Seven Survey Results Where Afghanistan Outperforms the USA

Fragility and Transparency

less than 1 minute read

Published: July 20, 2015

When the OECD released their 2015 Fragility Report I remember looking at the penta-Venn Diagram of the different states of fragility and wondering why Afghanistan was not fragile in institutions, which was supposed to capture corruption among other governance issues. This question eventually led to a Monkey Cage post on my attempt to replicate their measures of fragility.

The OECD responded in a comment to the initial posting pointing out some problems with my replication while admitting certain errors. However, after a revised replication that incorporates those edits, all up on Github, I still get very different results.

I look forward to seeing OECD’s 2016 report as they have discussed some interesting revisions to their measure of fragility. Hopefully along with substantive improvements they will also incorporate improve their methodology especially by way of transparency. As the OECD continues to work with this data in order to provide a public good, the greatest good will come from being as public as possible.

Freakonomics, Princeton Hospitals, and Healthcare Costs

5 minute read

Published: April 11, 2015

The latest Freakonomics episode, How Many Doctors Does It Take to Start a Healthcare Revolution, Jeffrey Brenner, executive director and founder of the Camden Coalition of Healthcare Providers, uses Princeton, NJ as an example of over active hospital financing. The Coalition is currently working JPAL on an RCT of an care management program targeting healthcare system “super-utilizers” identified by healthcare “hotspotting”.  From the transcript:

BRENNER: One of the problems is that we have a giant economic bubble underlying this where we have hospital financing authorities underpinning, that are run by states that help hospitals float bonds. And we have this giant bond market called the hospital bond market that’s considered very secure, very safe, good investment. And you know, that bond market has floated too much hospital capacity and created and brought online too many hospital beds, far more hospital beds than we need in America. So you know, the most dangerous thing in America is an empty hospital bed. In the center of New Jersey, near Princeton, a couple years ago, we built two brand-new hospitals. These are two $1 billion hospitals, 10 miles apart, very close to Princeton. So one is called Capital Health, and the other is Princeton Medical Center. I don’t remember anyone in New Jersey voting to build two brand-new hospitals. But we are all going to be paying for that the rest of our lives. We’ll pay for it in increased rates for health insurance. And, boy, you better worry if you go to one of those emergency rooms, because the chances of being admitted to the hospital when there are empty beds upstairs that they need to fill are going to be much, much higher than when all the beds are full–whether there’s medical necessity or you need it or not. So I’d be very worried if you live in Princeton that there are now two $1 billion hospitals waiting to be filled by you.

The RCT is fascinating, but also interested me since I spent two years volunteering with Princeton First Aid and Rescue on the ambulance taking patients to the $520 million Princeton Medical Center, opened in 2012.¹

I do not recall taking anyone to the Capital Health Medical Center - Hopewell, opened in 2011, but Capital Health Regional Medical Center in Trenton was our go to trauma center.  To get an idea of the layout, the map below shows the Regional Medical Center in red, the two new hospitals in green, and the old Princeton Medical Center in Orange.²

Map of past and current hospitals in the Princeton area.

The hospital construction was also brought up in a 2014 NYT article asking why a procedure in retired math professor was billed $5,435 at the Princeton medical center and $1,714 in Boston for the same procedure:

But that cost must cover some expenses in the United States not found in other medical systems. The area around Princeton has had a spate of new hospital building in the past five years. The University Medical Center of Princeton at Plainsboro, which has no connection to Princeton University, cost more than $500 million to build and has a curving atrium decorated with artwork from the hospital’s permanent collection. “It was like a luxurious museum,” Mr. Charlap said.

University Medical Center of Princeton at Plainsboro: curved for your health

I know little about health care finances and have no strong feelings about the hospital construction, which seems like it isn’t even the biggest factor in rising health care costs. I am happy to see that people are thinking about and questioning the status quo.

For my two cents, I felt that I transported many patients that did not really need an emergency room, not out of any financial interest but because of protocols.  If a patient wanted to go to the hospital, I wasn’t qualified to refuse him or her by judging the trip unnecessary. Similarly, if a patient did not want to go to the hospital, they can deemed unqualified to refuse for a number of reasons including alcohol use. Often is seemed someone was of sound mind even after a couple drinks, but when there are liability concerns why risk releasing a not sober but medically sound student who could then turn around and sue you when he later electrocutes himself on the Dinky, Princeton’s iconoclastic rail car? The rules of when to transport is probably a relatively small factor in the larger world of health care costs, but from my view in the back of the ambulance it would also be worth a rigorous evaluation.

FOOTNOTES:

Ebola and Conflict addendum: rainfall and HIV/AIDS

1 minute read

Published: February 13, 2015

In mid-November the international community was still seriously concerned about Ebola and its effects on West Africa. Some prominent figures even called Ebola a threat to international peace. My realist/cynical side figured the calls might simply be an attempt to raise awareness and aid, but I was intrigued by the question, has disease ever led to war?

In my Foreign Policy piece (USIP mirror) I examine the literature on how disease could directly or indirectly lead to war. The short answer is that disease does not lead to war, but depending on the exact effect of an epidemic and government’s response, disease could lead to other forms of conflict.

Two sections were cut for the final version of the article. First, we cut out the research on whether economic shocks lead to conflict using rainfall as an instrumental variable. This growing body of literature launched by Miguel, Satyanath and Sergenti is fascinating, but trying to explain instrumental variables proved unwieldy in such a compact article.

The other section was a quick data probe inspired by a report by the US Institute of Peace from 2001 that discussed how HIV/AIDS could lead to conflict in Sub-Saharan Africa. I pulled UNAIDS figures on the national prevelance of HIV/AIDS in 2001 and UCDP/PRIO data on whether a country experienced civil war in from 2002 to 2012. Dividing the countries up into quartiles based on the prvalence of HIV/AIDS gives the following figure:

If HIV/AIDS increased the possibility of conflict, we would expect that those with the highest rates of HIV/AIDS would be the most likely to experience conflict. However, I find that those countries with the highest prevalence of HIV/AIDS in 2001 also were the least likely to experience a conflict in the 10 years after. While not particularly rigorous or scientific, this simple data exercise challenges some assumptions and raises some questions.

1 minute read