School Lunches: The only place where a tater tot is the equivalent of a green, leafy vegetable

School lunches have never had a good reputation. Decrypting the true identity of "mystery meat", eating applesauce that is more reminiscent of paste than apples, or chewing green beans that have a questionably squishy texture... complaining about school lunches is a rite of passage for a lot of people. However, the complaint at this point in time isn't about texture or taste-- it's about nutritional content and the obesity epidemic that is occurring in the youngest populations.

Congress has been asked to make legislation that improves the quality of food that school children eat to make it more nutritious. Foods like pizza, french fries, and chicken nuggets appear regularly on school lunch menus and comprise a large part of the average American child's diet. This is problematic as these foods are correlated with higher body mass indexes (BMI)--which is also correlated with health problems in childhood, as well as in their later adult years. Cost has been the primary barrier to providing more healthful food--as it costs more to provide healthy foods than it does to provide less healthy foods (EX: fresh vegetables cost more than tater tots). Also- special interest groups (namely potato and salt industry) have a vested interest in making sure kids continue to eat their current school lunches which are often very high in white potatoes, white flour, and sugar (think: flavored milk). As of now, Congress has backed down on improving the quality of school lunches--and is remaining with the status quo.

The question is-- is this within the realm of what Congress should be doing? (Not that Congress always spends it's time on worthy things-- I remember them getting involved in some of the business with the baseball players who used steroids, and then lied about their usage...just saying). If the answer is yes-- then I think Congress should re-visit the cost-benefit analysis here.

What is the monetary benefit of improving the quality of school lunches? I'm not sure it's possible to determine how school lunches directly effect childhood obesity, but common sense tells me, if a child receives zero healthy meals per day, giving them 1 healthy meal per day at school would be an improvement. Also- this would expose them to healthy foods, which they may discover are actually pretty tasty--thus increasing the likelihood that the child will request mom or dad purchase these types of foods in the future.

Even if having more healthy foods results in very little weight loss in overweight or obese children-- it would still be a WIN on a population level. Imagine all children are on a standard deviation curve where the heaviest are in the right tail and the lowest weight children are in the left tail. If we shift those children in the right tail down the curve 1-2 pounds worth-- that results in less children in the overweight/ obese category (where there are well-known health risks that are very costly). Not having those kids suffer with the chronic conditions that occur due to excessive weight would obviously be good for the kids themselves--but would also be good for society from a cost perspective (and the reward would keep giving overtime--since overweight kids with health problems often turn into overweight adults with even more health problems).

In sum- it would be useful to know the relationship (or elasticity, in Economics-speak),between dollars spent on increasing healthy food for school lunches, and the percent reduction in children above the 85th BMI percentile (IE: the kids who are overweight or obese, by CDC standards). What an awesome experiment this would make! Obviously there would be lots of measurement challenges, and like any observational study, the results would show correlation-- not causation (if they show anything at all)... but it would still be a useful piece of information for Congress, schools, and the food industry to have.

Until then, if you have the resources, brown-bag lunches are looking like a pretty good option!

No cost birth control

An expert panel for the Institute of Medicine has recommended a number of medical services be given at no cost-- one of which is birth control. This raised concern (outrage?) in the pro-life and Catholic communities. Women's right's groups are ecstatic.

What we do know is that about half of all pregnancies are unintended. Women who do not want to be pregnant are less likely to get proper prenatal care and are more likely to have complications later on (low birth weight, delayed development/ development problems). So, we can deduce that for some women who do not want to be pregnant, it can have a distinctly negative impact on the resulting child.

Many women choose not to use birth control due to cost. By the law of demand, lowering the cost (to zero) of birth control more women can afford to take birth control-- thus we can reduce the number of unplanned pregnancies (and unhealthy pregnancies/ births).

Cost-Effectiveness of Meningitis Vaccine

Generally preventative medicines have a good shot at being cost-effective. They prevent hospitalizations, medical/ surgical procedures, additional medicines, etc. The trade-off is that vaccines need to be given to everyone who can get the vaccine for it to be effective. Like the flu vaccine ads say,"don't get it for you-- get it for ___ (insert name here)___" highlighting how getting a vaccine not only protects the person who gets it-- but also the all of the people who that person comes in comes in contact with.

What we don't want to see is the resources a vaccines saves in illness care for the small number of people who are infected, get made up for in the quantity of people having to get the vaccine (albeit, the vaccine is much less expensive than the medical treatment treating the disease). This is the case when the vaccine is very expensive and the disease the immunization protects against is relatively rare.

