Marginal Revolution

A sexual selection model of schizophrenia

Schizophrenia is a mental disorder marked by an evolutionarily puzzling combination of high heritability, reduced reproductive success, and a remarkably stable prevalence. Recently, it has been proposed that sexual selection may be crucially involved in the evolution of schizophrenia. In the sexual selection model (SSM) of schizophrenia and schizotypy, schizophrenia represents the negative extreme of a sexually selected indicator of genetic fitness and condition. Schizotypal personality traits are hypothesized to increase the sensitivity of the fitness indicator, thus conferring mating advantages on high-fitness individuals but increasing the risk of schizophrenia in low-fitness individuals; the advantages of successful schzotypy would be mediated by enhanced courtship-related traits such as verbal creativity. Thus, schizotypy-increasing alleles would be maintained by sexual selection, and could be selectively neutral or even beneficial, at least in some populations. However, most empirical studies find that the reduction in fertility experienced by schizophrenic patients is not compensated for by increased fertility in their unaffected relatives. This finding has been interpreted as indicating strong negative selection on schizotypy-increasing alleles, and providing evidence against sexual selection on schizotypy.

That is from Marco Del Giudice and for the pointer I thank Harpersnotes.

Monopsony markets in everything

Two Mississippi sisters serving double life sentences for their roles in an $11 armed robbery will be released, but only on the condition that the younger sibling donate her kidney to her sister, whose organs are failing, state officials said Thursday.

Here is much more.

Facts about Brazil

[Rio favela] Complexo do Alemao ranks lower than the African country of Gabon on the United Nations Human Development Index, a world survey of living standards that measures factors like access to education and health care. By comparison, the Development Index scores of upscale Rio neighborhoods like Gavea and Leblon are higher than Norway, the world’s top-ranked country.

Here is more, mostly on the war against the drug gangs.

Economics and mental health care

Jacob, a loyal MR reader, writes to me:

I am a research assistant involved in an evaluation of the quality of mental health care.  It turns out that much of “quality” from a clinician's perspective involves coercing/convincing/luring patients into treatment – patients should show up quickly (“initiation”) and repeatedly (“engagement”) and for a really long time (“continuation-phase treatment”).  For example, health plans are graded on the proportion of depressed patients that they can keep on antidepressants for 6 months (link – pg 23).  

So, how do you think about markets and individual-level-decision making among the severely mentally ill. On one hand, it feels inadequate to throw up ones hands and say everyone is the best ruler of themselves.  But it also feels inadequate to defer fully to the experts.  I’m sure this topic has been tackled elsewhere but a thoughtful analysis has evaded me so far.

A few points:

1. Here are some recent reported results about conceptualizing mental illness; I cannot vouch for them.

2. Here is an article about the fracturing of the concept of mental illness.  Here is The Economist on the same topic.

3. The mentally ill have it tough in China.

4. Here is one story of rational economic man.

5. I disagree with Bryan Caplan's argument that mental illness is a false category; he is making an odd turn toward behaviorism.  That the behavior can be reduced to preferences and constraints does not mean that is the best or only way of understanding the phenomenon (which is not just about behavior).

6. Here is the major paper on economics and mental health.  Here is a collection on the same topic, by the same authors.

7. You won't find the answers to your questions in any of those places, or here.  I do, in the meantime, hold two views.  First, historically the concept has been used -- indeed abused -- to incorrectly rationalize a lot of forcible institutionalization.  Second, it is not a meaningless concept, though fractured it may be.

Women and alcohol

Is there a better blog post title?  Here is the abstract of a new paper, "Women or Wine, Monogamy and Alcohol":

Intriguingly, across the world the main social groups which practice polygyny do not consume alcohol. We investigate whether there is a correlation between alcohol consumption and polygynous/monogamous arrangements, both over time and across cultures. Historically, we find a correlation between the shift from polygyny to monogamy and the growth of alcohol consumption. Cross-culturally we also find that monogamous societies consume more alcohol than polygynous societies in the preindustrial world. We provide a series of possible explanations to explain the positive correlation between monogamy and alcohol consumption over time and across societies.

That's by Mara Squicciarini and Jo Swinnen.

We need more supply-side health policy

...in a fierce turf battle rooted in the growing pressures on the medical profession and academia, New York State’s 16 medical schools are attacking their foreign competitors. They have begun an aggressive campaign to persuade the State Board of Regents to make it harder, if not impossible, for foreign schools to use New York hospitals as extensions of their own campuses.

The changes, if approved, could put at least some of the Caribbean schools in jeopardy, their deans said, because their small islands lack the hospitals to provide the hands-on training that a doctor needs to be licensed in the United States.

The story is here.

Is RyanCare a version of Obamacare?

More or less, Ezra says:

The Ryan-Rivlin plan basically turns Medicare into Obamacare. And in that context, Republicans love the idea behind ObamaCare and think it'll save lots of money.

Under the Ryan-Rivlin plan, the current Medicare program is completely dissolved and replaced by a new Medicare program that "would provide a payment – based on what the average annual per-capita expenditure is in 2021 – to purchase health insurance." You'd get the health insurance from a "Medicare Exchange", and "health plans which choose to participate in the Medicare Exchange must agree to offer insurance to all Medicare beneficiaries, thereby preventing cherry picking and ensuring that Medicare’s sickest and highest cost beneficiaries receive coverage."

