A Win-Win Healthcare Reform... that is Stuck on Endless Hold. NewsWire

NEWSWIRE: 3/9/20

• More kidney transplants would save lives and money—but in the U.S. health care system, there are few incentives to donate. With 100,000 Americans waiting for a transplant, those with kidney failure are stuck going through the costly, time-consuming daily routine of dialysis instead. (The Economist)
• NH: What if I told you about a simple health policy reform which, if enacted, would save at least 10,000 lives each year, would improve the quality of life for at least 100,000 more, and (after totaling up what taxpayers, insurers, and patients owe) would actually save our society some $20 billion annually. You'd probably think I was crazy. It sounds like the ultimate win-win, too good to be true.
• But there is such a reform. It is to give living kidney donors a reasonable award to donate their organs. Any payment at all to donors is now prohibited by the National Organ Transplant Act of 1984 (NOTA).
• Currently, there are not nearly enough kidney donors. Nearly 100,000 Americans with irreversible failure in both kidneys (end-stage renal failure) are on a waiting list for transplantation. And nearly twice as many patients (35,000) are added to list each year as receive a transplant (20,000). People on the list have no choice but to wait long enough--now nearly four years--until enough of their fellow patients either die or become too sick for a transplant so they can move to the front of the line. See tables below. Indeed, the list is so long that doctors don't even bother to add high-risk patients to it. By one estimate, as many as 43,000 Americans whose lives could be saved by a kidney transplant die each year. That's a big number. It's more than all annual traffic fatalities in the United States.
• Why do so many die while waiting? Because they have to take regular trips (two or three times a week) to a hemodialysis center which, while it keeps them alive, gradually wastes their bodies. A dialysis machine is only about 15% as effective as a living kidney at cleaning the blood of waste products and stabilizing its chemistry.
• Why are the number of kidney-failure patients growing? For a lot of familiar reasons: the rising number of middle-aged and senior Americans (Boomers and Silent) and the rising rate of obesity, diabetes, and hypertension, especially among younger Americans (Millennials and Gen-Xers). Meanwhile, the annual number of living donors (5,000) remains grossly inadequate. Deceased donors make up the majority of transplants (15,000) and that number is rising. Doctors are finding that even a kidney transplanted from a deceased donor who is aged or diseased is a vastly superior option for most ESRD patients than remaining on dialysis.
• Not only does the long waiting list give rise to enormous suffering, it is also very expensive. ESRD benefits, constituting a special program within Medicare, come to $35 billion annually, or 7% of all Medicare spending. The program was originally intended in 1971 to provide dialysis to 10,000 patients. It now provides dialysis to over 500,000 patients. Some 250,000 more patients are covered by private insurance. Most of that spending goes to two firms (Fresenius Medical Care, FMS, and DaVita Kidney Care, DVA), a massive near-duopoly with a combined market cap of about $35 billion.
• OK, so what sort of inducement would it take to raise the number of willing kidney donors to meet the annual demand for transplants and thus to eliminate most of the waiting list? Economists differ, but one well-researched figure is $45,000. Even after paying this bounty and after the cost of transplantation, government and insurers would still win by billions of dollars because the medical cost of keeping dialysis patients alive is so high (the dialysis alone costs about $90,000 per year). Many lives would be saved. The recipients would be in better health because they no longer have to wait on dialysis. And the dialysis caseload would be greatly reduced. The idea has received support from doctors and donors and in the WP, in the NYT, and in BBC News.
• There are objections. Some say it's wrong to "commercialize" body parts. But it is now legal to get paid for your hair, your blood, your semen, and your eggs. You can even rent out your uterus (at considerable risk) to another mom. So what's new here? Some say a transplant should be motivated by altruism. But here's the thing. When a kidney is transplanted, everyone in the operating room is getting paid a lot of money (the surgeon, assistants, nurses, anesthesiologists, et al.)--everyone except the donor. How does that make sense? Some worry that, in return for quick cash, some donors might be exploited or hide their health problems. Fine. That could be solved by staggered payouts. Or paying donors via tax credits or higher lifetime Social Security benefits.
• We don't have to set up a "market for organs." While most Americans are in favor of compensating donors, the margin of support increases when the payment is offered not as a market purchase but rather as a public reward for saving the life of another person.
• Amazingly, under current law, kidney donors are not even compensated for their travel to the hospital, their accommodations, their recovery time, or their lost wages. (President Trump, to his credit, has recently issued an executive order that aims to ameliorate these disincentives and improve services to dialysis patients.)
• I have argued countless times in these pages that our healthcare system suffers from critical dysfunction. Here is another case in point. Allow me to quote The Economist in conclusion: "The curious case of the kidney gives a few insights into the larger workings of the American health-care system. Small, fossilised provisions morph into huge programmes decades later. Government influence over prices may limit overall growth in costs, but can coincide with abnormally high profits for a few operators. And comparatively clear ideas for reducing billions in costs while improving thousands of lives can go ignored for years."

