Archive for July, 2011

Randomized Medicaid. Also, working papers

Karen Grepin gives some background:

“Back in 2008, Oregon had a long waiting list of low-income adults wanting to enroll in its state Medicaid program. Given severely constrained resources it was not able to provide insurance to everyone who wanted it, so it decided to allocate eligibility to enroll into the program by lottery – it randomly assigned insurance eligibility – creating one of the most incredible opportunities to study the impact of health insurance. Period.”

This study is the talk of the town amongst health / economics / research methodology wonks: here’s some other commentary by Ezra Klein, David McKenzie of the World Bank, and William Savedoff of CGD.

One outstanding question to me is how on earth the Medicaid lottery happened in the first place. Yes, it was an environment of limited resources, which explains not making health insurance available to everyone who needed it in this particular timeframe. But why not choose to give the insurance to the poorest, oldest, sickest, etc? Did the officials who made that decision not have data to make such decisions? Did they think it would be less ethical? Did they think it would be more expensive to put the neediest (and most likely to use the service) on Medicaid? Did they anticipate the evidentiary value of their decision? I’m guessing it’s some combination of the above, but I want to learn more.

A side note on working papers: all this talk is about a working paper (available here), which reminds me of Berk Özler’s recent post on the World Bank’s consistently excellent Development Impact blog criticizing the system of economics working papers. Özler cites as an example his own experience with a working paper on the role of conditionalities in cash transfer programs:

“Our findings in the March 2010 [working paper] suggested that CCTs that had regular school attendance as a requirement to receive cash transfers did NOT improve school enrollment over and above cash transfers with no strings attached. Our findings in the December 2010 version DID…. However, the earlier (and erroneous) finding that conditions did not improve schooling outcomes was news enough that it stuck. Many people, including good researchers, colleagues at the Bank, bloggers, policymakers, think that UCTs are as effective as CCTs in reducing dropout rates – at least in Malawi.”

Ouch. This hits home in part because I remember reading that original working paper as part of a literature review for a grad school project on health impacts of conditional cash transfers (in which we designed a hypothetical community-based cluster-randomized trial in Bangladesh). I disseminated those results — in part because they were counterintuitive — to more than a few of my peers, but I didn’t realize Özler had reversed his findings. If nothing else, we should take working papers that have not been through the full peer-review process with a large grain of salt.


07 2011

Equality in NY

I had this post saved as a draft for the last week or so — oops:


It’s a great summer to be in New York City. I was watching the news on same sex marriage pretty closely, and as soon as the religious exemptions amendment passed — signalling that passage of the bill itself was just a matter of time — bloggers started noting that crowds were gathering in front of the Stonewall Inn in Greenwich Village. I live about a mile east of there in the East Village, so I headed out immediately to be there at the historic moment.

This may come as a surprise for gay rights advocates — or for pretty much anyone who didn’t go to an extremely conservative university — but I hadn’t heard of the Stonewall Riots until a year or two ago. The Stonewall has been on my long list of historical sights to see in New York but I hadn’t been there yet, and what better time to visit than on this historic occasion?

Sure enough, there was a big crowd gathered and quite a few media outlets on hand. I snapped this shot of an endearing older couple being interviewed:

And here are two NYPD officers doing crowd control, chatting amiably with the celebrants:

While the pace of change can often seem glacial for those eagerly advocating (as they rightly should) for justice now, it struck me that on a grander scale this progress has come impressively fast. Just a little over 40 years ago — half a lifetime — the police were systematically oppressing and raiding the few gay establishments in New York. Their actions were hardly inconsistent with popular will either, as there really was no gay rights movement yet. And now, in 2011, there the officers were, guarding a peaceful and spontaneous celebration by New Yorkers — male and female, gay and straight — of marriage equality, something that was probably inconceivable to the Stonewall rioters. Yes, the law is not yet perfect and we still have far to go, but for that night it felt right to pause and reflect on just how far we’ve come.


07 2011

A few updates

Hopkins: In May I finished final exams for my 4th quarter at Johns Hopkins. That means I’m done with the required four quarters (one year) of coursework towards the MSPH in International Health “Global Disease Epidemiology and Control” (GDEC) track. Looking back I realize that I’ve learned an incredible amount this year. At some point I hope to write a bit more about the Hopkins experience and major themes in our GDEC coursework, especially for the prospective students who I see end up here through Google searches.

