Riders for Specific Procedures

Health insurance in the United States is shaped by many mandates . An interesting issue has arisen with respect to the debate over how abortion should be handled in health care reform. Now, this post is not intended to take a position one way or the other on abortion.  I have one--but that is not the issue here. Rather, this post is to prompt some thinking about what people should be required to buy.


Why do insurance policies have riders in general? When I purchase car insurance, I can purchase extra insurance to pay for a rental car while my car is in the shop or go without that coverage. When I purchase home owners insurance, I can purchase extra coverage against sewage from the city's water line backing up into my house or remain at risk for such an event. It is my choice whether to accept the risk or purchase insurance.

At present, there is discussion of whether abortion should be offered as a rider on health insurance policies. In other words, make the basic policy not cover abortion. Make insurers offer coverage for abortion as an "add on". We could apply the same logic to other procedures, but abortion is the current topic of debate.

Is this fair? The argument that this is not fair goes something like this. This is already covered without a rider. Making it a rider would make women have to anticipate an unexpected event. This would take away coverage they have. The argument that this is fair would go something like this. If it is already in most plans, then women are already paying for it. The whole point of insurance is to purchase protection against unplanned events (I certainly don't plan to have a car accident or have city sewer water back up into my basement). If someone has strict views that would preclude them ever having a demand for an abortion why should they have to pay for that possibility. If some women want to remain at risk, that is their prerogative. People who want the coverage can still buy it. It is just that their premium will then reflect the risk that they pose--in terms of the probability of the event and the cost of the event.  Just like any rider is priced in any insurance market.

It would be difficult to do this for every service because we don't buy health insurance "by the service". Suppose someone says they will never get a colonoscopy? Suppose someone says they will never get any specific procedure? Could they price their insurance accordingly? Probably not. So, the idea of riders may be impractical to apply broadly (beyond the abortion issue), but riders for insurance coverage that are left to the choice of the individual are not so different from the way that other insurance markets operate.

A major company drops the copayment for primary care physician visits

The Wall Street Journal reported this week that IBM was dropping the copayment for primary care visits.  In other words, employees (and their insured family members) who had to pay $20 to go to a primary care physician now have to pay nothing.  The goal is to save costs.  What is the logic here?

Step 1: Decreasing the cost of primary care visits will lead to greater use of primary care providers.  In some ways this is a "no brainer".  Make something less costly and people will use more.  One question is whether they will use it well.  Another question is just how much more.  From a back of the envelope calculation approach, we can take one estimate of physician visit elasticity (by what percentage the quantity of something changes relative to the change in price).  A 100% decrease in price could result in a 20% increase in utilization. 

Step 2: What does the increase in utilization mean for IBM?  Well, it now has 20% more visits and it (or its insurer, although it is likely self-insured) is paying for the entire visit rather than the visit cost less $20.  So far, this means that the company (or the employees through premiums) are paying more--not less.

Step 3: What happens to the demand for ER care and hospitalizations?  We hope that those are substitutes for primary care--in other words when the price of primary care goes down the demand for ER care and hospital care goes down.  Technically, this is just trying to keep people out of the hospital by getting them better primary care.  Economically, the question is what is the "cross price elasticity of demand".  In other words, when we change the price of one service (primary care) how does it affect the demand for others.  So, it all depends on how good primary care is as a substitute for ER and hospitalization.  That will depend on the quality of the primary care provider and the decision by the patients to use primary care.

Step 4: Assess overall economic effects.  Once we know something about how good primary care is as a substitute for other forms of care, we can project whether IBM will save money or whether paying $20 extra for all the visits that were happening already plus the entire cost for each extra visit as demands change will simply be too expensive to offset with the hoped for avoided hospital and ER care.

Step 4:

The Value of Prevention

I got The Nation's Health in the mail yesterday.  This is APHA's newspaper that I think has been mentioned in my blog before.  I read with interest the cover page article titled "Value of prevention debated as part of the U.S. health reform"  (This is in the November issue which may not be online yet.)  The entire article is basically an argument for communicating about the value of spending on prevention rather than trying to promote prevention as cost-saving.  I have no problem whatsoever with that argument.  It is a reasonable argument to make.  There is plenty of evidence suggesting that prevention saves money at a population level in a limited number of cases--the prevention certainly saves money for the person for whom a disease or its progression is prevented but the prevention is applied to many people who will never get the disease or suffer from its progression.  However, many preventions are still cost-effective in some sense.  So why the fuss in the article and why might I find the presentation in this article to be of concern?

