Matthew Yglesias: Kleiman on Hunger and Malnutrition

Kleiman on Hunger and Malnutrition

Read Mark Kleiman's excellent post on malnutrition, obesity, and poverty. We've come to learn two very interesting things over the past few decades. One is that (coming very close to) eliminating actual inability to acquire food does not (come very close to) eliminating malnutrition. The other is that health care, in the sense of doctors providing medical treatment to sick people, does rather less to promote health (some combination of long-livedness and physical ability at any given age) than do other things. Getting people to eat better (and exercise more) are two of the key challenges of the coming age, though Radley will throw a fit if you try and do anything about it.

My one quibble with Mark's analysis is that just as you should never be too sure that spending more money on health care is the most cost-effective way to make people healthier, you also shouldn't be quick to assume that making people healthier is going to reduce health care costs. The relative insensitivity of health outcomes to health care expenditures is a two-way street. If it was possible to develop a set of lifestyle choices (diet, execise, drug consumption, etc.) that was so healthy as to allow everyone to live forever without getting sick, then this would, of course, reduce health care costs. As things are, however, everyone (who doesn't die violently, or in accidents or natural disasters) gets sick and eventually dies, with the full set of related costs. At best, improving health shifts health care costs into the future, making things temporarily cheaper. In the long term, the bills come due no matter what. Death & taxes and all that.

January 9, 2005 | Permalink

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Tracked on Jan 10, 2005 11:00:34 AM

Tracked on Jan 10, 2005 11:02:32 AM

Comments

You pose an interesting question: does dying at a later age consume as many resources as is currently the case? I think it depends on whether the causes of death are similar. Having a big stroke at ninety is less costly than spending seven years on dialysis, or with emphysema, for example. My uninformed guess is that alot of the diseases that would be reduced by exercise and better nutrition (diabetes and emphysema for examples) would not just be pushed down the road but would be reduced in frequency as well.

Posted by: QuietStorm | Jan 9, 2005 1:16:21 PM

At best, improving health shifts health care costs into the future, making things temporarily cheaper. In the long term, the bills come due no matter what. Death & taxes and all that.

Right. It's not inconceivable that some day we could effectively stop the ability of cancer, heart disease, diabetes and alzheimers to kill people. But we won't necessarily do this by coming up with vaccines. We might perfect artificial hearts, say, or grow natural, replacement models available for people when the ones they're born with are ready to give out. In doing so we'll enable people to live a lot longer. But it'll be expensive. I'm not sure what the leading cause of death might be for the over 130 crowd in the year 2092 -- some type of final cellular exhaustion. But I doubt they'll just drop dead. They may well need a lot of care for the last 40 years of their lives, and that, too, will be expesive. Perhaps people in the year 2114 will be talking about the "assisted living crisis" in the same manner we talk about the "healthcare crisis".

Posted by: P.B. Almeida | Jan 9, 2005 1:18:18 PM

"you also shouldn't be quick to assume that making people healthier is going to reduce health care costs."

I don't think that's right, Matt. All else equal, delaying the onset of health problems reduces health costs, just as delaying the age of childbearing reduces population growth. I'm not sure whether all else is equal, but it's certainly a reasonable assumption.

The bigger issue is Radley's. There's a categorical difference between getting people to change their eating and exercise habits and paying for medical care. You don't need to be a libertarian to insist on making your own choices about eating, exercise, smoking, etc.

Posted by: AF | Jan 9, 2005 2:03:56 PM

Come to think of it, while healthier living probably does reduce health care costs, it isn't necessarily a net fiscal positive. Why? Because healthier living leads to longer lives which increases Social Security costs. There are actually a lot of studies on this, regarding smoking. When you take into account the Social Security savings from the premature deaths of smokers, the negative fiscal impact of smoking is greatly reduced; some studies even find a positive impact.

These studies haven't been of much political use to the tobacco industry, however; they have had the good sense not to argue that smoking saves money by killing people.

Posted by: AF | Jan 9, 2005 2:15:13 PM

The real problem is that most health expenditures happen in either (1) the last 6 months of life, when organ systems are breaking down, or (2) warehousing Alzheimers' victims. #2 is actually MORE likely to happen to people who take good care of themselves (they don't die of something else first). Good health practices enhance the likelihood of a good quality of life, but don't do anything about either of these situations. At some point our health care system is going to have to face these two issues, and it isn't going to be pretty.

Posted by: Rebecca Allen, PhD | Jan 9, 2005 2:15:16 PM

I love the recent studies showing a perfect correlation between the fall in smoking and the rise in obesity...

Posted by: Petey | Jan 9, 2005 2:17:02 PM

I think Radley's problem is with trying to force people to change, not trying to do something about it. Hence, his support for allowing insurance companies to charge different amounts based on things like being overweight.

