As summer enters its dog days, you can feel the great gears of the news machine slowing, slowing, slowing, like a locomotive as it pulls into a station. So now seems like a good moment to re-offer you some of the best of our WBUR/Slate podcast, The Checkup, for your listening pleasure on those long car trips and plane rides to vacationland.The Checkup: a WBUR/Slate health podcast Subscribe on iTunes | The Checkup on Slate
In particular, in case you missed this delectable morsel, may we recommend our episode titled “Scary Food Stories”? It features three particular cautionary tales: on kale, chia seeds and sugar. Download it here before your next meal. Or if you don’t, don’t say we didn’t warn you…
In case you missed other recent episodes: “Teenage Zombies,” explored the curious minds of adolescents, with segments on sleep, porn and impulsive choices; “Power to the Patient” looked at ways we can all feel in more control of our health care; “High Anxiety” included reports on hormones, parenting and fear of flying; and “Sexual Reality Checks” examined penis size, female desire and aging.
Better yet, don’t miss a single episode and just subscribe now.
The sustainability of the U.S. fiscal outlook depends on the path of health costs, particularly Medicare, the health insurance program for the elderly and disabled. If health costs continue to rise more rapidly than gross domestic product, then Medicare will be increasingly unaffordable. The recent slowdown in Medicare spending has been touted as evidence that the health cost curve has finally "bent" and that the Medicare financing problem can be managed with modest changes in policy.
The Medicare Trustees report, released last week, basically confirms this view. Under the trustees' baseline projection, Medicare spending increases from 3.5% of GDP today to 5.5% by 2050 and 6% by 2080. In contrast, the Congressional Budget Office, in June, projected much larger increases in Medicare spending over time, with spending reaching 7% of GDP by 2050 and over 11% by 2080.
How can projections by the government's best experts be so different? And which should we believe?
Both the trustees and the CBO assume that the growth both of public and private health spending will slow over time, as the incremental benefit from additional health care becomes less valuable. Where they differ is in what is assumed about Medicare spending growth relative to growth other health spending.
The trustees assume that per capita Medicare spending will rise more slowly than other health spending; CBO assumes that Medicare spending will rise more rapidly.
The trustees look at the provisions of the Affordable Care Act governing provider reimbursements and conclude that Medicare payments under the Affordable Care Act are increasingly likely to fall below reimbursement by private insurers and Medicaid (the state-federal program for the poor) over time. Thus, they expect Medicare spending to rise more slowly than other health spending.
CBO economists believe future health spending is too uncertain to be modeled. They consider the effects of legislation only over the ten-year budget window—that is, from fiscal years 2015 to 2024.
After that, they use a mechanical rule to project Medicare spending per beneficiary. But this mechanical rule assumes that, under current law, Medicare will have less flexibility than private insurers and Medicaid to take measures to slow health spending growth. Thus, CBO assumes that per beneficiary Medicare spending increases faster than other health spending.
Which of these should be believed? Neither. Health spending is almost impossible to predict. Assuming that past trends continue indefinitely produces nonsensical results, as it implies that health spending will eventually consume all of GDP. But forecasting how the future will be different from the past is not something we know how to do. The large wedge between these two arguably sensible projections of Medicare should be taken as evidence that we really don't know how big a fiscal problem health spending will be 25 or 50 years in the future.
A version of this post appeared on the Wall Street Journal's Think Tank blog.Authors
By Marina Renton
Would I make it to the train station in time? Or would I miss my train home? The concern gnawed at me as I fidgeted on the uncomfortably warm and crowded subway platform. As I anxiously scanned the tracks for approaching lights, the watch on my wrist buzzed. It was telling me to check my stress levels. I pulled out my phone. High, it said; surprisingly high.
That may sound like the first draft of a science fiction novel but, in fact, it’s describing events from last month, when I tried out a watch that has sensors to measure the autonomic nervous system, which regulates our fight-or-flight response.
Neumitra, a Boston-based startup, developed the technology, and plans to launch an ambitious project this fall that would use it to chart the stress not just of individuals but of professions and institutions — even of a whole city. It may be a no-brainer that catching a train is stressful, but how does stress at Harvard compare to stress at Northeastern? North Shore to South Shore? Emergency room at Boston Medical Center to Massachusetts General Hospital?
“We’re using data from the body and data from mobile phones to understand how everyone is affected by stress,” said Rob Goldberg, co-founder of Neumitra and a neuroscientist formerly at MIT. “Our aim here is for thousands of people in Boston to be using these technologies, so we can understand the difference between a veteran, a police officer, a student, a mother, a nurse — and sometimes you belong to multiple of these categories, so what are the combined effects?”
Sync to see your stress
“I’m so stressed!” is a frequent response to the innocuous, “How are you?” The exclamation, or variations thereof, can be overheard at the office, between classes, at home…practically anywhere.