The first sentence of this article is "Prevention, a touchstone of public health, has landed in the crosshairs of the national health reform debate, with cost-effectiveness pitted against the sometimes incalculable value of a healthy life."  That is an interesting sentence.  I don't see the science of cost-effectiveness as being pitted against the value of  human life.  And, the value of human life (from a policy perspective) is not incalculable.  While we may not be able to express a value, we ultimately decide that there are some things we are not willing to do to protect our lives.  That implies that the value may be difficult to calculate but is certainly finite.  And understanding that incalculable is not synonymous with infinite is the first step in sorting out this discussion.

One difficulty in this debate is that some people interpret cost-effective as meaning cost-saving.  That is not what people who "practice" the science of cost-effectiveness ever mean.  This is an important distinction between the casual use of terminology and the academic (or jargon-based) use of terminology.  It is why part of the argument on which we must focus is the communication issue so that we are all talking about the same thing.

And, if we switch the conversation to "value", I can't figure out why that is any different from cost-effectiveness--or at least one interpretation of the cost-effectiveness science called cost-consequence analysis.  Cost-effectiveness ultimately asks "how much more health are we getting for more spending".  And, just as we would in a grocery store, hardware store, shoe store, or book store, we then ask "is that too much to pay for that amount of health."  How is assessing "value" any different?  Maybe we don't come up with a measure like quality adjusted life years and put the outcomes of care for all conditions on the same scale.  Maybe we just describe the extra costs and the health benefits.

Even if we don't want to place a value directly on human life, we still place an implicit value on human life.  We still will choose to implement some activities related to prevention and not implement others.  Even if everything seems like a relatively good buy there is a limit to our resources.  What I ask is whether we want to talk about value in terms of numerous outcomes and leave the decision about whether it is worthwhile to spend the money to decision makers who don't have to explain the choices in a systematic way or whether we want to try to achieve some measure that helps us to compare the efforts aimed at different programs to use as the basis of comparison, while acknowledging that there may still be things that are difficult to capture.

Value is a good concept.  But even if we agree to look at value we will ultimately have to decide how to measure that value.  And we can spend as much time debating the appropriate measure of value as we are now spending debating whether cost savings or being a good value should be the right criterion.  The key is that we have to realize that not everyone comes at this from the same perspective and respect those differences in the debate.

Consumer Electronics Can Help Improve Patient Health

The Johns Hopkins Bloomberg School of Public Health news center today publicized a journal article by a team of individuals that includes many with whom I've worked.  Figured I should say that to start, so that if anyone questions my incentives to be easy or hard on this article, they will know how I relate to the authors.  In any case, the team reviewed evidence related to whether consumer electronics help to improve patient health.  You can find the news center story  here.


In any case, what these researchers found was that personal informatics tools can be helpful and there is no evidence that they are harmful.  While I do not often pull full paragraphs from the sources I am citing here are some definitions that will help:


"Consumer health informatics applications are defined as any electronic tool, technology or electronic application designed to interact directly with consumers, with or without the presence of a health care professional, and that provides or uses individualized (personal) information to help a patient better manage his or her health or health care." 


"Personalized informatics tools can include applications such as online health calculators, interactive computer programs to aid decision making, SMS text and email messages, which can be applied to a variety of clinical conditions, including cancer, smoking, diabetes mellitus, physical activity and mental health disorders."


The authors clearly indicated that there is no evidence of economic benefit or harm, and it all seems quite harmless.  So, why write about this?


I have a concern.  These tools seem to be able to make a difference now.  However, I wonder about the future.  Why?  I can think of any number of times that I have been fascinated with a new tool (of any sort) and eventually found it to be overwhelming (perhaps Facebook?), or not as useful as it originally was, or simply no longer novel.  It seems like human nature sometimes just to move on to the next thing.  Think of the number of people now who complain about how much email they get when it was supposed to make our lives easier.