Posted by: Maestro | Jan 9, 2005 2:52:30 PM

Everyone on this blog, including Matt, seems to always assume that Alzheimers and related forms of Dementia are inevitables, barring death by other causes. Having known plenty of people who passed on in their 90s and even 100s without said ailments, I'm curious what this assumption is based on. I'm thinking a very healthy, ancient person is most likeley to die of simple heart failure (from weakness, not clogging) or pneumonia.

And in this
As things are, however, everyone (who doesn't die violently, or in accidents or natural disasters) gets sick and eventually dies, with the full set of related costs.
I'm really not sure what you mean by full set? It really seems to depend on circumstances

I live for time T, and hc(t) are my health costs as a function of my age, in, say, real dollars, the sum total of my health care expenditures is the integral of hc(t) from 0 to T. if hc(t) stays low for most of that time for a high value of T and then spikes very sharply at the very end, it's still possible that the full integral (area under this function) will be less than a high hc(t) integrated over a medium or low sized T. So we really need to see some numbers. . .

Posted by: Saheli | Jan 9, 2005 4:55:59 PM

Me & the monsters just walked four miles, burning off exactly 421.5 Kcals, says my belt pedometer. I am having a brain explosion involving charging people a dollar a mile to walk huge tread/waterwheels solving our fiscal, energy, and health crises simultaneously.

I said it first.

Posted by: bob mcmanus | Jan 9, 2005 5:00:25 PM

I don't have a cite at my fingertips, but I have often heard that the really heavy users of the health care system are not the extreme elderly--who tend to exit fairly quickly once the curtain starts to fall--but those in their 50s who need exotic treatments to respond to problems that are often lifestyle related. Part of this may be definitional--whether warehousing Alzheimer's is "health care" or something else.

Posted by: Buce | Jan 9, 2005 5:25:06 PM

From here:

One out of every 10 persons 65 years and older is a victim of Alzheimer s disease, though some are in their 40s and 50s. Approximately 20 percent of Americans between the ages of 75 and 84, and almost half of those 85 years and older suffer from Alzheimer s disease.

However this reference is one citation supporting the notion that we can't be sure that future cohorts will suffer from the disease at the same rate, because:

"Some epidemiological studies have found a link between people taking statin drugs to lower blood cholesterol and a lower incidence of Alzheimer's. Statins work by inhibiting an enzyme involved in cholesterol production, and currently are being tested in clinical trials for their possible effects in slowing the progression of Alzheimer's."

This is one example that might suggest that past experience (leading to the conclusion that medical intervention makes less difference than lifestyle changes) may not be entirely predictive of the future.

Posted by: cafl | Jan 9, 2005 5:54:35 PM

"I don't think that's right, Matt. All else equal, delaying the onset of health problems reduces health costs, just as delaying the age of childbearing reduces population growth. I'm not sure whether all else is equal, but it's certainly a reasonable assumption."

I admit to knowing nothing about the health care costs of people with poor diets who don't exercise vs the health care costs of those with great diets and who exercise regularly, but I do know that the health care costs of smokers vs the health care costs of non-smokers is roughly equal, given the fact that smokers don't live as long, and therefore don't spend years in nursing homes, etc.

Posted by: Green Dem | Jan 9, 2005 7:13:31 PM

"I love the recent studies showing a perfect correlation between the fall in smoking and the rise in obesity..."

Isn't it perfectly obvious that we should all be snorting more coke?

Posted by: Green Dem | Jan 9, 2005 7:15:43 PM

"Isn't it perfectly obvious that we should all be snorting more coke?"

Meth keeps me even skinnier. And boy, howdy, is my house ever clean!

But Bolivian Marching Powder jokes aside, I've never understood why the involuntarily obese don't try the time-tested and civilized solution of converting to a cigarettes and coffee diet.

Not only does it work, but it makes you smarter too.

Posted by: Petey | Jan 9, 2005 7:32:56 PM

"Not only does it work, but it makes you smarter too."

Indeed, as does speed, and more charming to boot (at least for the first 48 hours or so.)

Posted by: Green Dem | Jan 9, 2005 7:47:04 PM

"Indeed, as does speed, and more charming to boot (at least for the first 48 hours or so.)"

What makes cigarettes and coffee the civilized solution is that it's sustainable indefinitely.

Posted by: Petey | Jan 9, 2005 7:55:49 PM

Thanks Cafl. Well, that's a lot more than I thought, but still not most. Of course the every persons is in America. How much of this is based on current American demographics? Alzheimers certainly has a genetic correlation, and may very well have an ethnic correlation. How much will that change with changing demographics?

Part of this may be definitional--whether warehousing Alzheimer's is "health care" or something else.

