I'd make the same comment about these studies as Vinasy Prasad made about a recent mask study, the time period studied wss too short to realistically measure effect. For example, the health effects of less food insecurity early in life is that children are taller, which is the effect of years. Further, the amount of money was low, likely driven by the stuy budget rather than the amount to Also, the outcome studied were those that were easy to study, not necessarily the ones that count (like the drunk looking for his lost keys not where he lost them but under the light because that's where he could easily see). ED visits and MD visits and admissions are easy to count, but they are not the best measure of health (longevity is bettter, for example). In the studies food insecurity did decrease, and as I remember the study money was spent on the necessities of life. One example of the effect of even the meager amount given was that with the added security that person could undertake education that led to a higher paying job. Not everything that can be counted, counts. Not everything that counts, can be easily counted. That creates a challenge, but it must be met rather than substituting measurable and short term irrelevancies.
You write "there were no differences in health outcome measures, such as BP, BMI, HbA1c or cholesterol level.". These are not health outcome measures - they are risk factors.
I appreciate that these researchers published these randomized trials. Otherwise our society risks spending finite resources on measures that may sound good but are not effective, and indirectly diverting resources from other uses.
Many comments are accurate, but miss the primary point of the study. The question is does a cash payment have such a powerful impact on health that it overcomes all the variables? These studies would say no, and most people here (and most people overall) would not be surprised by that.
But public and government policy is usually just big sticks -- universal basic income, universal pre-school, subsidies for fresh vegetable carts in food deserts, etc. Answering if a policy can be powerful enough to outweigh the variables of humanity is a great reason to do the studies.
Otherwise we risk putting huge resources into policies that do no good based on faith, the way so many people who comment "know" the actual cause for poor health outcomes.
Are the participants educated about how food can make a difference between health and unhealthy.
Are the participants regularly seen throughout the trial? If not, why?
Are they working? At what? If not, why?
How many hours of sleep?
After seeing a doctor and being prescribed medications, are they taken regularly?
Are they single, married, have a family, pregnant?
Smoking, who does, who doesn't?
Illegal drug intake?
Do they take the bus or drive?
There are way too many variables to make these trials worthwhile.
Of course I could be missing some or all of this information somewhere along the line. I can't see how either trial was worth the money or time without having more stringent protocols and mandatory interventions.
Neither study looked at the availability and quality of the healthcare providers in the area.. how about a random study with a heath center specific to the group with doctors and nurses who care about the health and wellbeing of the patients and not getting them in and out as fast as possible. I personally love my doctor, but I have friends that don’t have a relationship with a doctor and they dread going to the doctor because they never know what they are walking into..
I'd like to see a study on healthcare access that controls for all the dangerous medical interventions (statins, opioids, etc) that US healthcare providers push on people.
I'm no socialist but 400 seems a little low to make a meaningful difference. If your income is only 16000 per year absolutely every extra dollar you get (up to a point, ways away from 400) will be vacuumed up by everyday expenses.
“Knowing what does not work” is pure music in the ears of the left…aka Dems and RINOs… for they will call the study racist and display the very results as reason to pronounce it as capitalist and worthy of even greater tax payer funded support to all…to absolutely include every illegal who steps on US territory of any type…St Thomas…All US protected island changes…any military base overseas. Does this same result apply to statins in those without heart symptoms but with calcifications in the elderly where the cardiologist pushes even more powerful statins..you being the independent cardiologist.
"If low income causes poor health, then treating low income (with cash) should improve health."
Cash giveaways are too small to improve outcomes. That's not what they're used for. Cash Giveaways are behaviour modifiers for the poor, because as we all know, the wealthy don't need behavioural modification, they're just perfect as they are.
In order to improve outcomes, a cash giveaway would need to be substantial, at a minimum, rent for a month.
Here's one that should strike a chord: As a license requirement, what are the benefits of mandatory controlled drug training or domestic abuse training? My hypothesis is that there are none, but the requirement is designed to create a demand for useless courses so the license applicant can check the box.
Hello Dr. Mandrola, thank you for sharing your valuable analysis of the two studies.