So, what seems like a good thing now because it makes it easier and quicker to get the information (thereby reducing the cost of getting information and thereby reducing the constraints on staying healthy) may turn out to be a fleeting change.  This may be particularly true if in the process of using a tool that does not require the presence of a health care professional, the involved professionals lose site of the inherently hands on nature of patient care.  If that happens, once a person tires of a new technology, the need for continued information may be there but the competing demands may grow, the tools may no longer seem as interesting, and the long term consequences may be unclear.


Don't get me wrong.  As a fan of email, my iPhone, electronic music production, Facebook, and blogging, I love technology.  I just worry about too much reliance on a set of tools that may not live up to expectations once they are treated as "been there--done that" kind of technologies.

Interesting link with obesity

In the October 26 Baltimore Sun, there is a very short article on the link between childhood neglect and obesity.   While there is nothing particularly economic about the article, I would draw your attention to this as it illustrates how difficult it can be to determine where to "draw the boundary" when we are conducting a cost-benefit or cost-effectiveness analysis.

The article comments on a study in the journal Obesity shows that children who are subject to various types of abuse and neglect are more likely to be obese as adults.

So, if we were to do a cost-effectiveness analysis or cost-benefit analysis of a program to reduce childhood abuse and neglect, we could think of a whole bunch of things that would be offset by a successful program of this sort.  We'd have less use of child social services, we'd have less use of criminal justice departments, we'd have less use of a few other types of services.  These are all important and are much more short run than the problem with obesity as adults.

However, given the quality and length of of life impact of obesity, a team trying to demonstrate the cost-effectiveness of an abuse and neglect prevention program would do well to include the obesity relationship.  Of course, this only works if the relationship that has been shown in one study generalizes.

Why did I not mention the costs of obesity?  At least one study has shown that over a lifetime healthy adults may spend as much as obese adults.  Why?  In any given year that both individuals are alive, it is probably the case that the health adult will spend less.  However, healthy adults are likely to live longer and accumulate expenditures that are as great over a lifetime.

All of this goes to show how complicated an analysis of abuse and neglect prevention is when we try to extend beyond the simplest relationships and associations with the most directly affected outcomes.

The Ongoing Saga of H1N1 Vaccinations

The Washington Post reported on the "scramble to parcel out the H1N1 vaccine". This is an interesting article about how people have been affected by the lack of availability of H1N1 vaccine at this point.


Interesting observations:

(1) Some people are making a lot of calls looking for the vaccination. The plan, of course, was to have people getting vaccinated at this time. Plans were made for what the article calls a massive vaccination campaign. The resources that could have been used for such a massive campaign now must wait to be used while other people are handling far more phone calls than expected. Not a very efficient use of resources, although not totally within anyone's control and certainly not by choice. Points to the difficulty of planning under uncertainty--a key facet of economics.

(2) The article also notes "incomplete or conflicting information on state and local government Web sites". This would be viewed as bad in general. It is viewed as particularly disadvantageous from an economics perspective where choices are supposed to be made with full and accurate information. So, even if people want to make rational choices, it is made difficulty by the failure to provide all the information necessary.

(3) A note that confidence in the government's ability to respond is down. This may or may not affect this influenza issue much but is bound to affect how people plan for future infectious disease issues or disasters. If people do not feel they can rely on central planners, they will need to plan for themselves. To a degree, this is fine and probably appropriate. However, if high levels of coordination are needed for future responses and people are acting in their own interests and feel averse toward listening to authorities they do not trust, this could affect the ability to respond efficiently.

(4) The demand for the vaccination is varying around the country--at least in part correlated with the spread of the virus. This demonstrates the basic response to take more preventive steps when the perceived threat is higher.

Just a few examples of basic economic concepts being demonstrated by people's behavior with respect to H1N1 vaccinations.

