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Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

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Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#191

Post by yummyfajitas »

Fomite wrote: post #186
aamar wrote: post #96

Earlier quoted context omitted.

> "1 in 1000 uninsured people die each year. It's not an exaggeration to say that due to the work we're doing here, 5,000-10,000 people will live to see the end of 2014." This probably a significant exaggeration. It is based on a 2009 study[1] which examined correlation, not causation. It did not control for many factors that may be relevant (e.g. smoking). The study expressed this in much more careful words: "Lack o…

> It did not control for many factors that may be relevant (e.g. smoking). From the abstract: "After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use" > On the authors of the correlation study, who should never have studied this question without looking at extensive control variables or without mor…

A randomized controlled trial where we deprive people of health insurance?

Yes.

Before instituting Obamacare/Romneycare/$POLICY, we should have run a pilot program based on random assignment with clear predefined success metrics. But that's politically dangerous - after all, what if the experiment shows that $POLICY doesn't work?

We did that, by accident, in Oregon (google Oregon Health Experiment). There were no statistically significant results beyond the placebo effect [1]. Strangely, none of our fact based politicians have proposed scrapping the medicaid expansion based on that.

[1] People with insurance perceived themselves to be healthier before actually consuming any medical care and became less depressed. But no statistically significant difference was observed in any of the objective metrics chosen before the study started.

Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#192

Post by Fomite »

ekianjo wrote: post #190
Fomite wrote: post #187

Earlier quoted context omitted.

Not only do they have significant value, but they're the only type of evidence you'll ever have for something like this - it's impossible, and almost certainly unethical - to run a randomized trial of keeping people from having health insurance. Also, while "Correlation is not causation" is, as you mentioned, a tired canard on the internet, people often seem to forget that all things that do have a causal relationshi…

Sorry, but no. 100 times no. Correlation is very often linked to a third factor or multiple factors which are not visible, nor measured in observational studies. Besides, let's not disregard the fact that correlation still has some good chance to be pure luck. Even correlation with 95% confidence statistical significance can be a random result in a non-nil number of times. So, no, you never prove anything nor imply a…

Find me where I said proof.

There are all kinds of things that we cannot prove, because it is either impossible or wildly unethical to conduct a randomized study. For those things, you can make a determined effort to control for as many "third factors" - the technical term for them is confounders - and that gives you a level of evidence which is well above guessing.

Since I can't reply to your comment, my responses here:

> "You didn't say proof but you said it's better than guessing, and I don't agree with you at all."

It is better than guessing. You're welcome to disagree, but a well conducted observational study is considerably firmer evidence than pulling it from your posterior.

> "What if there is a correlation between Vegetarian-lifestyle and Serial-killers ? Does it tell you that it's better than guessing ? Do you even question if the association/correlation makes remote sense ? Is there any underlying mechanism of action that would remotely explain rationally why this correlation could be linked to any real causation phenomenon ?"

All you've done is describe a really bad study. You can have really bad RCTs as well, by the way.

Of course you question whether or not an observed association has a clear biological or social mechanism. And you attempt to control for other variables that might influence the link between your exposure and your outcome. You run followup studies in different populations to try to understand if the result is a widespread phenomena, or a fleeting bit of statistical noise.

Basically, you do your job well. Which is why I used phrases like "a good first step".

Your example is about as useful as "Programming is useless because once I coded something poorly and corrupted my data".

Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#193

Post by Fomite »

yummyfajitas wrote: post #191
Fomite wrote: post #186

Earlier quoted context omitted.

> It did not control for many factors that may be relevant (e.g. smoking). From the abstract: "After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use" > On the authors of the correlation study, who should never have studied this question without looking at extensive control variables or without mor…

A randomized controlled trial where we deprive people of health insurance? Yes. Before instituting Obamacare/Romneycare/$POLICY, we should have run a pilot program based on random assignment with clear predefined success metrics. But that's politically dangerous - after all, what if the experiment shows that $POLICY doesn't work? We did that, by accident, in Oregon (google Oregon Health Experiment). There were no sta…

Medical and public health researchers are bound to ethical guidelines that would prevent something like this, because the preponderance of evidence is that having health insurance is a net positive for someone's health - the only reason it made sense in Oregon is the fact that they needed a lottery anyway.