• From 2015 to 2018, marijuana use increased by 75% among Americans age 65 and older. A study from JAMA Internal Medicine shows that the increase has been driven largely among people without multiple chronic health conditions—in other words, that it’s recreational use rather than medicinal. (Reuters) 
• NH: Boomers are still toking after all these years. New data show that in just four years, past-year cannabis use grew from 2.4% (in 2015) to 4.2% (in 2018) among adults age 65 and older. That’s a 75% relative increase. And from a longer-term perspective: In 2006, the share of this age group that had used cannabis in the past year was a mere 0.4%. That means that cannabis use is up ten times among adults 65 and older over the past decade. Demographically, the biggest increases in this group over the 2015-2018 period occurred among women, the college-educated, nonwhites, and those with household incomes of $75K or more.
• These figures line up with previous data about rising cannabis use among Boomers. (See “Boomers and Xers Toke Up” and “Boomers Spend Big on Cannabis Products.”) What’s new is the breakdown on who’s using it. Legalization efforts have undoubtedly played a role in expanding the number of older users, particularly among nonwhites. But most of them don’t fall into the traditional “medical marijuana” category. In 2015, cancer was the chronic disease most likely to align with cannabis use. By 2018, that changed to heart disease. Those with fewer than two chronic diseases are also now markedly more likely to use cannabis (4.7%) than those with two diseases or more. Notably, however, there was a significant increase in cannabis use among those who had received mental health treatment in the past year (from 2.8% to 7.2%).
• One thing the study doesn’t reveal, unfortunately, is how many of these people are new users--versus longtime users simply aging into the “65 and older” bracket. Neither is there a more detailed examination of frequency or type of use (e.g. is it being mixed with alcohol?). There’s probably a good mix of both new and old users who are toking up in both healthy and unhealthy ways. But we await future studies to find out.

• Since 2005, the share of Japanese citizens with a passport has ticked down from 27% to 24%. Interest in foreign travel and study abroad programs has been dwindling, with demographic, economic, and work trends all converging to keep more Japanese at home. (The Economist)
• NH: This is clearly a generational trend. Back in the 1980s and 1990s, the authors explain, Japanese young people celebrated the excitement and adventure of travel abroad. Over the last twenty years, that enthusiasm has waned. Risk-averse Millennials report worrying about the dangers of foreign lands. Or about the high cost of travel. Or about their embarrassment over not speaking English well. Studying abroad peaked in 2004 at 83,000. It is now down to 56,000.
• Some of this shift is due to demographic aging. The number of elders in Japan is rising, and the number of young people is declining. One could also point to a recent ebbing in global trade (as a share of global GDP) as a bellwether, perhaps, for declining opportunities in commercial or professional employment abroad. Clearly, the coronavirus pandemic is going to suppress interest in foreign travel even further for the foreseeable future.
• But I don't think these explanations are adequate. There's something deeper going on, socially and culturally. Around the world, and especially in south and east Asia, we are witnessing the rise of ethnocentric nationalism. And its biggest supporters are Millennials, who are more likely than older citizens to vote for or favor a new wave of charismatic and authoritarian leaders who focus on their nation's cultural roots. This includes the Narendra Modi in India (Hindu roots), San Suu Kyi in Burma (Buddhist roots), Xi Jinping in China (Han roots). And yes it includes Shinzo Abe in Japan, whose Japan-first traditionalism--including visiting the controversial Yaskuni Shrine and creating new national holidays--is actually favored by most young voters. Thanks to their support, he just became the longest-serving Prime Minister in Japanese history.
• As for students studying abroad, this number has recently been decelerating or declining in nearly every major Asian nation. The turnaround has been especially sharp in the number coming to study in the United States during the Trump presidency. (See "Why Has Global Higher Ed Lost Its Luster?")