Tradeoffs with Formaldehyde

A Wall Street Journal article highlights how regulations that can improve health can also increase costs.  There is a law under discussion that would put a maximum on the amount of formaldehyde emissions in the home.  This would affect the production of materials like "particleboard, plywood and medium-density fiberboard, all commonly used materials in household furniture."  The key is that producing these products with less formaldehyde will make them more expensive.  The key question is how much safer are we with lower emissions (manufacturers say that we are already quite safe) and how much more it will cost.  We must essentially ask what individuals are willing to pay and what the market will bear as a price to know that one's furniture poses less of a risk.  Not a simple question--particularly considering the importance of furniture in our lives and the relatively low risks from formaldehyde.

If people knew the risks and the options, the market could in theory solve this problem itself.  Just like some people like cherry and others by much less expensive woods for their furtniture based on appearance and durability, we could see a new line of "health safe" furniture that those who could afford could pay more for while leaving those who find the risk of little consequence to purchase less expensive furniture.

Cancer Screening

In yesterday's New York Times, there is an article that discusses just what is gained from screening for prostate cancer and breast cancer. This is an interesting topic, because I have (honestly) been puzzled by the term overdiagnosis of cancer in the past.

What does this article tell us? It tells us (reporting on a recent study in the Journal of the American Medical Association) that screening for prostate cancer has led to a lot more diagnosis of early stage cancer but not so much less diagnosis of late stage cancer and not so much of a decrease in deaths due to prostate cancer. While there has been some debate about prostate cancer screening that has made it to the popular press for years, the fact that questions are also being raised about breast cancer screening is a relatively new point in the general popular press.

What does this mean? We spend a lot on screening as a society. We spend a lot on treating early storage cancers. We have changed late stage outcomes less than might be expected. We create risks for people by treating them early.

Does this mean that screening is not cost-effective? Not necessarily. It only means that some cancer screenings are not the ultimate solution for the relevant cancers. And it suggests the need for more research that will help medical care practitioners to identify which cancers are more likely to be dangerous to the patients and which cancers are less likely to be dangerous. If this could be figured out and the treatments could then be directed only to those most at risk for adverse consequences of rapidly growing cancers, the cost-effectiveness of the combination of screening and treatment could be greatly increased.

It will be interesting to see how this discussion continues to develop and what medical care practitioners and the general public make of the changes in the tradeoffs that this implies in the future.

Health Care Costs and History

There is an editorial in today's Wall Street Journal that focuses on health care costs and history. The main take away message is related to a mentor's comment to me that I have blogged about before--health economics is the study of unintended consequences. The key here is not so much that the consequences were unintended but more unanticipated and a demonstration of just how tenuous economic projections are. The figures given show the original projections for different programs (including Medicare and Medicaid in general, specific aspects of these, and the state children's health insurance program). The key findings--projections consistently underestimate the actual expenditures. Does that mean that anyone else has done better? Not necessarily. It just means that we should be very cautious when interpreting any projections (government, congress, or otherwise) on how much money we will spend under any health care reform.

Gardasil won regulators' approval for use in males

The Wall Street Journal reported that Gardasil (the vaccine against HPV which can lead to cervical cancer in women) has been approved for regular use in males. The choice of what to do with this information represents an interesting study in economics.


What do males get from HPV? Well, they can get genital warts--those are not as life threatening as cervical cancer. There has been an increase in cancers of the neck and throat. And, most importantly, a male with multiple partners would have the chance to pass the HPV on to another female placing her at risk for complications of the infection including cervical cancer.

Is there any harm in allowing Gardasil to be given to males? Not really as far as this economist's read goes.

Are parents of boys likely to decide to give their boys a vaccine that will have much more benefit for the women they may eventually have sexual relationships with? Perhaps, but it does not seem likely. Why not? First, most parents don't like imagining their children with multiple sex partners. (At least not most parents I know.) If two individuals are completely monogamous for their lifetimes, this is a non-issue. Maybe that is unrealistic, but it is a possibility and some/many parents like to maintain the idea that could describe their children. Second, the risks for the women are much higher than the risks for the men. This is an example of an externality. The boys (and the parents on behalf of the boys) do not necessarily see the benefit of such a vaccination.

Should we mandate that boys get the shot? That seems a bit overly paternalistic and like a boon for the manufacturer of Gardasil.

Would a voluntary program for boys be more cost effective than trying harder to get girls to get the vaccination? Not according to the latest research in the area.