As for the Oregon study, the results of that study are still relatively new (the idea that any measure focused on preventative health will show results after two years is pretty suspect). The authors of the study discuss this for diabetes:

"Medicaid significantly increased the probability of being diagnosed with diabetes after the lottery (by 3.8 percentage points, relative to a base rate of 1.1) and use of diabetes medication (by 5.4 percentage points, relative to a base rate of 6.4). As discussed in the paper, based on clinical trial evidence on diabetes medication, we would expect this increase in the use of medication for diabetes to decrease the average glycated hemoglobin level in the study population by 0.05 percentage points, which is well within our 95% confidence interval for the impact of Medicaid on the level of glycated hemoglobin."

Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#194

Post by yummyfajitas »

aamar wrote: post #180
dannyr wrote: post #174

Earlier quoted context omitted.

I'm curious what do you think would have happened if you just let it go. "This is a hard and unanswered problem. This statement is so strong that, if it were true, it would eliminate a vast territory of alternate paths to answers ("oh, you did X? My code saved 50 lives this year.")." It seems like you are more of the problem rather than Brandon's statement. No matter what Brandon says, accurate or not, people will st…

I hope my clarifications help explain what I meant in my parent comment. I believe the following are potentially bad consequences of Grayson's/Mikey's claim spreading: - People work on insuring others, at the expense of other activities that they would otherwise believe to be more valuable. - Insuring people (or the ACA) is deemed a failure because mortality rates do not come down as "expected", plausibly leading to…

Why would your second point be a bad consequence? If the ACA doesn't work and we repeal it, isn't that a good thing?

Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#195

Post by abecedarius »

JonFish85 wrote: post #26
pdeuchler wrote: post #21

>> "It is also a story of an Obama Administration obsessed with health care reform policy but above the nitty-gritty of implementing it. No one in the White House meetings leading up to the launch had any idea whether the technology worked." I used to be this guy. The guy with the lofty ideas, but who thought the implementation was "beneath me". The guy who would sit around, waxing poetic about various features, user…

>It hit me then that while ideas may have value, the implementation usurps all of it. An idea alone is powerful, but once it's implemented the idea becomes worthless. You need both. Implementation people aren't all that useful without a vision. A vision isn't all that useful without implementation. It's a symbiotic relationship. Steve Jobs without a Steve Wozniak probably wouldn't have been as successful. Steve Wozni…

Jobs and Wozniak don't match this discussion very well: Woz was responsible for both the idea and the implementation, to first order. It's true that without Jobs there wouldn't have been a company.

Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#196

Post by yummyfajitas »

Fomite wrote: post #193
yummyfajitas wrote: post #191

Earlier quoted context omitted.

A randomized controlled trial where we deprive people of health insurance? Yes. Before instituting Obamacare/Romneycare/$POLICY, we should have run a pilot program based on random assignment with clear predefined success metrics. But that's politically dangerous - after all, what if the experiment shows that $POLICY doesn't work? We did that, by accident, in Oregon (google Oregon Health Experiment). There were no sta…

Medical and public health researchers are bound to ethical guidelines that would prevent something like this, because the preponderance of evidence is that having health insurance is a net positive for someone's health - the only reason it made sense in Oregon is the fact that they needed a lottery anyway. As for the Oregon study, the results of that study are still relatively new (the idea that any measure focused o…

By this logic, it would be unethical for the FDA to demand a random trial for any drug that has some correlation studies showing it is effective.

As for the number you are cherrypicking, it is true that health insurance increased medical consumption (including ER visits, in spite of what ACA supports claimed) among people who received it. However, no measurable effect on health (besides depression) was observed.

Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#197

Post by ekianjo »

Fomite wrote: post #192
ekianjo wrote: post #190

Earlier quoted context omitted.

