Internalize and Trade

Health care providers incorporate a variety of incentive methods to encourage healthy behavior.  Many HMO’s will pay $25/mo toward a gym membership fee if their member goes to workout twelve times in a month. In effect they are internalizing the externalities of poor future health by inducing members to live a healthier lifestyle. The numbers must indicate that $25 is both enough to change behavior and in doing so avoid future medical procedures.

This transaction all occurs within the same group, those covered by an HMO’s policy. The trade of cash towards a gym fee benefits the same people who will then incur fewer medical costs in the future.  But what about a hybrid trade that included beneficiaries outside the group?

Obesity in the US has been on the rise for a number of years. It is becoming a leading public health crisis as rates of obesity among Americans are running above 40% in all age groups. The CDC outlines a number of health effects that stem from carrying around excessive weight.

One remedy is weight-loss (bariatric) surgery.  There are several procedures that help you lose weight which lowers your risk of medical problems associated with obesity. The cost of weight loss surgeries can range from $14,000 to $23,000 and are being covered more frequently by health insurance.

Since there are also downsides to surgery in general, what if the HMO tried an incentive program to get the member to a healthy weight? Say the cost was determined to be $20,000 for the surgery, and the member was considered to be 80 pounds overweight. Say the sum of the surgery could be divided up over a five year time span where the member received a portion for every 20 pounds lost, the HMO retained a portion and, a single mom in a third world country received food subsidies for a year.

A recent contest found that the most compelling argument that resulted in the highest philanthropic donations was a scenario structured in a similar fashion. I describe this structure in the post Philosophy and Philanthropy. Perhaps a late middle aged mom has served her family diligently, and in the process lost site of her own needs. Perhaps she has gained a bunch of weight that she can’t seem to shake, at least not for herself. But if you gave her the option to feed a single mom with five kids, maybe she would see her way to bringing her own weight in line.

It’s all about the Group

Amy Finkelstein’s video for MRU about the economics of mammograms just popped into my email. She and her colleagues are wondering about the efficacy of the present policy for screening for breast cancer. The blurb following the video explains.

One in eight women will be diagnosed with breast cancer. The current recommendation is that women should receive annual mammograms starting at age 40. But who is actually following this recommendation, and does that affect the test’s efficacy? MIT’s Amy Finkelstein and two of her coauthors, Tamar Oostrom and Abigail Ostriker, explore this question in this video. This video is based on the following paper: Screening and Selection: The Case of Mammograms Liran Einav, Amy Finkelstein, Tamar Oostrom, Abigail Ostriker, and Heidi Williams https://economics.mit.edu/files/20062

Past studies suggested dividing women into two groups in order to tackle a public health response to cancer: those under age 40 and those over age 40. Once over forty years of age, women are considered at a higher risk and thus were encouraged to have mammograms on a regular basis. The Susan G Komen organization provides data on how screening has saved lives. “From 1989-2017 (most recent data available), breast cancer mortality decreased by 40 percent due to improved breast cancer treatment and early detection [60]. Since 1989, about 375,900 breast cancer deaths in U.S. women have been avoided [60].”

It wasn’t long, however, that the drawbacks of misdiagnosis became apparent. False positive tests were causing patients unnecessary mental and physical costs. The fear and treatment associated with a false positive took time, energy and resources away from women who were in fact not likely to acquire the disease.

Amy and her MIT colleagues found that grouping by age was not specific enough. They observed that women who comply, and get screened, share habits that actually make them less likely to be prone for a positive test. Based on information from the medical community, women who disregarded screenings were more likely to eventually experience breast cancer.

By regrouping the women in consideration of their norms and lifestyles, the MIT professors are acknowledging that the public health of women in regards to breast cancer is multidimensional. They do not propose a new public policy but rather further insight into how the topic should be considered. Tamar Oostrom voices in the video: “our paper brings an additional dimension” to the issue.

When you think of the nature of people who would follow the recommendations and comply with regular testing, they are probably folks who can afford to be tested, both in the sense of the medical services expense and in the time it takes out of their lives. They probably have access to transportation to be tested. They have the willpower and ability to prepare and eat a healthy diet and exercise. It’s interesting to note that many if not all of these activities are tied into access to other public goods.

This video confirms a couple of things. Putting public resources towards a problem reaches a point of no additional returns, and can cause additional costs to the targeted group. Secondly, solving for the optimal amount of screening involves an understanding of how to distinguish groups and there access to other public goods markets.

