Renault, but she seems fascinating. While I'm reasonably knowledgeable about Greek mythology, I did not know much about Theseus. Your point is excellent. And that question long preceded the Greeks. Exodus 9:12 says that "The Lord hardened Pharaoh's heart, so that he would not let the children of Israel go." This has spawned a long theological debate over whether Pharaoh's self-destructive command was his own decision or whether he was merely a pawn of God.
It is the self-discipline and forethought, reinforced by social norms. In "Bonfire of the Vanities", Tom Wolfe described the "social X-ray", a wealthy woman thin to the point of scrawny so she can fit into designer clothing. Look at a group picture of executives of a large corporation. Few or none are fat because a trim, fit executive is much more likely than a fatty to get promoted.
Excellent observation! People often say that (1) data indicate that obese people are less productive, so (2) It in the employer's interest to fight obesity among their employees. There are multiple problems with that chain of reasoning. First, it's not clear that employers--including the military--have any real capacity to reduce obesity among employees. Second, to the extent that employers can nudge obese employees to lose weight, the cost of doing so likely exceeds gains from productivity. Third, even in the unlikely possibility that the cost of thinning down an employee is less than the productivity gains of doing so, it's likely that the employee will have moved on to another employer. Fourth, as you suggest the thin/high-performing relationship may be an instance of correlation, not causality. And fifth, it is likely that employers have already priced the reduced productivity into the employee's compensation.
I believe this was also a strong theme running through "The Bell Curve" by Murray and Herrnstein, with respect to the justice system, that is, that the justice system is designed by people (lawyers, legislators, judges) to work for people like themselves -- who, of course, are almost never its "clients." Consequently, for the people who actually become enmeshed in it, its systems of motivations and its general machinery are baffling, ineffective, in turn laughable and horrific, and its outcomes far more mediocre than the theory of its designers would suggest. I found this a very persuasive point of view. It doesn't surprise me at all that it should apply to the socialized aspects of medicine -- or old age medical care and pensions, while we're at it.