File under "True, True, True."  My view is that when it comes to health care economics, just about everyone should have egg on their faces.

The health care plan of Kim Meyers

If in a calendar year a person has in excess of $100,000 in medical expense they are transferred over to Medicare, regardless of age.

The remainder of the citizenry is able to choose from a competitive insurance market, which is essentially selling $100,000 “Term” health insurance policies.

That is from Kim Meyers of Northwestern.  As she notes in an email to me, this can be combined with health savings accounts and various kinds of deregulation for the coverage of the lesser expenses.  You also can raise the Medicare eligiblity age and I would say you could raise it to a very high level indeed. 

I view this as the most plausible way of bringing a Singapore-like health care system to the United States.

Device Lag at the FDA

A new survey of the FDAs impact on medical technology innovation reports that the FDA is slow, inefficient and costly.  The survey is from the Medical Device Manufacturers Association so take it with a grain of salt (but see below). What is most telling, however, is how manufacturers rate the FDA compared to its European counterpart(s).

Overall Experience: 75 percent of respondents rated their regulatory experience in the EU excellent or very good. Only 16 percent gave the same ratings to the FDA...

Respondents also cite specific concerns with the FDA process (not just a general complaint of slowness which could be efficient) such as:

...44 percent of participants indicated that part-way through the regulatory process they experienced untimely changes in key personnel, including the lead reviewer and/or branch chief responsible for the product’s evaluation.

As a result:

On average, the products represented in the survey were available to patients in the U.S. a full two years after they were available to patients in Europe (range = 3 to 70 months later).

In some cases, respondents said they initiated their regulatory processes within and outside the U.S. at the same time, but received clearance/approval in the U.S. much later. In anticipation of long, expensive FDA reviews, others said they decided to seek or obtain European approval first in an effort to generate sales overseas that could help fund their U.S. regulatory efforts.

The survey has a good discussion of potential biases. To those not familiar with the industry it might seem obvious that the MDMA would want to bash the FDA but my experience is that companies in the business don't like to complain. Indeed, the survey notes:

A number of companies indicated that they would not respond due to fear of retribution from the FDA (despite assurances we would maintain their confidentiality).

See FDAReview for more on the FDA. Hat tip: Mike Mandel.

Addendum: Loyal reader Josh Turnage has produced a video plea to the FDA on behalf of his mother to leave Avastin approved for breast cancer.

Follow the reimbursement rates

That is the theme of my current New York Times column.  Since the non-high-technology supply side of medicine is so restricted and unresponsive to market incentives, the health care market is out of balance.  A large number of doctors, for instance, do not accept Medicaid patients and that is because the Medicaid reimbursement rate is lower than Medicare or private insurance.  It's a key question how the queueing of Medicaid patients (and to some extent Medicare patients) will proceed as the demand for health care rises.

The new health care bill will on net make this problem worse, even though it has some offsetting incentives for more GPs.  Most Republican Party proposals will make this problem worse, by bolstering reimbursement rates for Medicare and perhaps also by worsening Medicaid.  In Massachusetts the number of emergency room visits has gone up rather than down, even as near-universal coverage was achieved.  And so where do we stand?

The American system of federalism, with its checks and balances and slow policy evolution, has many strengths, but it has also helped create this crazy quilt of health care reimbursement rates. The more demand-side pressure is placed on medical supply, the more Medicaid and Medicare reimbursements rates will determine who and what is rationed.

One option is to simply allow budget pressures to dominate, forcing down even private insurance reimbursements. Most people would end up with low, Medicaid-like reimbursement rates, and would endure long waits and low-quality service. But wealthier people could jump the line by paying more. Think of “Medicaid for everyone” but the rich.

An alternative is giving most people means-tested vouchers for a fixed amount of insurance coverage — which can run out or face up-front caps — making Medicaid and Medicare less of a blank check. The cost explosion would be checked by shifting more of the burden onto consumers. We would have better incentives for consumer-oriented care, and cost control, but we would be making an explicit public decision, at some point or another, to let some people do without medical care.

Recently the Arizona state government restricted transplant coverage for Medicaid patients, but it remains to be seen whether such measures can be applied to Medicare recipients. President Obama already has reversed some of the planned, budget-saving cuts to Medicare.

An entirely different approach is suggested by the system in Singapore, where the government requires savings (say 10 percent to 12 percent of income), patients pay for medical care from those savings, and the government takes care of additional catastrophic expenses. That system has a good record for cost control and access, but would Americans accept so much required saving?

The default course is to maintain or extend Medicare reimbursement rates, raise taxes considerably and accept that Medicaid recipients will face worsening health care access. If you hear of a new solution to the health care puzzle, put aside the politics and instead think through the endgame. Ask not about the rhetoric, but rather about the reimbursement rates.

Here is a good post on Medicare reimbursement rates.  Ezra Klein recently had a good post on how the coexistence of private insurance and Medicare messes around with both, but I cannot find it through Google; please leave the link if you know it (update: link is here).

One general problem is that Medicaid is crushing state budgets, but diminishing Medicaid -- overall the cheapest form of coverage currently available -- would likely impose greater health care costs on some other part of the system.  One big question, which I did not have space to consider, is whether cheap private insurance could be much better in the absence of coverage mandates.

Addendum: Arnold Kling comments.