Saturday, July 20, 2013
Organ allocation always involves contestable values. New technologies of regenerative medicine will raise similar concerns. Slate's Michael Bennett offers the following, interesting set of dilemmas at the intersection of cutting edge health care and finance:
Our society at large resembles . . . the arrangement of classes defining the experience of contemporary air travel. Will you be able to afford an economy class liver? Perhaps a business class model? Will organ markets reproduce the qualitative differences we’ve come to accept with commercial air classifications? Should organ performance track organ price? . . . If you’re underwater on your liver mortgage, it’s safe to assume you’ll be hard-pressed to walk away.
As Deven Desai has argued, in a world of person-machine merger, "Simply saying you signed this contract, and we can do what we like is an error." Neither organs nor their financing should be "subprime" in the world Bennett describes.
Thursday, July 18, 2013
Michael Simkovic(Seton Hall) & Frank McIntyre(Rutgers Business School), The Economic Value of a Law Degree (PowerPoint):
Legal academics and journalists have marshaled statistics purporting to show that enrolling in law school is irrational. We investigate the economic value of a law degree and find the opposite: given current tuition levels, the median and even 25th percentile annual earnings premiums justify enrollment. For most law school graduates, the net present value of a law degree typically exceeds its cost by hundreds of thousands of dollars.
We improve upon previous studies by tracking lifetime earnings of a large sample of law degree holders. Previous studies focused on starting salaries, generic professional degree holders, or the subset of law degree holders who practice law. We also include unemployment and disability risk rather than assume continuous full time employment.
After controlling for observable ability sorting, we find that a law degree is associated with a 60 percent median increase in monthly earnings and 50 percent increase in median hourly wages. The mean annual earnings premium of a law degree is approximately $53,300 in 2012 dollars. The law degree earnings premium is cyclical and recent years are within historic norms.
We estimate the mean pre-tax lifetime value of a law degree as approximately $1,000,000.
- Michael Simkovic (Seton Hall), The Economic Value of a Law Degree (Part 1 of About 5)
- ABA Journal, What’s the Value of a Law Degree? $1M in a Lifetime, Report Says
- Business Insider, Study: A Law Degree Is Actually an Amazingly Good Investment
- Inside Higher Ed, The Upside of Law School
- Dan Filler (Drexel), What Is a JD Worth? Study Suggests Lifetime Value of $1 Million, on Average
- Brian Leiter (Chicago), "The Economic Value of a Law Degree"
- Kyle McEntee (Law School Transparency), New Study on Economic Value of Law Degree
- Elie Mystal (Above the Law), Another Garbage Study Offering Misleading Statistics on the Value of a Law Degree
- Frank Pasquale (Maryland), "Fundamentally Changing the Conversation about the Economic Value of Legal Education"
Hat Tip to my friend Paul Caron over at TaxProf Blog.
Wednesday, July 17, 2013
Many readers of this blog may know well my dear friends and colleagues, Peggy Battin and Brooke Hopkins. Over the past nearly-five years, they have dealt with Brooke's biking accident which left him essentially unable to move below his shoulders. This Sunday's New York Times magazine will feature a story by Robin Marantz Henig about Peggy and Brooke: how they have thought about dying, autonomy, and living with disability. They are both truly remarkable, and the story is worth reading, again and again, for this alone--as well as for the bioethics thinking it reflects.
A subtheme of their lives is home care. Some of these issues that they and others face are financial--our failure to pay for long term care through traditional insurance, the incentives that favor institutioinalization over living at home, the characterization of expenses such as modifying a shower as not medical, and the sheer expense of equipment such as wheelchairs. But some are regulatory: what type of wheelchair will be covered, what kinds of licensing requirements apply to home aides, and perhaps most troubling what activities can result in decisions to terminate the home health services that are available. Too often, we insist that people must only use devices such as wheelchairs within the home, or that people must only stay within the home except for medical appointments, in order to continue to qualify for home health services.
I fully recognize that all of these issues are contested ones. However, I hope that those reading the story will appreciate the amazing lives that Brooke and Peggy live and the importance of Brooke's being able to live at home for them both, as well as their enormous skill in negotiating the troubling realities of home care today.