Sorry, but no. 100 times no. Correlation is very often linked to a third factor or multiple factors which are not visible, nor measured in observational studies. Besides, let's not disregard the fact that correlation still has some good chance to be pure luck. Even correlation with 95% confidence statistical significance can be a random result in a non-nil number of times. So, no, you never prove anything nor imply a…

Find me where I said proof . There are all kinds of things that we cannot prove, because it is either impossible or wildly unethical to conduct a randomized study. For those things, you can make a determined effort to control for as many "third factors" - the technical term for them is confounders - and that gives you a level of evidence which is well above guessing. Since I can't reply to your comment, my responses…

You didn't say proof but you said it's better than guessing, and I don't agree with you at all. What if there is a correlation between Vegetarian-lifestyle and Serial-killers ? Does it tell you that it's better than guessing ? Do you even question if the association/correlation makes remote sense ? Is there any underlying mechanism of action that would remotely explain rationally why this correlation could be linked to any real causation phenomenon ?

Correlation is useless, and there's a ton of observational studies out there finding correlations every single day for which we have no rational explanation at all. Observational studies are full of variations in the way they are designed, the way they are reported and the subjects of the studies, it's rather a miracle if you actually detect a hint of causation based on the garbage noise that you get.

Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#198

Post by Fomite »

yummyfajitas wrote: post #196
Fomite wrote: post #193

Earlier quoted context omitted.

Medical and public health researchers are bound to ethical guidelines that would prevent something like this, because the preponderance of evidence is that having health insurance is a net positive for someone's health - the only reason it made sense in Oregon is the fact that they needed a lottery anyway. As for the Oregon study, the results of that study are still relatively new (the idea that any measure focused o…

By this logic, it would be unethical for the FDA to demand a random trial for any drug that has some correlation studies showing it is effective. As for the number you are cherrypicking, it is true that health insurance increased medical consumption (including ER visits, in spite of what ACA supports claimed) among people who received it. However, no measurable effect on health (besides depression) was observed.

You'll find that clinical trials are regularly halted when the treatment is found to be markedly superior or inferior to placebo or the control group.

The original study that showed aspirin's effect on heart attack prevention comes to mind for the former circumstance, and a number of HIV prevention studies for the latter.

Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#199

Post by vinhboy »

kalvin wrote: post #160
brandonb wrote: post #38

I've been working on healthcare.gov for the last few months alongside a bunch of other Google, Facebook, and Y Combinator alums. I'll always remember what Mikey told us in December, after the site was back up, could handle a non-trivial amount of traffic, and people who wanted health insurance could finally get it: "1 in 1000 uninsured people die each year. It's not an exaggeration to say that due to the work we're d…

(I'm working with Brandon) To clarify, you don't need to be able to commit long term-- if you can take leave from what you're otherwise doing for a few months, that's enough. If you want to work on something with real impact and help change the culture of government technology, email Brandon above! We're actively looking for a few good people.

So, out of genuine curiosity, why are you doing it? To help the country? It's exciting? For the money? Or some other reason completely?

What about your co-workers. What's everyone motivation to help fix this site?

Re: Obama's Trauma Team: Inside the Nightmare Launch of HealthCare.Gov

#200

Post by yummyfajitas »

Fomite wrote: post #198
yummyfajitas wrote: post #196

Earlier quoted context omitted.

By this logic, it would be unethical for the FDA to demand a random trial for any drug that has some correlation studies showing it is effective. As for the number you are cherrypicking, it is true that health insurance increased medical consumption (including ER visits, in spite of what ACA supports claimed) among people who received it. However, no measurable effect on health (besides depression) was observed.

You'll find that clinical trials are regularly halted when the treatment is found to be markedly superior or inferior to placebo or the control group. The original study that showed aspirin's effect on heart attack prevention comes to mind for the former circumstance, and a number of HIV prevention studies for the latter.

Halting a clinical trial when the result is clear is very different from skipping the clinical trial on the basis of a correlation study or two. Your comparison is so nonsensical that either you are being deliberately disingenuous or you don't understand statistics at all.

Either way, no point in continuing this.

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