• A new study finds that a company’s political slant can make consumers less likely to buy their products or apply for a job there—but only if the company has conservative values. Liberal activism doesn’t affect Republicans’ or Democrats’ opinions of a company one way or another; it’s only conservative activism that turns off Democrats. (Harvard Business Review)
• NH: Businesses are increasingly associating themselves with the trendiest political cause (see “Shopping Along Partisan Lines”). But what do the actual shoppers think of companies taking a stand? 
• This Harvard survey told participants basic information about a fictional company and asked them their opinion of the brand. Then the surveyors told them that the company held either conservative or liberal values and then again asked participants to rate the business.
• When told that the company was liberal, participants did not have a significant change in attitude towards the organization. But when told the business was conservative, opinion of the company dropped 33%. Conservatives didn't mind a liberal brand, but liberals were turned off by associating with conservative firms.
• When looking at polarization, a recent Pew survey has shown that animus for the opposing party is associated with education level (see “Politics-Related Stress Worse Since Last Election”). Lower-educated Republicans are more likely to demonize the other side than lower-educated liberals. But the opposite is true for the highly educated: Democrats are more “partisan” than their Republican counterparts.
• How does the Pew survey shed light on the study published in the HBR? The subjects of the HBR study (conducted by two professors at GW University) were all either business managers or Harvard MBA students-- in other words, the highly educated. The Republicans in this group had no special ill-feeling toward liberal businesses, but the liberals detested the liberal brands.
• But the same might not have been true if the professors had looked at consumers of lower socioeconomic status. Take Wonder Bread for example. It is very likely that Flower Foods (FLO), the firm that produces this bread-in-name-only, wasn't much concerned about the NYT article that reported that the Georgia-based company gives over 99% of its political donations to Republican candidates. Why? They know who their customers are.

• A new book, The Ones We’ve Been Waiting For, argues that Millennials will use their political power to change America for the better. Time respondent Charlotte Alter profiles ten up-and-coming Millennial politicians from both sides of the aisle and their shared concerns about student debt and climate change. (New York)
• NH: Charlotte Alter, herself a Millennial, is a perfect representative of her generation. Her book opens with a dedication to her mom and dad, “who taught me everything.” She goes on to present a hopeful portrait of Millennials as a political generation, which both in framing and content reads like the predictions Bill Strauss and I made in Millennials Rising coming to fruition.
• Most of the figures that she covers are Democrats, who are divided between wanting to fix the system (Pete Buttigieg) and burn it down (AOC), but in service of the same vision of government: one that works actively to help its citizens. Another subject is Black Lives Matter activist Braxton Winston, who went from facing off with riot police to running for Charlotte, NC city council. Then there’s Svante Myrick, the youngest-ever mayor of Ithaca, NY, who made repairing the town’s infrastructure one of his top policy priorities.
• The book is organized around the events and touchstones that shaped these people’s views and pushed them into politics: 9/11, school shootings, the Great Recession, the Harry Potter books, Obama’s election, Trump’s election. Our longtime readers will recognize these already, but it’s rewarding to see them portrayed “from the inside.”
• Young Republicans make appearances, too--but true to Millennials’ political leanings, not many. The two who get the most page time are New York’s Elise Stefanik and Texas’s Dan Crenshaw.
• One place where Alter shines is in highlighting the shift from the culture wars of the ‘90s (which Boomer Republicans championed) to the PC wars of the ‘10s (which Millennial Republicans have taken up). The bitter battles over abortion and gay rights have transformed into fights over identity politics and censorship--an area that Crenshaw has seized on and one of the few issues where the GOP is gaining ground with young people. On issues like climate change, Millennial Republicans and Democrats look a lot more like each other than the partisans in older generations do. But on this one, they’re moving further and further apart.