Tuesday, July 16, 2013
Last week, I mentioned that I had just finished reading Prof. Andrew Koppelman's book "The Tough-Luck Constitution," and said that it was a little outside of my usual summer reading lists. Then I thought about it, and realized that despite my best efforts to avoid health-care-related summer reading in favor of lighter fare, every summer I wind up reading at least one or two health-related books that don't involve bodice-ripping and swooning, but are not quite as heavy as a casebook or treatise. So here are a few of the books that I have read over the past several years that I think belong on any health law wonk's summer reading list. They also make great supplements for health law classes:
The Truth About the Drug Companies - Dr. Marcia Angell
The Great Influenza - John Barry
How We Do Harm - Dr. Otis Brawley
The Spirit Catches You and You Fall Down - Anne Fadiman
Flu - Gina Kolata
Unaccountable - Dr. Marty Makary
Medicine & Culture - Lynn Payer
The Healing of America - T.R. Reid
A Taste of My Own Medicine - Dr. Edward E. Rosenbaum
Hospital - Julie Salomon
God's Hotel - Dr. Victoria Sweet
I have avoided some very worthy, but more academic reads, such as Paul Starr's seminal "The Social Transformation of American Medicine," but of course, if you can concentrate while sipping that Corona at the beach or on your boat, go for it. And no, I get no kickbacks, incentives, or pens with names on them from any of these authors in exchange for my listing.
Sunday, July 14, 2013
Substance abuse treatment is an important health care need. The Fair Housing Act (FHA), the Americans with Disabilities Act (ADA), and the Rehabilitation Act (for entities receiving federal funding), all protect people recovering from substance abuse against discrimination based on disability. Yet it remains difficult for treatment facilities to find appropriate locations in which to offer their services. Neighborhoods fear reduced property values, risks of violence, and other community disturbances and often voice these fears loudly in zoning board hearings. Elected public officials find these protests difficult to ignore. Although some NIMBY concerns are well founded, others are rooted in stereotypes or unfounded beliefs about the nature of substance abuse or the services provided by treatment facilities. Oxford Houses, a nationwide program of treatment facilities, has litigated recent NIMBY cases in a number of jurisdictions, with some success. (e.g., Oxford House, Inc. v. City of Baton Rouge, 2013 U.S. Dist. LEXIS 38002 (M.D. La. March 18)).
Nonetheless, it remains difficult for many facilities to obtain success in court when they are denied permits at the local level. A recent decision of the federal district court involving a facility in Detroit is illustrative. Get Back Up v. City of Detroit, 2013 U.S. Dist. LEXIS 91816 (E.D. Mich. July 1), involved a treatment program that had purchased a school located in an area zoned as a general business district. This zoning classification also permits some residential uses “by right” and some “conditional” uses. “By right” uses include hospitals and nursing homes; “conditional uses include fraternity houses, multiple family dwellings, rooming houses, pre-release adjustment centers, and substance-abuse service facilities. The court granted summary judgment to the City on claims that the ordinance discriminated on its face, that it differentially impacted people with disabilities, and that the City had failed to make reasonable accommodations. The court’s view was that this did not discriminate on its face merely by singling out treatment facilities; instead, it drew neutral lines among materially different types of institutions, treating substance abuse facilities like rooming houses and unlike nursing homes or hospitals. The physical infirmity of nursing home residents, in the judgment of the court, made a material difference between these institutions and substance abuse treatment facilities.
Most disturbing about the court’s decision is that it credits the City’s claims that residents from the facility had harassed people in a neighboring residential area and were responsible for increases in robberies in the area, without subjecting this evidence to the assessment of credibility it would have received in the case had gone to trial. If this decision stands, Get Back Up will presumably need to find new facilities in which to operate, losing its investment in the school that it had purchased.
As Nelson Mandela's life may be nearing its end, his family may face difficult decisions about the use or withdrawal of artificial ventilation and other life-sustaining treatments. The New York Times reported on Friday how uncertainties in South African end-of-life law and political considerations may complicate the decision making process.
Unfortunately, as we've seen over and over in the United States, a factor that might make things especially difficult is the potential for disagreements among Mandela's family members. Many of the most important--and troubling--cases in the United States came to court when family members staked out different positions on a patient's end-of-life care. In the Schiavo case, for example, Terri Schiavo's husband believed she would not want to receive artificial nutrition and hydration while her parents believed she would.
According to the Times, Mandela's family "has shown itself to be fractious about decisions regarding inheritance, his eventual burial location and his legacy." Unfortunately, even when legislators have enacted good end-of-life statutes, family disagreements can preclude a dignified process for making life-sustaining treatment decisions for incapacitated patients.