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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

#201

Post by aamar »

yummyfajitas wrote: post #194
aamar wrote: post #180

Earlier quoted context omitted.

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?

In the ideal world, we'd analyze all of the ACA's costs and benefits and decide whether or not to repeal. But realistically, the most visible "promised" benefits (not necessarily those promised by the authors of the bill) are overweighted in the analysis.

I believe the ACA should be understood to promise increased insurance rates leading to (a) less medical bankruptcy and (b) moderate improvement in certain healthcare measures (not mortality). I don't think it should be deemed a failure in any sense if it fails to reduce mortality amongst the newly insured.

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

#203

Post by laz »

edabobojr wrote: post #6

One question I have - were the high-tech wizards paid standard gsa rates? https://www.gsaadvantage.gov/ref_text/GS35F5457H/0LUS2P.2NVK... Page 25. Top developer rate for 2014 is $99/hr which requires 10 years of experience.

That was not the hourly rate

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

#204

Post by aamar »

thisisdave wrote: post #175
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). Unless I'm misreading the polifact article you linked to in [2], it says that the 2009 study did control for smoking, and that they did a better job of controlling for such factors than previous studies. > Still, their work stands out from previous efforts because it used more recent survey data and presented a more apples-to-apples analysis be…

You are right, the 2009 Wilpers paper does bucket out current and former smokers, as well as look at BMI and other factors. The authors should be credited for that. But when those factors are considered, the null hypothesis is only barely rejected at 95% confidence. The Kronick paper uses a much larger dataset and discusses the issue of what is controlled for more extensively.

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

#205

Post by Fomite »

yummyfajitas wrote: post #200
Fomite wrote: post #198

Earlier quoted context omitted.

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.

I was being charitable to your example, because generally speaking there are no observational studies done before a drug is put up for approval - that's not how the approval pipeline works. The closest I can come up to your example is the occasional off-label use of a drug for some other condition, but the reports from those are largely small n studies. That's entirely different from a series of studies based on NHANES.

Beyond that, in an intentional randomized trial, rather than the 'happy accident' like the Oregon study, the actual control is not 'Nothing' but the medically indicated standard of care. Studies are often required to provide medical care, education, etc. to their participants. I cannot imagine a study managing to get "We deny a bunch of folks health insurance" by an IRB unless it was an externally forced process, like the Oregon study.

Your insult about not understanding statistics, in addition to being off-base, is rather spurious. This isn't a statistical question, it's a public health ethics question. Statistics doesn't really come into whether or not "Keep a bunch of people from accessing healthcare" will get nailed by an approval board.

Also, the FDA often does take observational evidence into account, especially when expanding things like what age range a drug is medically indicated for.

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

#206

Post by Fomite »

yummyfajitas wrote: post #200
Fomite wrote: post #198

Earlier quoted context omitted.

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.

While we're on the topic, Bayesianwitch.com's description:

"Your new homepage goes viral, but you aren't sure what copy is converting. Hook that copy up to BayesianWitch and only converting copy will be showing. No waiting days for the answers from an A/B test."

Seems to imply a reliance on "correlational" data. Is there some hidden randomization in there? Or are you giving your clients a lower standard of evidence?

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

#207

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…

If you refer to Table 2 of the NEJM article 'The Oregon Experiment — Effects of Medicaid on Clinical Outcomes', while none of the results are statistically significant, most of the effect measures are headed in the right direction.

Someone who works for 'Bayesianwitch' should know better than to rely on p = 0.05 as the sole basis on which to evaluate something.

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

#208

Post by Fomite »

aamar wrote: post #204
thisisdave wrote: post #175

Earlier quoted context omitted.

>It did not control for many factors that may be relevant (e.g. smoking). Unless I'm misreading the polifact article you linked to in [2], it says that the 2009 study did control for smoking, and that they did a better job of controlling for such factors than previous studies. > Still, their work stands out from previous efforts because it used more recent survey data and presented a more apples-to-apples analysis be…

You are right, the 2009 Wilpers paper does bucket out current and former smokers, as well as look at BMI and other factors. The authors should be credited for that. But when those factors are considered, the null hypothesis is only barely rejected at 95% confidence. The Kronick paper uses a much larger dataset and discusses the issue of what is controlled for more extensively.

So wait, now not only are we using hypothesis testing as your sole means of evaluating whether or not an effect exists, but you're moving the threshold around because...you want to?

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

#209

Post by anatoly »

Fomite wrote: post #187
slurry wrote: post #138

Earlier quoted context omitted.

Why would you blame the study authors for doing a correlation study? I know "CORRELATION IS NOT CAUSATION!!!" is the go-to takedown on the internet, but correlation studies actually can have significant value - otherwise peer-reviewed journals wouldn't publish them. I'm also skeptical of Politifact's competence to adjudicate public health scholarship.

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…

You keep saying 'unethical' as if it's the end of the discussion. But what if our current standard of medical ethics prevent us from finding the better policies or the better treatments? Is this standard set in stone and never to be doubted?

Probably taking away insurance from people who have it as an experiment is too extreme, and not implementable anyway. But is it really that unethical to take a subset of population without insurance, give it to a random subset for some time, and observe the differences? Why? No one from the control group is prevented from getting insurance on their own (compare with the candidate drug trials, where the control group can't just buy the drug on their own).

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

#210

Post by dannyr »

RickHull wrote: post #179
dannyr wrote: post #154

Earlier quoted context omitted.

"But I don't think a statistic like this should be left unchallenged on HN." Yeah, thanks for fighting for the cause! #sarcasm Is HN supposed to be a place where we try to find a flaw on every statement and make sure it doesn't go unnoticed? What you pointed out doesn't even diminish an ounce of what Brandon and his teammates are doing.

> What you pointed out doesn't even diminish an ounce of what Brandon and his teammates are doing. Right. It sounds like you're implying that was his intent, and he failed. I really think it was an noble effort to get to the heart of what might be a misleading soundbite. Very much in the spirit of HN.

But it's such a small part of Brandon's post.

Is the spirit of HN nitpicking the smallest things?

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