• Board games are the latest item that’s being rebooted for nostalgic Xers and their kids. Game companies are rushing to remake 1980s classics like Dark Tower and are betting that Xers will turn to them as a good option for screen-free family time. (Bloomberg)
• NH: I have often talked about the resurgence of 80’s pop culture from TV shows like Stranger Things to books like Ready Player One (See “Lego: New Stress Reliever for Adults”). We're talking about Gen-X nostalgia. There comes a time when every generation begins to look back at the culture of their youth. Bringing back old board games is a lucrative way to cash in on memories which (in this case) midlife parents can share with their children.
• While the article frets about the cost of these games, they're actually a pretty good deal. Most new board games cost anywhere from $40 to $60. (The article talks about a $120 game, but that’s way out of the norm.) So let’s say you went with a higher end game and paid $60. If you play that game only 6 times in the entirety of owning it that’s only $10 a game. If four people play that’s only $2.50 per person.
• So board games are economical. They're perfect for Gen-X parents who want a closer sense of family. They're a last resort when you can't go outside (coronavirus?). And young people love the tactile experience: Along with vinyl records, board games enable them to escape the tyranny of their wall-to-wall digital environment. See "To Learn a Life Skill, Click Here."

• In Canada, youth hockey is increasingly too expensive for the next generation of kids to play. The average family spends about $1,700 CAD annually on gear, tournaments, and other fees, and those hoping to propel their kids to the pros shell out even more. (The New York Times)
• NH: Older hockey fans get wistful when they watch documentaries about NHL greats like Sidney Crosby or the Staal brothers growing up in the frozen and rural Canadian north. Ah, the innocent joy of it... carefree kids, grabbing some old sticks and skates in their spare time and running off to play "pond hockey" until the sun set. Everyone had fun and got exercise, the cost was minimal, and if a few kids happened to become skillful enough to be junior champions and graduate to the NHL, well, so much the better.
• But all that wistfulness disappears once today's fan becomes a parent of a kid who wants to play hockey.
• Carefree? Today's hockey training regimen for kids starts as early as age three and has all the spontaneity of a gladiatorial camp. To begin with, it monopolizes the time of both parent and kids--taking over their lives with training, practices, travel, and competition every weekday and (sometimes) every weekend. The activities are all choreographed with complex scheduling that requires dedicated software. The rules, regulations, and qualifying guidelines are mind-numbing. Sure you can skip a practice or event if you want, but that will give rise to whispers that you or your kid just aren't investing the effort to keep up with all your sleepless competitors.
• And yes, there's also the growing out-of-pocket cost. Which is the subject of this article. Who buys a $20 wooden hockey stick when you can buy a lighter and more powerful composite stick--for well over $100. Ditto for other equipment. A 2019 Canadian survey found that half of all parents of hockey kids were spending between $500 and $1,000 (CAD) on equipment for each kid per season. And then there are the registration fees, the ice-time fees, and the travel costs. Most punishing of all are expensive sessions with expert trainers or pricey tuition at elite hockey academies. A quarter of parents get an extra job or work overtime to cover the cost. A third take out loans.
• An economist would say that the cost in time and money keeps rising because the ultimate prize (a good college scholarship or a professional career) is a "positional good." There are only a fixed number of opportunities out there. So the marginal price of entry is determined entirely by the number of passionate parents with deep pockets. Inevitably, the price will keep rising until the rest are pushed out.
• As a result, youth involvement in Canadian hockey may be starting to wane. Hockey Canada reports that minor registrations have now been declining for four years straight among boys. Meanwhile, participation in more casual tennis and basketball leagues has risen. Many Canadian parents now report they can only afford to support hockey for one of their children. According to Joe Thornton, the veteran San Jose Sharks star, "If I were starting out to play hockey now, my parents wouldn’t have been able to afford to put me in the sport, that’s just the reality of it."
• So let Boomers and Xers reminisce fondly about their carefree sporting experiences twenty or thirty years ago. The reality for Millennials and Homelanders is very different. The quasi-professionalization of youth sports is harmful all around: It means that a growing share of kids don't play any sports; and, among those that do, repetitive stress injuries and emotional burnout is commonplace. (See "Kid Sports Are a Ticking Time Bomb")
• Glen Mulcahy, a Candian youth coach, recently wrote an essay called "Why Kids Quit Hockey." Here were his reasons, in this order: (1) it is no longer fun; (2) it is too competitive; (3) the time and travel commitment; (4) it costs too much; (5) to avoid coach or parent criticism. I think that list says it all.

