It’s possible that I shall make an ass of myself. But in that case one can always get out of it with a little dialectic. I have, of course, so worded my proposition as to be right either way (K.Marx, Letter to F.Engels on the Indian Mutiny)
Wednesday, July 26, 2023
Ground-breaking e-scooter study shows surface transitions as most common hurdle
A historic study has provided first-time insights on electric scooters.
IMAGE: VTTI CONDUCTED THE FIRST LARGE-SCALE NATURALISTIC DRIVING STUDY OF ELECTRIC SCOOTER RIDERS. PHOTO BY JACOB LEVIN FOR VIRGINIA TECH.view more
CREDIT: VIRGINIA TECH
A historic study has provided first-time insights on electric scooters.
In September 2019, Virginia Tech Transportation Institute (VTTI) began the first large-scale naturalistic driving study of electric scooter, also known as e-scooter, riders. Over the span of 18 months, 50 scooters, equipped with forward-facing cameras and other research equipment, collected over 9,000 miles of data from over 200,000 rides on Virginia Tech's Blacksburg campus. Deployment of the scooters began in August 2019. After being removed from campus during the COVID-19 pandemic, they were redeployed in August 2021 through the academic year.
“The e-scooter deployment at Virginia Tech collected the largest naturalistic e-scooter data set known to date and quantified the safety risks associated with behavioral, infrastructure, and environmental factors,” said Elizabeth White, programs and business manager for VTTI. “This was a very exciting research program to be a part of, and our collaboration with many departments on campus was invaluable to ensuring a safe deployment.
White was the lead researcher of the team that included six other Virginia Tech researchers and other industry experts. The results were recently published in published in the Journal of Safety Research.
Utilizing VTTI’s proprietary data acquisition system (DAS), researchers found that infrastructure-related factors, the behaviors of e-scooter riders and other around them, and environmental factors all created risk for e-scooter users. They found loss of control related to infrastructure was the greatest contributor, to all crash- and near-crash events, equating to 47 percent. In total, infrastructure caused 67 percent of incidents, followed by the presence of other road users at 19 percent and rider behavior at 14 percent.
Transitions from surfaces, such as moving from gravel or dirt to grass, proved to be the riskiest. Those riders were almost 60 times more likely to have a crash or near-crash experience. This was supported by data showing that riding off a designated path, or off-road, made users nearly 25 times more likely to experience such issues compared to those who rode on a shared-use path.
uring the study, there were no crashes between an e-scooter and a moving vehicle captured. Conflicts with other road users were shown to be more avoidable through evasive maneuvers when compared to infrastructure-related events. Researchers believe this is likely caused by riders misjudging the terrain or infrastructure or a lack of skill in navigating those obstacles.
VTTI pioneered DAS in the 1990s and it is frequently used by researchers to provide an in-depth look at driver behaviors. These systems allowed rider behavior, interactions with other road users, and other valuable safety data to be recorded and analyzed for various trends. To date, it has been used on everything from e-scooters to semi-trucks. For the e-scooter study, devices did not film the rider, just the riding behavior in order to maintain rider privacy. Riders also were limited to the Blacksburg campus.
To improve safety for riders, the research team recommends all riders engage in an educational outreach program that discusses the significant risks associated with infrastructure, behavior, and environmental factors. Meanwhile, VTTI and its partners will continue to study ways to improve safety around Blacksburg and beyond.
“We are in continued conversations with campus stakeholders to determine the future of micromobility on the Virginia Tech campus,” said White.
More information on the origins of the research can be found online.
The project was funded in part by the Safety Through Disruption, a grant from the U.S. Department of Transportation’s University Transportation Centers program. The research was conducted in partnership with Ford and Spin.
IMAGE: A NEW STUDY EXAMINES CONSUMERS’ FAMILIARITY WITH BIOPLASTICS IN JAPAN, THEIR PREFERENCES FOR BIOPLASTIC PRODUCTS, AND THE EFFECT OF EDUCATIONAL INTERVENTIONS ON THEIR PREFERENCES.view more
CREDIT: TAKURO UEHARA FROM RITSUMEIKAN UNIVERSITY, JAPAN
Non-biodegradable plastics are major contributors to land and marine pollution, destroying habitats and causing harm to both flora and fauna. Hence, the switch to bioplastics is imperative to ensure sustainability. The success of environmental initiatives aimed at increasing bioplastic adoption critically hinges on understanding consumer behavior. However, consumer preferences and perceptions around bioplastics, particularly in Japan and other Asian countries, are not well understood.