So, the FDA's decision is probably clinically acceptable but a lot more thinking needs to be done before the opportunity to vaccinate boys is turned into any sort of policy.

Choosing a Medigap Plan

In the United States, Medicare is the nearly universal plan for adults over the age of 65.  However, it does not cover all costs.  As a result many older adults also buy Medigap plans.

There are twelve plans to choose form--already a difficult choice.  Some older adults purchase right away when they become eligible at age 65.  Others wait.

For those who choose to wait over the next several years, the choice may become more difficult in the next few years as indicated in a New York Times article.

The health care bill that is under continuing discussion in the Senate would change the copayments for visits in the year 2015.  If that were to come to pass, an older adult deciding whether to buy into this program in the years between now and 2015 would not only need to compare the potential savings on out of pocket costs from buying a plan now with the savings on premiums from not buying a plan now, but also look at the tradeoffs from facing higher copayments on new policies bought in the future.  Definitely an incentive to purchase now.  However, this is an information subtlety that many older adults may not understand.

The question the government must address is whether this is an appropriate incentive for older adults and how to provide the information in ways that will make decision making as rational and as well grounded as possible.

Prostate Surgery

An article in yesterday's New York Times talks about an article that describes different results from different types of prostate surgery. A key finding is that minimally invasive surgery is associated with similar outcomes with respect to cancer, fewer short-term side effects, but more long-term side effects.


Why is this "economics"? Quite simply it demonstrates tradeoffs. A main short-term risk that is referred to is pneumonia. Main long-term risks are impotence and incontinence. This is something that society in general might have opinions about and is certainly something that individual men who are undergoing prostate cancer treatment have opinions about. This can be analyzed using a cost-effectiveness analysis to describe average results within a population and can also be analyzed at the individual level looking at a "decision support system" which is intended to provide information for an individual to make decisions What are the costs and risks associated with pneumonia? What are the costs and risks associated with incontinence and impotence? Is there specific information about these risks for men just like the patient in question?

It is also economics because a key question is why there is the demand for a service that has not been shown to be clearly superior. This is an interesting question about technology diffusion, marketing, and how hospitals make decisions about the expected return on investment from the acquisition of new technology. Hospitals that calculated a favorable return on investment invested in new technologies and now need to achieve the return on investment.


As a result, the more expensive and less invasive technology may continue to penetrate the market despite mixed clinical evidence. This is another point at which some additional regulation or oversight of investment and coverage decisions may help the market for medical care.

More on the tax on high cost health insurance plans

An article in Monday's New York Times provides a thorough discussion of the potential effects of the tax on high premium plans.

A few interesting observations:

1. If employers and employees look for cheaper plans to avoid paying premiums that are so high and the related tax, then employees could end up paying more for care and employees might get raises.  If the employees get raises, they will pay more income and payroll taxes.  It is important to recognize that the money they would get back to replace the high premium insurance plans would be taxed even though their benefits are not taxed now.  So, even if there is shopping for cheaper health insurance plans, the individuals may still end up paying more taxes.  In other words, don't think that avoiding taxes on health insurance will necessarily mean avoiding all new taxes.
2. The article suggested that employees will blame employers rather than the government for the increased taxes or decreased benefits.  That shows an unintended consequence and the importance of using economic incentive studies to follow all the consequences of an action when doing an economic analysis and when just trying to figure out things in life in general.  This unintended consequence of a negative relationship between employers and employees would be a failure to trace all consequences.

So, two key points from the article (and there are others if you choose to look at the entire article) are that avoiding taxes on insurance does not necessarily mean avoiding all new taxes and that there may be important impacts on the perception of who is to blame that are misoplaced because of an inability to trace all consequences.

An Economist, An Ethicist, and An Internist

No, this is not the start of some bad joke.  Instead, this is a short story about a panel presentation in a class on health policy yesterday.  I was asked to participate in this discussion yesterday with the main focus of attention being obesity. 

What was interesting about this presentation?  Well, the three of us on the panel really didn't have all that different views of what causes obesity.  A combination of factors that include the food environment, other parts of the market economy (like people's jobs), the "built" environment (like a lack of sidewalks for walking to school and exercise).  We all agreed that is was partly a matter of social factors and partly a matter of individual choice.