Regarding your magnificent critique of Agarwal's article (which has accustomed us to these interesting research ideas), "Effect of Cash Benefits on Health Care Utilization and Health," [ 1], I would say that while money is the essence of the capitalist world, "money isn't everything in life." And, to coin a popular Spanish saying: "Lo que no nos cuesta, volvamoslo fiesta". ("What costs us nothing, let’s make a celebration of it.")
In essence, incentives, whether in cash or in-kind, for vulnerable people should aim to modify their habits and customs, not increase their pocket money, especially intended for "educational security" in nutrition. This is in complete opposition to the standard North American diet, with 70% carbohydrates and genetically modified polyunsaturated fatty acids, which, without euphemism, are responsible for 80% of the disease burden, consultations, emergencies, hospitalizations, morbidity, and death, not just in the USA. [2]. To coin another pair of sayings, 'We shouldn’t just give fish but teach how to fish,' or 'We shouldn’t just provide food but teach how to eat and then supply or subsidize healthy foods.
Of course, all health policies must be scientifically evaluated (very few are), through experimental or at least quasi-experimental studies. A few years ago, we had the opportunity to closely observe the results of the observational study that estimated the risk factors associated with the escalation of violent death experienced in the city of Bogotá, Colombia, which at that time was higher than the armed conflict in Afghanistan and the Gulf War : From those risk factors, the Mayor's Office of Bogotá, under Antanas Mockus, "devised" an ecological quasi-experiment of "before and after," design, which was called "Ley Zanahoria" (Carrot Law). It was very simple but forceful: to enforce the closure of establishments selling alcohol at 11 pm. The following weekend, from a rate of 161/100,000 inhabitants of violent deaths before the "Ley Zanahoria," it dropped to 27/100,000, a humanly significant reduction of 6 times in the mortality rate (in just one week). Of course, every human intervention is susceptible to side effects: the ruin of the "night society," which forced the subsequent mayors to gradually increase the closing time to 12 pm, 1 am... until the balance of saved lives reached an "equilibrium" with the ruin of others!!!!
In other words, real interventions in health policies should address the causal reality and not paternalistic assistance. By the way, I believe you are aware of the existence of these two powerful randomized ecological experiments cited bellow [ 3, 4], on violent and economically vulnerable clusters in Philadelphia, showing how beautifying abandoned lots and areas not only reduces shut and crime violence, sexual assault, and drug trafficking rates but also reduces the feeling of anxiety and other mental health aspects in the "experimentally intervened" individuals.
Let me Know, what do you think about that?
A hug and congratulations on "Sensible Medicine."
------
References cited:
1. Agarwal, S. D., Cook, B. L., & Liebman, J. B. (2024). Effect of Cash Benefits on Health Care Utilization and Health: A Randomized Study. JAMA, e2413004. Advance online publication. https://doi.org/10.1001/jama.2024.130042.
2. Echeverry-Raad, J. (2024). A falsehood that has been repeated many times becomes true: The origin of the diabesity pandemic, the most lethal of the 21st century? Journal of Diabetes and Metabolic Disorders, 11(1), 39-50. https://doi.org/10.15406/jdmdc.2024.11.00276
3. Branas CC, South E, Kondo MC, et al. (2018). Citywide cluster randomized trial to restore blighted vacant land and its effects on violence, crime, and fear. Proc Natl Acad Sci U S A;115(12):2946-2951. doi:10.1073/pnas.1718503115
4. South EC, MacDonald JM, Tam VW, Ridgeway G, Branas CC.(2023) Effect of Abandoned Housing Interventions on Gun Violence, Perceptions of Safety, and Substance Use in Black Neighborhoods: A Citywide Cluster Randomized Trial. JAMA Intern Med.;183(1):31-39. doi:10.1001/jamainternmed.2022.5460
Ever think that even randomized trials or double blinded trials are not what they are cracked up to be? In any trial, how can you account for every factor that might affect the outcome of that trial? Unless the trial participants are pre-programmed robots, many will stray the course and trial sponsors might never know by how much. There can never be a one-size-fits-all assumption for any trial or any practice of medical interventions.