A recent study published online on July 10, 2023 in the Journal of Cleaner Productionattempted to find answers to questions surrounding Japanese consumers’ preferences for bioplastics. “So far, attempts to improve bioplastic adoption in Japan have been hindered by a lack of clarity on the factors influencing consumer preferences. We attempted to shed light on these factors in our comprehensive large-scale study,” explains Professor Takuro Uehara from the College of Policy Science, Ritsumeikan University, who led the study.
The goal of the study was three-fold: understanding how familiar consumers in Japan are with bioplastics, revealing their preferences for bioplastics based on different factors, and examining how educational interventions affect their choices. To achieve this, the researchers surveyed over 12,000 respondents using questions focused on three products — 500 mL PET water bottles, three-color ballpoint pens, and 500 mL shampoo bottles. The respondents were divided into two groups: the treatment group, who were educated on the basic distinctions between bio-based and biodegradable plastics, and the control group, who did not receive educational interventions. Then, the researchers performed discrete choice experiments and text mining based on responses from these 12,000 participants.
Their findings yielded interesting insights, particularly highlighting a common trend among Japanese consumers and their European counterparts, which is a limited comprehension of the distinctions between bio-based, biodegradable, and bioplastics. Surprisingly, most respondents were unaware of the fact that not all bioplastics are biodegradable and bio-based. This demonstrated the need to improve consumer awareness regarding the characteristics and environmental impact of bioplastics.
Another important finding was the complexity of consumer preferences for bioplastics in Japan and the influence of general perceptions and personal values on these preferences. Notably, the preference for bioplastics among these consumers was not unconditional. In fact, most consumers were not in favor of using biomass in any of the three products. Among the different types of feedstock, they preferred sugarcane over wood chips, and favored waste cooking oil the least. This was likely owing to their greater emphasis on quality than on the trade-offs of biomass feedstock.
Nevertheless, there were several key factors the respondents considered valuable in their preference for bioplastics. These included the reduction in carbon dioxide emissions, which was the most valued attribute across all three products in both the control and treatment groups. Another key factor was biodegradability, which was associated with positive responses from participants. Significantly, the respondents expressed a preference for domestic products, although the reasons were generally related to safety, quality, and reliability rather than environmental considerations.
Finally, the findings showed that educational interventions can influence consumer decisions, increasing their willingness to pay for more environmentally friendly products, including those with better feedstock incorporation and those enabling reductions in CO2 emissions. For example, after learning that bioplastics can be fossil-based, respondents gave greater value to products with reduced CO2 emissions. Interestingly, this preference was only significant for water bottles, suggesting that consumers were more sensitive to water bottles — that tend to be less durable — than to the other two products.
Overall, the findings provide a picture of the kinds of products Japanese consumers prefer and the attributes they focus on while making choices surrounding bioplastics. Prof. Uehara comments, “Our results will help Japanese industries and governments understand the type of bioplastics that would be preferred and accepted by consumers, giving them an impetus to develop more such products and improve bioplastic use.” He adds, “Information dissemination can influence consumer preference for bioplastic products, which highlights the importance of awareness campaigns.”
The findings from Prof. Uehara and his group could serve as a foundational roadmap for increasing bioplastic use in Japan and mark a significant step in Japan’s transformation into a bioeconomy.
About Ritsumeikan University, Japan Ritsumeikan University is one of the most prestigious private universities in Japan. Its main campus is in Kyoto, where inspiring settings await researchers. With an unwavering objective to generate social symbiotic values and emergent talents, it aims to emerge as a next-generation research university. It will enhance researcher potential by providing support best suited to the needs of young and leading researchers, according to their career stage. Ritsumeikan University also endeavors to build a global research network as a “knowledge node” and disseminate achievements internationally, thereby contributing to the resolution of social/humanistic issues through interdisciplinary research and social implementation.
About Professor Takuro Uehara from Ritsumeikan University, Japan Takuro Uehara is a Professor at the College of Policy Science, Ritsumeikan University. His research deals with a range of subjects, including social-ecological modeling, economic valuation of nature, sustainability, resilience, relational values, and marine plastic pollution.