The quarter system has pros and cons: it moves fast, which can burn students out by the third or fourth term, but you’re also able to shovel a huge dose of knowledge into your brain in a short period of time, leaving the second year of the Masters program more open-ended in comparison to other programs. One reason I chose the MSPH at Hopkins is that flexibility in the second year: you can return and take additional classes after your practicum, or you can spend the entire second year working abroad gaining additional field experience. That flexibility is nice, especially since I’m hoping to work abroad after completing my graduate education and most of my experience in the developing world has been for short periods of time.

In early June I took the comprehensive exams for the MSPH (and hopefully passed!). That means the only requirements I have remaining are a practicum — 4+ months doing work in international health using the skills I’ve acquired — and a Masters paper/thesis based on that practicum. My original plan was to move abroad for a year-long practicum in September, possibly in Nepal, and be done with the MSPH in May of 2012, but that’s changed a bit.

New York: This summer I’m part of the New York City Department of Health’s Epi Scholars program. Epi Scholars is a training program that pairs graduate students in epidemiology with researcher mentors in the Department of Health. It’s been great so far and I plan to write more about the Department, the training experience, and my particular project — an in-depth review and analysis of severe lead poisoning cases in New York City in the last 5-10 years. The Epi Scholars program is in its fifth year and has its largest class to date (11 participants this year) so it’s been great getting to know the other students as well.

Princeton: This fall I’ll be starting work on a Masters of Public Affairs (MPA) at Princeton’s Woodrow Wilson School. I’ll be doing the Field IV (Economics and Public Policy) concentration at WWS to get their most rigorous training in economics, but I imagine I’ll take a number of courses from the Field III (Development Studies) concentration as well. While Hopkins and Princeton don’t have an official joint degree program, I’ve been able to make arrangements to complete both Masters degrees in a total of three years. The right people at both schools have been incredibly supportive of this idea and have helped me work out the details. My timeline will be something like this:

  • August 2010 – May 2011 – coursework at Johns Hopkins in Baltimore, MD done!
  • June – August 2011 – summer internship (NYC Dept of Health Epi Scholars Program) in New York, NY (in progress)
  • August 2011 – May 2012 – coursework at the Woodrow Wilson School in Princeton, NJ
  • June – December 2012 – practicum work abroad (including writing my Masters thesis for Hopkins), location TBA
  • January – May 2013 – back at Princeton for a final semester

The Woodrow Wilson School also gives students the option of taking a “middle year out” if their summer internship is going well or leads naturally to a full-time job. If I went that route I might not finish the MPA until May 2014, but I’d have significantly more work experience when I finally get back on the job market.

I decided to pursue the dual degree as I realized more and more that my interests — and the work I want to be prepared to do — lie at the intersection of global health and economics. I’m interested in the traditional ‘applied epidemiology’ of studying public health interventions, as well as how those methods are increasingly being used to evaluate development interventions outside of health programs. (Aside: fascinatingly, a recurring critique this year of the development economists conducting RCTs from my public health professors has been that they are much, much too concerned with randomization.) I’m interested in cost-effectiveness evaluations of health and other interventions, and how politics and evidence from various disciplines — from epidemiology to economics — get used and misused to make health and development policy.

I’ll wrap up the Epi Scholars program here in New York in August in order to move to Princeton by August 20 to start “Math Camp” — a three week crash course in math and economics to get us all up to speed before real classes start. I’ve already started to meet some of my incoming WWS classmates as they pass through NYC and I think it will be an amazing experience.


07 2011

The next step in tobacco control?

From The Guardian:

Iceland is considering banning the sale of cigarettes and making them a prescription-only product.

The parliament in Reykjavik is to debate a proposal that would outlaw the sale of cigarettes in normal shops. Only pharmacies would be allowed to dispense them – initially to those aged 20 and up, and eventually only to those with a valid medical certificate.

The radical initiative is part of a 10-year plan that also aims to ban smoking in all public places, including pavements and parks, and in cars where children are present. Iceland also wants to follow Australia’s lead by forcing tobacco manufacturers to sell cigarettes in plain, brown packaging plastered with health warnings rather than branding.

Under the mooted law, doctors will be encouraged to help addicts kick the habit with treatments and education programmes. If these do not work, they may prescribe cigarettes.

I’ll hazard a guess that this approach would not be popular in the United States.


07 2011