The Trick with Triplexes

A little over a year ago Minneapolis was getting a lot of attention for ending single family zoning which secured one family home for one lot in 70 percent of the city. Politco ran a headline with dramatic vivid language of strangleholds, and further reported on how activists were taking victory laps following the City Council’s 12-1 vote to reverse single family zoning across the city. The Atlantic ran an article. And the New York Times gave Minneapolis‘s story first consideration in their article.

Yet in this first part of 2020 their have only been, drum roll please, 3 permit requests to take advantage of this up-zoning. The reason being, according to the Government Affairs Director with the Minneapolis Realtor Association, Eric Meyers, “even though new zoning laws permit triplexes, the underlying code was still written with single-family homes in mind. Height restrictions are the same, as are setback requirements.” A seemingly simple request to increase the height of a garage peak by one foot drew an extensive and heated debate. 

Since demand for housing continues to be strong in Minneapolis –the median sale price has risen 5.5% over the last twelve months– and hence the need for more housing units is unwavering, one would think that the spirit of releasing the stranglehold of the single family home would make the process more forgiving.

Emily Hamilton at Bloomberg explains it best: Want More Housing? Ending Single-Family Zoning Won’t Do It. Regulations that have been built over years won’t be undone with that quickly. Think of this at step one. Now investors are reconvening to put together documentation on the obstacles that stand in the way of the envisioned housing option. They will spend time and resources to go back through the city process and seek approval for building conversions and new builds.

Some investors will call it quits and sit out this process as they fear it is too expensive. But it is in this back and forth between the private and the public that incremental changes are made in order to achieve the goal of more housing units. And in doing so lower the cost of homes.

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Here’s the deal 101

Our local NBC news outlet recently ran a story about an elderly couple receiving help from neighbors after being criticized for not keeping up the exterior paint on their home. It totaled $67,000 worth of help. There is no name given to this transfer of money. When a private party helps themselves to $67,000 from their employer it is called embezzlement. When a politician helps themselves to $67,000 from their campaign fund it is called corruption.

The old school explanation for this activity is to denote it as a form of charity. But is it really a gift? Neighborliness is a term that shows up on surveys. But what does that mean? I see this exchange between the neighbors of Gloucester is the most basic transaction in a economy of groups. Let’s pull it apart.

It all started with an anonymous note left for the couple which read, “Please Paint Me! 😦 Eye sore – Your Neighbors. Thanks.” Although clearly written by one individual, the message is presented as a community concern. Signed, your neighbors. You’ve probably heard this type of chatter before. A house on a main road is dilapidated, or decorated with eccentric siding. Comments like, ‘I really wish someone would do something about that place.’ Or, ‘Some people are bringing down the neighborhood!’ So although one neighbor wrote the note, thoughts of this nature were undoubtedly mulled over by many a passerby.

A personal residence is deemed the bastion of private property, and property rights are a keystone feature of our economic system. But the note indicates that there is a hazy area not reflected in the legal deed, filed in the county records, which spells out the owners names. The area residents feel they have a right to demand that the exterior meet their expectations. This is not a novel idea. In fact cities even have ordinances which address the exteriors of properties regarding thresholds for debris removal and grass mowing.

The couples’ daughter took to social media to voice her response to the note. She points out that her parents had lived in community for the past 50 years. And that during this long history they had maintained their home, and hence contributed many years of service towards an acceptable streetscape. “My family for many years took care and maintained this house as best they could…” 

The reason for the disrepair could happen to anyone, it was an act of nature. The article reports that “Marilyn, 72, developed multiple sclerosis about 30 years ago and is mostly confined to her bed, and Jimmy, 71, recently recovered from a quadruple bypass…” Health concerns take time and resources away from the couples ability to comply with the norms of the neighborhood.

Once the word got out about the need, once demand for goods and services was established, a voluntary response from the community resulted in a $67,000 balance in a GoFundMe account. Currency is very liquid, yet these funds are not fungible. As the report confirms the money is “to be used for new siding on their home, new windows, roof and stairs.”

There is no reporting of free riding or extortion, even though funds are seemingly extracted from a greater group to a private party. Nor is this activity portrayed in a religious or moral sense. The voluntary transfer of resources to improve the exterior of the home is held together by a communal objective, one that the recipients contributed to over. This transparent and voluntary activity is the most basic transaction in economy of groups.

“People look out for each other in Gloucester,” he said. “If somebody needs some help, we just get together and do it. It’s all just very heartwarming.” What I hear him saying is that Gloucester is a town with a free an open economy. And yes, that is heartwarming.