But it’s one thing to verbally express feelings of stress, and quite another to quantify those sensations. That’s where Neumitra comes in.
You can track your stress level in real time through an app that displays the data that the watch collects. The app syncs with your calendar and GPS, so you can also look back to see which events and locations cause the most stress. When your stress spikes, the watch vibrates — an alert that it might be time to take a step back and recalibrate.
The app displays stress using a color gradient: Blue means relaxed or restful, orange and red signify increasing tension. During my entire subway ride, I was either in the dark-orange or red zone. Once I was back home, I spent more time in the blue regions. Exercise brought me back into the orange (among other things, the watch measures skin conductance and temperature, so physical exertion can register as stress), but it didn’t exceed the stress I demonstrated while standing (read: trying not to fall on anyone) in a crowded subway car.
This technology is certainly fascinating, but does it really tell us anything we didn’t already know? Goldberg’s answer is an emphatic yes. “We think we [know how we feel], but we’re very detached from that,” he said.
Science at a new scale
In this age of “smart” or “connected” everything, we’re getting used to devices that monitor us, but Goldberg says Neumitra’s plans for the technology’s use on a large scale might lead to a whole new understanding of the effects of daily life on stress.
“We don’t understand what we’re all struggling with on a day-to-day basis, and with data of this type it allows it to become much more visible,” he said.
This coming fall marks the planned launch of the Boston Stress Study, which aims to “quantify brain health across an urban population,” according to its website.
Goldberg compared the Boston Stress Study with the landmark Framingham Heart Study, which began in 1948 with over 5,000 participants and continues to this day with subsequent generations. The Framingham Heart Study has been crucial to the identification of risk factors for cardiovascular disease.
The data gathered as part of the Boston Stress Study will be aggregated, with the goal of showing the differences in stress level by profession and, in the long term, by socioeconomic status, gender, even university.
“We’ve all heard stories about what does it mean to feel stress at MIT, or Harvard, or at Boston University,” Goldberg said. “But what would it mean to quantify that?”
The study’s data will come from participants who are willing to have their anonymized biofeedback information uploaded to the cloud. From day one, researchers will be able to begin analyzing the results, but Goldberg says users’ confidentiality will be protected.
“Physiological data doesn’t really have much personally-identifying within it,” he said. So, showing the stress level of the city at, say, 9 a.m. — or during a cold snap or heat wave — shouldn’t be a problem. Most privacy concerns would arise with location data being aggregated and released to the public. “We want to take our time to make sure we get that absolutely right,” Goldberg said.
“Our goal is to do science at a scale and in a way that’s never been possible before. These technologies, worn computers, really do make that possible,” he said. “The longer-term goal is to understand the relationships between stress and chronic health conditions as well as stress and performance and productivity issues.”
Already, he says, with the few participants in a pilot phase aimed at refining the design and algorithms, “we’re pretty impressed by what we’ve been able to see so far. And, for those folks who are using our technologies, it becomes pretty clear how simply visualizing what you’re experiencing every day becomes immensely valuable to help you understand yourself better.”
“Supporting the individual”
While Goldberg expressed excitement about the possible big-picture implications of the Boston Stress Study’s results, he emphasized that the primary purpose of the technology is to benefit the individual. The integration with the app allows for very personalized visualizations. For instance, you can see how that beloved mellow song or dreaded dentist appointment affected your stress level.
“If we don’t do a good job of supporting the individual, then all of our grand ambitions, all the great questions we want to answer, won’t ever come to fruition,” Goldberg said.
The individual benefit of the technologies is compelling to Dr. Joseph Kvedar, vice president of Connected Health at Partners HealthCare. “Stress is one of those things that’s hard to measure, and having something like this to help us measure it…may help us combat stress and cope with it better,” he said.
Regarding the citywide analysis of stress, Kvedar said, “I’m not sure it’s going to be as compelling as it would on an individual basis, but I could be wrong.”
Time to recover
The results of the Boston Stress Study might influence workplace policies, Goldberg said.
The stress experienced on a morning commute can be equivalent to exercising, and “If we thought we were out for a run, we would give ourselves an hour or two to recover,” he said. “We don’t give ourselves an hour or two to recover from our commute, from a difficult meeting at work, from medical appointments.”
“What if it turns out that commutes are one of the most stressful times of day for a city?” Goldberg added. “Will companies take more seriously the fact that their people are showing up already highly revved up?” Beginning the day stressed might impede productivity, which employers could take into consideration when scheduling meetings or setting work hours, he said.
Rather than continue to manufacture a watch, Neumitra is working on incorporating the stress-measurement technology into lightweight “biomodules,” which could be incorporated into participants’ existing accessories, Goldberg said.
The watch loaned to me costs a hefty $1,500 — although its quality is on par with $20,000 medical equipment, Goldberg said — and would be out of reach for many people. Neumitra aims to make the biomodules more affordable.