Did we disagree?  I think only on emphasis in terms of the policy solutions.  As an economist, I tend to rank consumer sovereignty and market efficiency as the top two considerations.  Not that I don't consider other things, but this is really what neoclassical economics is designed to focus on.  My ethicist colleague is interested in "respect for the individual" (this sounds a little more gentle than consumer sovereignty) but then asks how the least well off in society are affected.  Can an economist ask the question about the least well off?  Sure, it is just not easy to quantifiably rank the least well of in comparison with others. 

The discussion was interesting. Students gave it positive reviews.  We'll probably do it again.

New rules for food sold in schools

An article in yesterday's New York Times discussed new rules about the types of snacks that can be sold in schools. They have to be healthier. A key set of issues were raised:

(1) Would schools receive less revenue as the demand for less healthy snacks is assumed to be lower than the demand for healthy snacks?

(2) If schools have a choice oaf how to promote children's health, why not require a daily physical education class?
On the first, with the right marketing, there might even be more demand for healthy snacks than for less healthy snacks. Seems reasonable to assume a lower demand but this is not guaranteed and is an empirical question.
On the second point, the incentives just don't line up. Schools are asked to put things like "No Child Left Behind" and other standardized testing first. Changing the rules about what food can be sold may be much less effective than physical education. But physical education requires a teacher and takes time away from other activities. In short, the incentives to say you are doing something are pretty strong and this can be done much less expensively by changing the food rules and claiming progress than by really reforming the children's educational process and how health is related to that process.

When a little regulation can make a market much more efficient

Usually, we don't think of economists mentioning regulation and efficiency in the same sentence--unless one is arguing that regulation will lead to inefficiency. However, there is a front page story in today's Wall Street Journal entitled "Hospitals Find Way to Make Care Cheaper -- Make It Better". (Unfortunately, for this one you'll need to either have an electronic subscription or get the paper copy to see it, so I won't provide a link.) This article focuses on experience in Pennsylvania with the Pennsylvania Health Care Cost Containment Council.

This council has required hospitals to report "death and complication rates...from more than 50 types of treatments and surgery at hospitals." Key finding: when these data are available to consumers—and to the employers of consumers—the care gets better and costs often go down.

Why is high quality care less expensive? Fewer complications and readmissions.

Why does this type of information lead to better care? Hospitals realize that if their quality is poor they will lose business.

Why are employers as important as consumers?  Employers are often the ones who choose which health plans to make available for their employees and the employers can work directly with health plans in ways that individuals cannot to make sure that patients are directed to higher quality hospitals?

Why does this information not come out of a free market on its own? Quality of medical care is hard to judge and the producers don't have to make as much effort if their quality level remains a mystery.

So, does this mean that all regulation is good? No. But in a situation in which there is a product with quality that is difficult to identify and prices that are not easily apparent to consumers, forcing producers to be as transparent as possible with quality data (and, arguably, there still are some shortcoming in the system) and prices can make the system operate more efficiently.

Reducing payments to physicians

In today's Wall Street Journal there is a commentary piece about a provision of the Baucus bill that would cut payments to any physician in the top 10% of costs to the program by 5%. What type of incentive would this set up?


Well, interestingly, even if every physician cut their costs, 1 in 10 doctors would still be in the top 10%. So, this starts off as a bit of an odd idea when it comes to potential implications. While a more complicated rule might be difficult to interpret, a more complicated rule might also be more fair. For example, why not penalize the top 10% of physicians based on costs it they exceed some level of cost growth over the previous year but not otherwise. That way, on the outside change that all physicians cut their patients' utilization by 5% in the same year, the top group would not be penalized for already having been very expensive when their own behaviors made such a difference.

The other problem with a system like this is that it is not clear which services would go unused when physicians (in concert with their patients, hopefully) try to reduce health care utilization. In short, previous studies suggest that when there is a cost-based pressure to control expenditures, a mixture of care that would not be considered essential as well as care that might be deemed necessary are cut. So, in physicians' rush to control costs to avoid the penalty, in the end the physicians who remain the highest sources of expenditures will still be penalized and in the process of reducing care they may forego some very important and necessary services.