• Today’s grandparents are more emotionally and financially involved in their grandkids’ lives than ever. But it’s not just the degree of involvement that’s changing: Increases in blended families and older parenthood are also redefining what these relationships look like. (Star-Tribune)
• NH: The new role that so many grandparents have taken up is a direct response to the disappearing nuclear family (see "Will the American Nuclear Family Die Out"). One of the reasons that intergenerational living is on the rise is that grandparents have had to step into the roles that Gen-X/Millennial parents have abdicated. Whether it's grandparents literally adopting their grandkids or simply helping the single parent with childcare, Silent and Boomer grandparents bring stability to the messy lives of the younger generations. With the nuclear family disintegrating, older generations pick up the pieces.  See "The New 30-Something: Bankrolled by Mom and Dad."
• And for Boomers, taking a great role in their grandchildren's lives isn't a problem. We have seen that, as Boomers move past age 65, they continue to want to live near (or with) their families. Since more of them are still working, they can help out materially as well. Helping their grandkids is no longer a burden but a meaningful priority.
• Did you ever actually imagine that the protective and involved uber-parents who raised the Millennial Generation were just going to watch their grandkids from afar?

• A handful of reality shows from the early 2000s are back—but this time, they’re kinder and gentler. In the reboots of Wife Swap, The Biggest Loser, Supernanny, and Extreme Makeover: Home Edition, there’s less conflict, less judgment, and more tears and hugs. (The Washington Post)
• NH: “The new niceness” in reality TV is a trend we picked up on all the way back in 2014. (See “All Aboard the Smile Train.”) For years, it’s expressed itself in two ways: in acerbic talk show hosts giving way to goofy, upbeat personalities (the latest in the lineup is Kelly Clarkson, whose talk show is a big hit), and in sweet-natured new series like Making It and Terrace House. (See “‘Kind’ Reality TV Takes Off” and “Niceness is Taking Over TV.”)
• Now reality TV’s entered its next phase: rebooting old shows and retrofitting them with the new tone. First was Netflix’s Queer Eye remake in 2018. Next came Lifetime’s Supernanny, which has swapped the title character’s pantsuit and no-nonsense demeanor for softer outfits and more compassionate parenting advice. Paramount’s Wife Swap has toned down the conflict and is more focused on finding common ground between the participants. The contestants on USA’s The Biggest Loser, meanwhile, no longer vote to eliminate other team members. Instead, they gather for group support sessions. The pivot to hugs and uplift doesn’t always work; once-nasty shows trying to embrace their feelings can feel a bit like Jerry Springer going from king of trash TV to solemn court judge. (Yes, that happened.)
• The one reboot that feels right at home is HGTV’s Extreme Makeover: Home Edition, which used to be a feel-good outlier in a sea of competition and catfights. The show has always been soppy, and now that matches what’s around it. The one big difference is that the houses in the new version, true to Millennial tastes, aren’t as “extreme.” Instead of McMansions, the participants are gifted with functional renovations and energy-efficient appliances. Now that’s nice.

DID YOU KNOW?

Have You Smiled At Your Boss Today? Employee monitoring in the workplace has become increasingly common in the name of security and productivity. Now employers are adding a new metric to the mix: happiness. According to The Wall Street Journal, more companies are tracking employees’ moods in hopes of improving morale and retention. Many are doing this by asking for feedback: Blue Cross Blue Shield, for instance, wants employees enrolled in their insurance programs to record their mood by dragging a slider between a smiley face and a frowny face. Amazon sends workers daily surveys asking questions like if they’ve had too many meetings recently. Other companies are automating the process: The software firm Receptiviti has three U.S. and Canadian-based clients signed up for its service, which searches e-mails and messaging systems for signs an employee is depressed or fatigued. No doubt that these efforts are being received differently across generations: Steady feedback is a natural fit for Millennials, but it screams Big Brother for Xers and Boomers.