As a recent NPR piece highlighted, the bacterial meningitis may be in the position discussed. At first the vaccine was only given once and cost $100. Now ACIP (Advistory Committee on Immunization Practices) is recommending a booster-- which raises the cost to $189. NPR states that this would cost the government $387 million annually. All of this is estimated to prevent only 23 deaths per year. Is that okay? If all 23 deaths were people covered by government health care-- that would be more than $16 million per life saved. If you included what other non-government entities were spending on the vaccine- the cost would be even higher--since there are still only 23 deaths per year. Is that an acceptable amount to pay to save a life given the fact that there are budgetary constraints?

From the article:

....experts can't solve the fundamental problem of how to put a dollar value on preventing death or disease, says Mark Pauly, a health economist at the University of Pennsylvania.

"You do have a rough idea that if it's $1.98 per life saved that sounds like a good thing to do and if it's $198 million per life saved, that sounds like not a good thing to do," he says. "But where to draw the line is the part that any sensible person will run away screaming from trying to answer that question."

Excess spending on end of life care

Chris sent me this article- and it was pretty interesting!

This describes a problem well-known to those who know anything about health care expenditures. I remember a vague statistic from my Health Economics course-- it was something like a third of all personal health care expenditures are spent at the end of life, on average (don't quote me on that). While it may not be a third, I think we can safely say it's a disproportionate amount of money...

Given that I have a degree in the dismal science, I'm about to get all dismal on you-- but just think about this without thinking about the morbidity of it:

When you think about how you want to die, you probably don't envision your death dragging out over months and months while you whither away. However, by spending ourselves into the ground (or under it?) we do just that-- we pay for treatments that keep us alive for a marginal amount of time while we suffer.

As you're probably already thinking-- this is pretty tricky. Ideally you would know which disease would be your final, and you would know not to pursue any additional treatments that would prove to be fruitless-- as they would only drag out your suffering (which, it is assumed, is not your goal). Anyway- you would know to just stop, and enjoy your time on Earth doing the things you like to do and spending time with the people you love.

As far as spending goes-- yes, we'd like to reduce end-of-life expenditures (we'd like to reduce all types of expenditures really)... but the problem is that you never know when the "end" really is. This really just adds fuel to the cost-effectiveness fire- and makes it even more of an important and critical type of research. If we're not wasting time or resources of treatments that are just not effective or worth spending money on, we can theoretically give the best reasonable care, while still being fiscally responsible.

C-sections galore!

NPR ran a story on the air today describing the increased rates of Caesarean section births in developing nations. It is relatively well-known that C-sections have increased in popularity in developed countries like the US due to their convenience (working moms can schedule the C-section and plan maternity leave more easily, avoid the pain associated with a vaginal birth, retain bladder control by preserving the pelvic floor, rates of inducing births have increased which can cause the need for a C-section birth, etc.) Now we're starting to see this trend in developing countries as well-- but this is causing something of a problem.

Now that more women are opting into C-sections they're taking up more space in operating rooms that were once used only for women who truly needed them for medical reasons. The concern that arises now is whether wealthier women who can afford to pay for an elective C-section are taking operating room space away from women (poor or wealthy) who really need it.

Obviously this also starts raising questions about cost-effectiveness.... why are we paying for unnecessary medical procedures? I wouldn't say that a C-section is unnecessary if a women just prefers it (she should be able to obtain it if she's willing to pay for it and understands the risks involved...not that she's bearing the full cost of the procedure at all due to insurance--but that's a different conversation altogether), but I would say that it's unnecessary if the woman has been unnecessarily pushed into a C-section either due to convenience or revenue considerations coming from the hospital. C-sections are revenue makers. They generate twice as much revenue as a vaginal delivery.

It seems that we're getting a little heavy-handed with the C-Section ordering pen, but are we really considering the Economic implications? With such a great deal of geographic variation in C-section births, it's hard to make the argument that C-sections are needed at the high rates seen in some hospital systems. These C-sections are coming at a much greater cost than the vaginal deliveries, and also are more risky, and result in more readmissions--and in some cases lock women into delivering via C-section for subsequent children. All of these factors add up to much larger expenses in the end. It may be time to re-examine what determines the need for a C-section, and what does not, so that we can avoid unnecessary surgical procedures.

Also of interest