Consider: Research shows children whose mothers stay home have healthier lifestyles

Here is a link to a commentary in the Baltimore Sun about a professional journal article from the Journal of Epidemiology and Community Health.  The main point of the article as interpreted in the Baltimore Sun headline: "Mommy Wars: Working mothers have fatter kids, study says".

Main findings in terms of "strikes against children of working mothers":

• more sugary beverages between meals
• used the television or computer more frequently 
• driven to school more
• ate fewer fruits and vegetables

The economic questions are twofold: (1) what does this do to kids?   (2) is there an economic interpretation for these results?

First, and let me be clear about this, the research seems to focus only on lifestyle.  So the headline (about fatter kids) may or may not be right.  If it is, these kids will probably have higher medical care spending in the long run.   However, with those four "strikes" against them, the kids with working moms (on average) are likely to be heavier.  It is always important to remember that this is just 'on average".  There are  plenty of healthy kids of working moms--and plenty of not so healthy kids of stay at home moms.  And, if the differences are "statistically significant" but not necessarily clinically meaningful, it may not result in much heavier kids.

Second, there is a simple economic logic.  The thought is that working moms have less time to monitor, occupy, and prepare healthy food for their children.  This does not mean that if they were not working they would do any of these any less than moms who are not working now--they care about their kids just as much.  It only means the constraints they face because of work lead to different choices.  The Baltimore Sun commentary raises a point about what role dads play in this equation.  Speaking from personal experience, I agree that it is unfair to place the whole burden on moms.  The key is how parents or the combination of all those who care for a child's well being use their information and allocate their time, money, and effort to care for their children.

People with different information facing different constraints are likely to make different decisions.  The piece in the Baltimore Sun reminds us of how this can affect the children.

Overheard in the grocery story checkout line

On my way home from work today, I found myself at the grocery store that is affiliated with the chain at which we shop the most but that is the slowest of the three stores I go to most often when it comes to getting checked out. So, I had a long time to stand in the checkout line at 5:55 this evening. The lines were ten people deep. The woman in front of me had a blue tooth phone in her ear. I overheard her saying something to the effect of "they tried to give my sister's boy the flu shot, but why should he get it. It is just like giving him the virus. Why not just wait and see?" Using a killed virus, it is not just like "giving the child the virus". I thought that the press in general has done a good job of trying to convince people that the flu shot will not give them the flu.

Why is this economics rather than just an interesting observation of human nature to believe what we want to believe rather than information that is put forward? It is an economic question because you could ask "Why did not you try to set here straight? You are a public health economist after all.

That is an interesting question. If the disease were not a contagious disease, what she or her sister chooses to believe and chooses to do would not affect me. However, since we are discussing an infectious disease, her actions and her sisters actions and how these actions affect their kids has the potential to affect my kids or me. We call this an externality.
Why was I not concerned enough about the externality to "set her straight". First, I could perceive that the cost associated with this particular person not getting her son a flu shot would have a limited chance of affecting me. Why? Unless I shop at that grocery store again in the near future (and after the 10 deep checkout line I do not expect to do so), I probably won't come across her and I have the preconceived notion that my kids won't come across hers or her sister's?

Second, I could perceive that even if I do cross paths with the woman, her sister, or their kids I am not likely to be affected. I've had a few bad colds but never really the flu. I am generally healthy. Haven’t had anything yet this fall. So, perhaps I just think there is no need to worry.

Third, I could perceive that even if I change one person's behavior there are so many others out their whose behavior I will not change that one person's behavior change will make little difference in population level outcomes.

Finally, I may perceive the cost of changing a person's behavior to be too high. In other words, even if I could see a tangible potential benefit for myself, the effort it would take from me to help her change her behavior was "too much" to be worth it or at least more than the value of possible prevention.

So, while the decision not to vaccinate that I heard being discussed was not necessarily economically rational (given the misinformation), my decision not to do anything could be considered rational and could suggest how I view the world working. And, just for the sake of argument, even with all the right information about the vaccine, choosing not to get one still could be an economically rational choice.