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Archive for March, 2010

Initially when I set out to respond to two posts skeptical of “sin taxes” at the League of Ordinary Gentlemen I planned to make a public health case involving herd immunity, drawing as a comparison the social consequences of the liberty of not being vaccinated – failing to tackle excessive drinking amounts to failure to reach the necessary levels of vaccination to secure herd immunity with similar harmful social effects. Luckily, I don’t have to make that case, a study in the Lancet (gated, pdf) addresses several of the questions concerned far more directly: “Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model” (by Robin C. Purshouse, Petra S. Meier, Alan Brennan, Karl B. Taylor, and Rachid Rafa, published March 24, 2010).

Before diving into the Lancet study, I need to explain the scare quotes around “sin tax”. Proposed taxes on alcohol have a public health purpose. Taxing alcohol, or cigarettes, or high fructose corn syrup, isn’t about moralizing. It is about liver damage, lung cancer, and obesity. That is to say, epidemiologists are not claiming to be holier than thou. Were a safe version of alcohol to be invented tomorrow, an alcohol without the adverse effects (impaired motor skills, heart disease, etc.), I would wholly accept that this alcohol mark two would not be subject to these harm taxes any more than bicycles and rocking chairs would be. In sum, the taxes are linked to the public health consequences of these products, not some sort of inherent evil in the product itself. Thus this class of taxes should not be categorized as analogous to prohibitionist efforts to stop Demon Rum. (The comments over at LOG had much discussion of capturing externalities of alcohol use and abuse, but rarely was the case discussed in explicit public health terms.)

On to the study in the Lancet: What are the public health consequences of a variety of government interventions in the sale of alcohol in England? The interventions the researchers modeled are “across-the-board price increases, policies setting a minimum price per unit (eg, a unit of alcohol, 10 mL ethanol, cannot be sold for less than £0.40), and policies restricting price-based promotions in the off-trade sector (eg, banning buy-one-get-one-free offers).”

The researchers found that the minimum price per unit of alcohol is the most proportional method for achieving the public health goals (less disease and death due to excessive drinking) while not being excessively punitive towards the moderate drinker. Since responsible drinkers consume less cheap alcohol, the minimum price approach is easier on their wallets. Minimum prices are distinct from a general tax in that they focus on the cheap, high strength alcohol products; those products with prices above the minimum price face no extra levy. Setting a minimum price of £0.50 per unit of alcohol raises the moderate drinker’s annual alcohol costs by £11.80. The same minimum price raises the hazardous drinker’s annual expenditure by £68.20 and the harmful drinker’s annual expenditure by £163.40. (Moderate, hazardous, and harmful are defined by the number of units of alcohol ingested per week. p. 7) The average English drinker’s annual expenditure would be raised by £37.80.

What does an extra £3.07 a month for the average English drinker buy in terms of health outcomes (ten years after implementation)?

  • 2,930 fewer deaths per year
  • 8,100 fewer acute illnesses
  • 20,700 quality-adjusted life years gained
  • 40,900 fewer chronic illnesses
  • 92,200 fewer admissions to hospital
  • £274 million annual savings to the health service

I’ll close with an attempt to address Mark Thompson’s quality of life point. Thompson writes,

Now, if by “quality of life,” we all mean a particular thing – say a particular lifestyle, or the maximization of life span – this is not a real problem. Unfortunately, one’s idea of “quality of life” can vary tremendously from person to person and locale to locale. For instance, one can rationally – and correctly – conclude that the happiness brought about by the occasional overindulgence in alcohol or the daily glass of soda one drinks makes life worth living in a way that a marginal increase in life expectancy does not.

I draw on two sources for my reply. One source is the idea of intergenerational justice (or intergenerational equity). The other source is behavioral economics, particularly a recent discussion between Glenn Loury and Sendhil Mullainathan (the first 10 minutes especially, “Behavioral economics, as illustrated by the snooze button”). Loury defines behavioral economics as “a departure from the tradition in economics inquiry of assuming that people act in a fully rational way on behalf of their well defined interest. And taking seriously what has been learned about the way that human beings actually make their choices and govern their behavior. What has been learned in the allied sciences of psychology, human cognition, and so on.”