He obtained his doctoral degree in Systems Science: Economics from Portland State University. He has authored research papers in leading journals, including Ecological Economics, Ecology and Society, Ecosystem Services, Journal of Environmental Management, Journal of Cleaner Production, People and Nature, Science of The Total Environment, and Sustainability Science.
Funding information This study was funded by the Environment Research and Technology Development Fund of the Environmental Restoration and Conservation Agency of Japan [JPMEERF21S11920].
(Boston)—World-wide obesity has nearly tripled since 1975, according to the World Health Organization. Numerous causes of obesity have been hypothesized including increased dietary fat, carbohydrate or ultra-processed food (UPF) consumption, inactivity, hyperlipidemia and hyperinsulinemia. Based on these hypotheses, solutions have been sought that involved decreasing consumption of suspected agents. Well-controlled studies have shown that increased consumption of UPF is associated with increased food consumption and weight gain while decreasing UPF consumption in the same subjects was associated with weight loss. However, these studies do not identify a specific cause of obesity since the diets include multiple variables.
In a new perspective, Barbara E. Corkey, PhD, professor emeritus of medicine and biochemistry at Boston University Chobanian & Avedisian School of Medicine, presents an alternative testable and actionable hypothesis/model about the cause of obesity. If validated, it could indicate clear steps to reverse obesity.
Humans vary in the efficiency with which they burn and store nutrients in response to overeating. Some people waste more energy when they overeat and store less. Those individuals tend not to gain weight easily. Humans also vary in their reaction to food deprivation. Some conserve energy better than others and when they diet, they don’t lose weight easily. “These are normal variations and we are each a bit different, due to genetics, but we respond to the same signals,” said Corkey.
Her hypothesis postulates that obesogens (certain chemical compounds that are hypothesized to disrupt normal development and the balance of lipid metabolism) which have entered the environment in the last 50 years, generate misinformation in our bodies, such as inappropriate insulin secretion or hunger, that lead to obesity. Obesogens, she believes, can generate changes in redox state (a normal signal of either excess or the need for energy) that are unrelated to energy needs but falsely stimulate hunger or fuel storage when not needed
“The increasing incidence of obesity correlates with heightened consumption of UPF along with thousands of potential environmental toxins including some derived from fertilizers, insecticides, plastics and air pollutants. Identifying these agents would allow us to remove them or inhibit their ability to generate misinformation,” said Corkey.
Corkey’s model, if validated, could impact many if not all obesity-related diseases. Her paper examines readily available ways to test her model. She believes the best outcome from this work would be identification of obesogens and their removal. The second best outcome would be treatments that block their effect on the body’s normal regulatory mechanisms for insulin secretions.
These findings are published by the Philosophical Transactions of the Royal Society B.
JOURNAL
Philosophical Transactions of the Royal Society B Biological Sciences
IMAGE: EMORY RESEARCHER PRESENTING FINDINGS AT THE INTERNATIONAL AIDS SOCIETY CONFERENCE IN BRISBANE, AUSTRALIAview more
CREDIT: EMORY UNIVERSITY
The results of a novel study presented by Emory researchers during the International AIDS Society (IAS) Conference in Brisbane, Australia, have revealed exciting findings in the pursuit of an HIV cure. The study, led by Monica Reece, a PhD candidate in Emory’s Microbiology and Genetics Program, and directed by Christina Gavegnano, PhD, demonstrates the potential of Jak inhibitors, specifically ruxolitinib, to significantly decay the viral reservoir in people with HIV, offering a novel pathway toward long-term remission or a cure.
The HIV viral reservoir, essentially a small number of immune cells containing dormant virus integrated into the genomes of individuals who have suppressed viral replication with HIV treatment, has posed a major impediment to achieving an HIV cure. These cells are completely undetectable by the immune system because the virus is dormant. But as soon as treatment stops, the virus reactivates.
“The barrier to an HIV cure is that the virus hides inside the DNA of cells,” says Gavegnano, director of the Gavegnano Drug Discovery Program and senior author on the study. “The brass ring is an agent that can eliminate these‘reservoir cells,’ which would ultimately eliminate HIV from a person’s body.”
While Gavegnano and her Emory colleagues have shown that Jak inhibitors (Janus kinase inhibitors) could reverse the immune dysfunction caused by HIV since their discovery in 2010, questions about their impact on the HIV reservoir and the exact mechanism contributing to the immunologic improvements have remained unanswered, until now.