Yeah, I think Bruce has a particularly good point. The whole economy and psychology of how we deal with the elderly is a little odd. I mean, I don't see what's wrong with the oldfashioned model of retired grandparents still pitching in economically by looking after grandchildren while parents work, and very elderly relatives being looked after by the whole extended family instead of being warehouse and outsourced out. I think our current social system has to be more expensive and inefficient.

Posted by: Saheli | Jan 9, 2005 8:15:08 PM

" I don't see what's wrong with the oldfashioned model of retired grandparents still pitching in economically by looking after grandchildren while parents work, and very elderly relatives being looked after by the whole extended family instead of being warehouse and outsourced out. I think our current social system has to be more expensive and inefficient."

Agreed, and I think we're likely to see the return of more multi-generational households, and chosen (non-blood related, that is) families living together as economic realities mandate it.

Posted by: Green Democrat | Jan 9, 2005 8:37:34 PM

"What makes cigarettes and coffee the civilized solution is that it's sustainable indefinitely."

Or at least until you drop dead of lung cancer or a heart attack, although from purely an esthetic point of view bad teeth are preferable to bad skin (which always seems to come about with semi-regular speed use), not to mention the temporary psychosis, which is usually unattractive (unless one finds that kind of thing sexy.)

Posted by: Green Dem | Jan 9, 2005 10:24:42 PM

Saheli is quite correct about his integrals.

Another way to look at it is to consider the health costs of staying alive as interest on the cost of the terminal disease. If it's less than market rates we come out ahead by keeping people alive. Otherwise we don't.

Posted by: Bernard Yomtov | Jan 9, 2005 10:45:08 PM

Hee hee, Bernard, I find it amusing that it's very likely people will find your clever but nonvisual way of phrasing it to be more intuitive than my ploddy, visual way. Wish everyone would take a little more calculus.

BTW, if by "his integrals" you mean, "Saheli's integrals" I must inform you that I am a she. :-)

Posted by: Saheli | Jan 10, 2005 3:53:21 AM

I completely disagree with the assumption that changes in eating habits and exercise are cheaper than health care. People enjoy eating unhealthy food and being lazy. Changing those habits would be very costly in terms of utility even if the monetary cost is very low. That's another reason why it's so important to avoid government regulation in this area. Government beaurocrats may be able to design a diet that is efficient in terms of production cost and nutritional value, but I have no faith in their ability to consider the individual tastes of consumers.

Posted by: Xavier | Jan 10, 2005 4:00:18 AM

xavier writes: People enjoy eating unhealthy food and being lazy.

You are assuming that people act so as to maximize their happiness (or enjoyment). Speaking as a lazy person who eats too much junk food, I don't think that's completely correct. I often make choices that don't optimize my own happiness or enjoyment.

When a person chooses to do X rather than Y it isn't because X leads to a better (more enjoyable, happier, or whatever) outcome than Y. It is that his anticipation of X is more comfortable or pleasurable than his anticipation of Y. Anticipations aren't necessarily accurate.

Overcoming laziness is like climbing a hill to get to a much better spot on the other side of the hill. The climb itself may not be pleasurable, but the result can be.

Posted by: Daryl McCullough | Jan 10, 2005 11:00:18 AM

I am a hemodialysis nurse working in a hospital and I can tell you that it's true that most of our health care dollars are spent on people in their last 6 mths of life. Many of our patients are in their 80s or 90s and some probably lived very healthy lifestyles. Once they start to go downhill as long as they or their family wants it they get the works. Operations, hemodialysis, ICU stays, expensive tests, usually to no avail. And lets face it very few people family or patients refuse this. I often do hemodialysis on patients who don't know whats going on. Also the largest factor in how long you live a healthy life is genetics. How else can you explain one person with a pretty normal lifestyle with a heartattack in his 40s and another with same lifestyle in his 90s. Remember Jim Fixx the marathon runner? He died at 52. This is not to say we shouldn't try to practice healthy lifestyles, but they aren't everything. Nuff said.

Posted by: Van Lynch | Jan 11, 2005 10:40:34 AM

We ARE throwing money at health care.

Most countries spend far less on health care and get similar to better results, i.e. equal or longer life spans.

Lowly Costa Rica spends a fraction (a smaller portion of their much smaller GDP) and Costa Ricans have almost the same life span as we do. Obviously, our health care delivery system is strictly from hunger. In my city, you watch the behemoths (hospitals) rapidly expanding their facilities while almost nobody (but the dying) spends the night in hospitals anymore. Empty beds, ho! And the cost of maintaining those beds and all that brick and mortar gets passed aroound to everyone's bills.

Medicare is a health provider welfare scheme.

Posted by: Jeffrey Davis | Jan 11, 2005 2:49:01 PM

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