I'd make the same comment about these studies as Vinasy Prasad made about a recent mask study, the time period studied wss too short to realistically measure effect. For example, the health effects of less food insecurity early in life is that children are taller, which is the effect of years. Further, the amount of money was low, likely driven by the stuy budget rather than the amount to Also, the outcome studied were those that were easy to study, not necessarily the ones that count (like the drunk looking for his lost keys not where he lost them but under the light because that's where he could easily see). ED visits and MD visits and admissions are easy to count, but they are not the best measure of health (longevity is bettter, for example). In the studies food insecurity did decrease, and as I remember the study money was spent on the necessities of life. One example of the effect of even the meager amount given was that with the added security that person could undertake education that led to a higher paying job. Not everything that can be counted, counts. Not everything that counts, can be easily counted. That creates a challenge, but it must be met rather than substituting measurable and short term irrelevancies.
You write "there were no differences in health outcome measures, such as BP, BMI, HbA1c or cholesterol level.". These are not health outcome measures - they are risk factors.
Example of unintended consequences:
Insurance mandates make insurance cost more -->
Many turn to income-based subsidies -->
Subsidies phase-out as income increases at 25 cents per dollar->
Subsidy ends up as de facto income tax -->
Reduced ability to increase take-home pay as much of additional income makes insurance more expensive
Thank you for the write-up.
I appreciate that these researchers published these randomized trials. Otherwise our society risks spending finite resources on measures that may sound good but are not effective, and indirectly diverting resources from other uses.
Many comments are accurate, but miss the primary point of the study. The question is does a cash payment have such a powerful impact on health that it overcomes all the variables? These studies would say no, and most people here (and most people overall) would not be surprised by that.
But public and government policy is usually just big sticks -- universal basic income, universal pre-school, subsidies for fresh vegetable carts in food deserts, etc. Answering if a policy can be powerful enough to outweigh the variables of humanity is a great reason to do the studies.
Otherwise we risk putting huge resources into policies that do no good based on faith, the way so many people who comment "know" the actual cause for poor health outcomes.
Yikes. Too many variables.
What was the money spent on
Are the participants educated about how food can make a difference between health and unhealthy.
Are the participants regularly seen throughout the trial? If not, why?
Are they working? At what? If not, why?
How many hours of sleep?
After seeing a doctor and being prescribed medications, are they taken regularly?
Are they single, married, have a family, pregnant?
Smoking, who does, who doesn't?
Illegal drug intake?
Do they take the bus or drive?
There are way too many variables to make these trials worthwhile.
Of course I could be missing some or all of this information somewhere along the line. I can't see how either trial was worth the money or time without having more stringent protocols and mandatory interventions.
Neither study looked at the availability and quality of the healthcare providers in the area.. how about a random study with a heath center specific to the group with doctors and nurses who care about the health and wellbeing of the patients and not getting them in and out as fast as possible. I personally love my doctor, but I have friends that don’t have a relationship with a doctor and they dread going to the doctor because they never know what they are walking into..
I'd like to see a study on healthcare access that controls for all the dangerous medical interventions (statins, opioids, etc) that US healthcare providers push on people.
I'm no socialist but 400 seems a little low to make a meaningful difference. If your income is only 16000 per year absolutely every extra dollar you get (up to a point, ways away from 400) will be vacuumed up by everyday expenses.
“Knowing what does not work” is pure music in the ears of the left…aka Dems and RINOs… for they will call the study racist and display the very results as reason to pronounce it as capitalist and worthy of even greater tax payer funded support to all…to absolutely include every illegal who steps on US territory of any type…St Thomas…All US protected island changes…any military base overseas. Does this same result apply to statins in those without heart symptoms but with calcifications in the elderly where the cardiologist pushes even more powerful statins..you being the independent cardiologist.
This is a faulty outlook on cash giveaways.
"If low income causes poor health, then treating low income (with cash) should improve health."
Cash giveaways are too small to improve outcomes. That's not what they're used for. Cash Giveaways are behaviour modifiers for the poor, because as we all know, the wealthy don't need behavioural modification, they're just perfect as they are.
In order to improve outcomes, a cash giveaway would need to be substantial, at a minimum, rent for a month.
The socialists will be extremely disappointed.
Well then I guess we should go back to workhouses...
Dr Mandrola, Great post on an important topic.
Here's one that should strike a chord: As a license requirement, what are the benefits of mandatory controlled drug training or domestic abuse training? My hypothesis is that there are none, but the requirement is designed to create a demand for useless courses so the license applicant can check the box.