The Boston Stress Study is still getting under way; participants are still being recruited and Neumitra is still refining the technologies and lining up funding.
Neumitra has partnered with a combination of commercial, nonprofit, and academic organizations to fund the study and recruit participants. The variety in partnerships is necessary to obtain a representative sample, Goldberg said.
“To do science at this scale, where every citizen both becomes a scientist and helps us to answer these questions as part of the organizations they belong to, this is really going to come from a mix of supporters,” he added.
Neumitra is currently working with clinical organizations in the area to find participants, and Mayor Walsh has written a letter in support of the Boston Stress Study.
“The data from your study could provide us with vital insight into the various causes and effects of acute and chronic stressors in the daily lives and work of Boston residents,” he wrote.
While I knew the subway commute was stressful, I didn’t perceive just how stressful until I used the watch. Not only that, but it taught me how strong an effect simply remembering a stressful event can have. The app can generate a line graph to illustrate your stress, and I could see clear spikes in the line that aligned with my recalling a stressful situation or embarrassing incident from earlier.
Stress triggers such pronounced physiological changes that it’s no wonder it takes a toll on the physical self as well as the psyche. From my time wearing the watch, I realized the power of being able to visualize the physiological response to stress.
On the other hand, I did find that watching my stress level rise second by second contributed to a heightened sense of anxiety. Yet, I also began to notice that consciously changing my thoughts allowed me to manage my physiological response.
I come away with a new note to self: When work piles up, or you have to run to catch the train, or you’re waiting in anticipation for a response to a text message, remember to make time for stress-relieving activities to allow yourself to recover from the strains of the day.
It is the current fashion, both in academics and popular culture, to convey information about more serious topics, such as war, chemistry, military life in a combat zone, autobiography, cancer, and pandemic preparedness in graphic novels. As a librarian and a reader, I’ve enjoyed the ability of graphic novels to communicate dense non-fiction material in a way that scarcely seems like work to absorb. Recently, a copy of The Illustrated Guide to Criminal Law landed in the office, and the arrival of this new acquisition seemed like a great time to highlight items in our collection that cover law and comics and graphic novels.
The Illustrated Guide to Criminal Law is Nathaniel Burney’s “attempt to debunk … [the many popular myths about criminal law]” (p. 7). Burney blogs regularly in graphic form at his website; you can find out how attention and memory work in criminal cases, view a Fifth Amendment flowchart, and read about traffic stops. He covers the basic principles of criminal law “in a way that was more accessible to a high school kid than my wordy and obscure law blog.” The content from the book is similar to the content of the website: purposes of punishment, mens rea, entrapment, and other basic concepts of criminal law are explained with humorous illustrations and movie quotations. Burney draws in occasional commentary from Lady Justice, a virago whom he depicts as “a sort of modern Athena/Roma.” He also employs stick figures (“Stickie McFigure” in the rape explanation) and anthropomorphic maps (England wearing a Union Jack top hat in the history of Blackstone’s influence). His cartoons are reminiscent of Marvel comics, Joe Palooka, and in at least one instance, George Herriman. Readers seeking a better basic understanding of criminal law would want to include this volume in their research bibliographies.
Similarly, readers of Trevor R. Getz’s and Liz Clarke’s Abina and the Important Men: A Graphic History can learn quite a bit about colonial law, the history of slavery in England and Ghana, Ghanaian history, English colonialism, and 19th century women’s history for a class of women whose voices are not often heard. Documents from the Gold Coast Colony Supreme Court Records, Regina v. Quamina Eddoo 1876, were used in the writing of this book, making it an interesting starting point for legal scholars and historians; the actual transcript from the case is included in the second part of the text. Abina Mansah, a native of the Gold Coast (the former name of Ghana), was the plaintiff in the case in which she charged a wealthy local planter, Quamina Eddoo, with enslaving her, which was against English law at the time. Mansah was pursuing her freedom as well as punishment for Eddoo for enslaving her. The book is designed for classroom use, so it is accessible to a wide variety of users. The volume is accompanied by Clarke’s illustrations, fully colored realistic drawings of the actual history of Abina Mansah’s life as narrated by her testimony given in Eddoo’s trial. Viewing the panels adds a new dimension of content to the history.The Pocket Lawyer for Comic Books: A Legal Toolkit for Indie Comic Book Artists and Writers provides legal guidance for independent cartoonists, promising that “[r]eaders will learn to protect their trademarks, hire artists so everyone wins, and learn the ins and outs of contracts with this helpful resource. ” Marc Greenberg’s Comic Art, Creativity and the Law discusses law and the creative process, copyright law as it applies to comics, the formation of the Comic Book Legal Defense Fund, the First Amendment and comics, and instances of censorship of comics. Whether you are a visual thinker or a verbal one, there’s material here to engross your attention.