What stood out to me is the breaking apart of interests. Disaggregating interest from a single, “I seek X” to a view where interests are conflicting within a single individual; the idea of “quality of life” can vary within the same person. One interest can defeat another for a period only later to be reversed. Mullainathan highlights the snooze button on alarm clocks, the MIT Media Lab alarm clock, Clocky, that rolls off the table and hides so you have to get up to turn it off and the Japanese alarm clock cum helicopter that floats off for a similar reason. As Mullainathan puts it, instead of setting the alarm clock for when we actually want to get up, why a snooze button that results in ten minute chunks of fitful sleep? In sum, the snooze button illustrates the conflicts between self-control and (pre)commitment and various mechanisms that might be employed to bring ourselves back under control.

Now as a thought experiment* loosely based on intergenerational justice, suppose we took a single individual and broke them up into various ages. Around the table is you at twenty years old, thirty years old, forty years old and so on. The various generations of you have convened a conference to discuss your health behavior across your lifetime. On whom do they focus? What are they advising? And why do they advise it? I would suggest their focus is going to be on the age twenty and thirty versions of you, they’re advising all sorts of healthy courses of action, eat right, exercise, don’t drink to excess, don’t smoke – public service ads galore. They suggest this advice because your quality of life will likely be substantially better for many years under their guidance. These older versions of you are interested in your not pressing the snooze button for the extra ten minutes of fitful sleep only to arrive at work ten minutes late; in the health sphere the short term gains are even more fleeting and the long term penalties are even more harmful. (This line of reasoning is the way that I make sense of discussions of quality-adjusted life years and disease burdens as related to an individual case.)

In fact, you’d probably be outvoted by the decades older versions of you insisting on healthier choices for their/your future benefit. All this is to say that when the government taxes alcohol, tobacco, etc., the government is really gently nudging you towards your own wise counsel.

* Crooked Timber’s Harry Brighouse on the role of thought experiments in moral philosophy here.

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With the passage of healthcare reform the gods of capitalism are weeping bitter tears. American citizens are expected to collect their Mao suits from the government distribution centers Monday morning. So go the parade of horribles on healthcare reform (Gawker).

For liberals there are several things to be upset about, the United States being last of the developed nations to adopt a (semi-)coherent program for healthcare. The UK’s NHS was founded shortly after WWII, when the UK was still reeling from the consequences of a war that fundamentally endangered the nation. Although under postwar austerity measures, the UK was still able to comprehensively establish the major tenets of a welfare state. Just to underline how late to the party the US is, the NHS celebrated its 60th birthday during the course of the healthcare debate.

One of the key texts in the UK’s history of establishing a state that cared for all citizens is the Beveridge Report (pdf). The Report’s guiding principles specifically set aside incrementalism as inadequate. In the US various centrist and center-right commentators urged a slow approach to reform, little by little, they urged the left to adopt minor, supposedly more manageable fixes. Luckily for the tens of millions of uninsured in America, this incrementalist approach was rejected in favor of an attempt at comprehensive reform. Astonishingly, in the four years following World War II, 1945-1949, the Labour government created the foundations of the British welfare state. It has taken America more than 40 years to get its act together, in piecemeal fashion addressing poverty for the elderly, healthcare for the elderly and poor, and finally healthcare for (almost) all.

A final complaint before celebrating of the triumph of the proletariat begins – I imagine lots of cackling whilst government bureaucrats seize stethoscopes from America’s doctors (you know, seizing the means of production). The wrangling over abortion demonstrates that those concerned about reproductive rights still have a great deal of advocacy work to do. NARAL and NOW are rightly upset about the Obama-Stupak deal (WaPo). The culture wars roll on in yet another iteration.

So those complaints aside, probably not comprehensive enough, not timely in comparison to peer nations, and ceding important reproductive rights territory, the administration and Democrats have a great deal to be proud of. When Fox News and various conservative Republicans (NRO) are hyperventilating, I can’t help but smile. The BBC only carried a portion of House Minority Leader John Boehner’s speech. He was screaming and it was hilarious. I expect conservatives to be similarly undignified (and amusing) in the final phases of Senate reconciliation. If your opponent isn’t going to be dignified in defeat, does the victor still have to be magnanimous in victory? Obama’s speech last night answers yes, but free from the confines of statesmen, I can revel in the ridiculing of outlandish conservative claims.

In 1942 Beveridge called for “a comprehensive policy of social progress,” the tenets were in place in the UK by 1949. Though it has taken America until 2010 to take the final steps, the accomplishment is still worthy of praise.

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