Hello Dr. Mandrola, thank you for sharing your valuable analysis of the two studies.
Regarding your magnificent critique of Agarwal's article (which has accustomed us to these interesting research ideas), "Effect of Cash Benefits on Health Care Utilization and Health," [ 1], I would say that while money is the essence of the capitalist world, "money isn't everything in life." And, to coin a popular Spanish saying: "Lo que no nos cuesta, volvamoslo fiesta". ("What costs us nothing, let’s make a celebration of it.")
In essence, incentives, whether in cash or in-kind, for vulnerable people should aim to modify their habits and customs, not increase their pocket money, especially intended for "educational security" in nutrition. This is in complete opposition to the standard North American diet, with 70% carbohydrates and genetically modified polyunsaturated fatty acids, which, without euphemism, are responsible for 80% of the disease burden, consultations, emergencies, hospitalizations, morbidity, and death, not just in the USA. [2]. To coin another pair of sayings, 'We shouldn’t just give fish but teach how to fish,' or 'We shouldn’t just provide food but teach how to eat and then supply or subsidize healthy foods.
Of course, all health policies must be scientifically evaluated (very few are), through experimental or at least quasi-experimental studies. A few years ago, we had the opportunity to closely observe the results of the observational study that estimated the risk factors associated with the escalation of violent death experienced in the city of Bogotá, Colombia, which at that time was higher than the armed conflict in Afghanistan and the Gulf War : From those risk factors, the Mayor's Office of Bogotá, under Antanas Mockus, "devised" an ecological quasi-experiment of "before and after," design, which was called "Ley Zanahoria" (Carrot Law). It was very simple but forceful: to enforce the closure of establishments selling alcohol at 11 pm. The following weekend, from a rate of 161/100,000 inhabitants of violent deaths before the "Ley Zanahoria," it dropped to 27/100,000, a humanly significant reduction of 6 times in the mortality rate (in just one week). Of course, every human intervention is susceptible to side effects: the ruin of the "night society," which forced the subsequent mayors to gradually increase the closing time to 12 pm, 1 am... until the balance of saved lives reached an "equilibrium" with the ruin of others!!!!
In other words, real interventions in health policies should address the causal reality and not paternalistic assistance. By the way, I believe you are aware of the existence of these two powerful randomized ecological experiments cited bellow [ 3, 4], on violent and economically vulnerable clusters in Philadelphia, showing how beautifying abandoned lots and areas not only reduces shut and crime violence, sexual assault, and drug trafficking rates but also reduces the feeling of anxiety and other mental health aspects in the "experimentally intervened" individuals.
Let me Know, what do you think about that?
A hug and congratulations on "Sensible Medicine."
------
References cited:
1. Agarwal, S. D., Cook, B. L., & Liebman, J. B. (2024). Effect of Cash Benefits on Health Care Utilization and Health: A Randomized Study. JAMA, e2413004. Advance online publication. https://doi.org/10.1001/jama.2024.130042.
2. Echeverry-Raad, J. (2024). A falsehood that has been repeated many times becomes true: The origin of the diabesity pandemic, the most lethal of the 21st century? Journal of Diabetes and Metabolic Disorders, 11(1), 39-50. https://doi.org/10.15406/jdmdc.2024.11.00276
3. Branas CC, South E, Kondo MC, et al. (2018). Citywide cluster randomized trial to restore blighted vacant land and its effects on violence, crime, and fear. Proc Natl Acad Sci U S A;115(12):2946-2951. doi:10.1073/pnas.1718503115
4. South EC, MacDonald JM, Tam VW, Ridgeway G, Branas CC.(2023) Effect of Abandoned Housing Interventions on Gun Violence, Perceptions of Safety, and Substance Use in Black Neighborhoods: A Citywide Cluster Randomized Trial. JAMA Intern Med.;183(1):31-39. doi:10.1001/jamainternmed.2022.5460
Ever think that even randomized trials or double blinded trials are not what they are cracked up to be? In any trial, how can you account for every factor that might affect the outcome of that trial? Unless the trial participants are pre-programmed robots, many will stray the course and trial sponsors might never know by how much. There can never be a one-size-fits-all assumption for any trial or any practice of medical interventions.