The data presented at IAS represented secondary results from a Phase 2a clinical trial centered on investigating ruxolitinib’s effects on viral reservoirs in people with HIV during a five-week regimen, specifically in a subset of individuals with high viral reservoir levels at baseline.
The study measured integrated proviral DNA, which is the genetic material of a virus as incorporated into, and able to replicate with, the genome of a host cell, and examined changes in total, intact only, and defective proviral DNA copies over time. Based on a linear model of decay, the researchers estimated an astonishing 99.99% clearance of the peripheral HIV-1 reservoir in less than three years. These data provide optimism for the use of Jak inhibitors as a backbone for cure-based eradication strategies in the battle against HIV.
Reece, lead author of the study says, “These data suggest that our Jak inhibitors can not only reverse the immune dysfunction that prevents HIV-1 cure, but also significantly decay the reservoir in people living with HIV. Collectively our trial demonstrates a mechanism by which ruxolitinib, or other Jak inhibitors such as baricitinib, also extensively studied by our group, decay the reservoir, which underscores potential for cure-based therapies.”
The profound impact of Ruxolitinib treatment was not limited to reservoir reduction. The study also shed light on several significant biomarkers that were altered by the drug primarily related to:
Immune activation: Ruxolitinib exhibited the potential to modulate immune activation, which is crucial in controlling viral replication and maintaining immune health in individuals with HIV.
Cell survival: Ruxolitinib demonstrated the ability to impact cell survival, influencing the lifespan of reservoir cells and potentially limiting viral reservoir longevity.
Immune dysregulation: The study identified ruxolitinib’s impact on immune dysregulation, offering hope for mitigating the chronic inflammation and immune dysfunction often observed in individuals with HIV.
It is important to note that the study focused on the peripheral viral reservoir and may not fully represent the entire viral reservoir within the body, including sanctuary sites where HIV can persist despite treatment.
Regardless, the findings from Emory University’s study offer hope and renewed enthusiasm for efforts to unravel the complexities of HIV persistence and ultimately find a cure.
“These data are valuable because they show that Jak inhibitors can contribute to a long-term cure strategy for HIV, but they can also be used to slow the inflammatory process caused by other infectious diseases,” says Vincent Marconi, MD, professor of medicine and global health at Emory University School of Medicine.
Marconi, who led the initial phase 2a trial, has already been investigating the efficacy of Jak inhibitors, like ruxolitinib and baricitinib, in patients with acute COVID and now long COVID. He continues, “using an anti-inflammatory drug to treat the effects of a virus could be revolutionary.”
In addition to the data presented by Reece and Gavegnano, another presentation at IAS has shown how ruxolitinib administered to a patient following a stem cell transplant led to an undetectable viral load 20 months after stopping antiretroviral therapy, highlighting the different mechanisms in which these class of drugs could be valuable in HIV care and treatment.
Further research and clinical trials will be needed to fully understand the effects of Jak inhibitor use in HIV and other immune-suppressing conditions. Emory researchers have an extensive history of working with Jak inhibitors. Gavegnano and researcher Raymond Schinazi are listed on the issued patents as sole inventors, and they, alongside their co-investigators, have built a roadmap for tackling a variety of immunosuppressive viruses with these drugs.
Gavegnano emphasizes, “The safety and efficacy outcomes we observed in this study provide a strong foundation for further research on cure-based interventions containing a Jak inhibitor, and we hope to bring this therapy one step closer to helping people living with HIV.”
METHOD OF RESEARCH
Randomized controlled/clinical trial
SUBJECT OF RESEARCH
People
COI STATEMENT
N/A
Residents must have a voice in ocean conservation
University of Miami Rosenstiel School researchers Daniel Suman and Claire B. Paris-Limouzy are co-authors of a recent journal article that outlines ways to achieve greater equity in ocean governance and science in the global tropics.
IMAGE: FISHERMEN WHO LIVE IN COASTAL COMMUNITIES MUST BECOME PART OF THE DECISION-MAKING PROCESS FOR LAWS THAT IMPACT THEIR LIVELIHOOD, ACCORDING TO A JOURNAL ARTICLE WRITTEN BY ROSENSTIEL SCHOOL RESEARCHERS AND OTHERS.view more
CREDIT: PHOTO COURTESY OF VANESSA CROOKS/OFFICE OF COMMUNICATIONS, SMITHSONIAN TROPICAL RESEARCH INSTITUTE
For the coastal residents in Sri Lanka, Southern India, and Thailand who survived the 2004 Indian Ocean tsunami that killed more than 200,000 people, the nightmare was just starting. After the disaster, their communities—and with them, their way of life—were permanently relocated inland, clearing the way for tourism development.
Today, people in another part of the world are also facing the threat of displacement. Thousands of villagers who live along the banks of Mozambique’s Zambezi River and depend on the waterway for their livelihood could be forced from their lands if a $4.2 billion mega dam project goes forward in their community.
While differing in the reason for displacement, both cases are prime examples of how poor, Indigenous people in tropical regions are excluded from the decision-making processes that affect the use of their lands.
“The tropics are a biodiversity storehouse, and the majority of people who are directly ocean-dependent live there,” said Daniel Suman, a professor of environmental science and policy at the University of Miami Rosenstiel School of Marine, Atmospheric, and Earth Science. “Those residents can be described as the ‘tropical majority.’ Yet, the laws and policies that affect the oceans and waterways in their countries are often made by international organizations, international financial institutions like the World Bank, and global environmental groups in richer countries located in temperate zones.”
Suman and Rosenstiel School biological oceanographer Claire B. Paris-Limouzy are two of 25 authors—80 percent of whom call the tropics home and three of whom are University of Miami alumni—who recently published a paper in the journal Ocean Sustainability that calls on policymakers to address inequities in ocean science and governance.
“We need to give a voice to the tropical majority,” said Suman, describing the problem as an “environmental justice issue” rife in many tropical countries, particularly in Latin American nations such as Honduras and Ecuador.
“People who live in or near mangroves there and have used those mangroves traditionally but don’t have property title to them have, in many cases, lost access to those mangroves because they have been privatized, or wealthier groups have come in and gotten concessions, legally or illegally, to build shrimp ponds, displacing locals,” explained Suman, who holds an adjunct appointment in the University’s School of Law.
To ensure the tropical majority can play a leading role in maintaining ocean sustainability and ecosystems, policymakers must center equity in ocean governance, reconnect people and the ocean, redefine ocean literacy, and decolonize ocean research, the authors agree.
“From many of the international agreements that come out of high-level United Nations meetings, specific goals related to issues such as sustainable fisheries or marine protected areas are already established,” Suman said. “Specific goals about equity, about fairness to people, about the inclusion of the rights of traditional peoples who rely on the oceans must also be incorporated. And it needs to be solid, actionable goals, not just words.”
Policymakers, Suman added, must incorporate into new laws the indigenous knowledge coastal residents have about the areas in which they live. “That knowledge must be respected just as much as the scientific information developed largely by scientists in wealthier countries,” he said. “Fishermen and poorer people know a lot about the environment. Even though they may not have received a formal education, they know about weather, and they know where the fish are. They know weather patterns, and their knowledge should be respected and included in ocean management.
“And recognizing that traditional users can be good stewards and good protectors of the environment by using their local knowledge is the most effective way to reconnect people and the ocean,” Suman continued. “The hope is that our journal article will help raise awareness about these issues.”
The idea for the article, “Engaging the tropical majority to make ocean governance and science more equitable and effective,” started at the eighth Our Ocean Conference held in Panama last March. Lead authors and Oregon State University researchers Ana K. Spalding and Kirsten Grorud-Colvert, who both earned graduate degrees from the Rosenstiel School, assembled a team of multidisciplinary scientists from around the global tropics to discuss actionable solutions for ocean conservation.
While the group, which included Suman and Paris-Limouzy, discussed the most pressing problems affecting the ocean, they also quickly realized that inequity in ocean governance and ocean science was a matter that required just as much attention.
“The thought was that an article like this might encourage the inclusion of equity in international ocean governance meetings and agreements,” Suman said.
It will be a challenge to accomplish that goal, he admitted.
“Among the biggest challenges is how to include traditional ecological knowledge within the decision-making process. There must be more inclusion and recognition by decision-makers of the need to include local users and invite those people to the table.” Suman said. “And it will certainly be a multiyear effort to make that happen.”
If you were ever to see sewage sludge up close, you might be hard-pressed to find any redeemable value; however, researchers at UBC’s Bioreactor Technology Group see it another way.
Using a combination of heat, water and phase separation, UBC researchers have developed a cost-effective method to concentrate phosphorous—which can be efficiently recovered by extraction—from wastewater sludge.
“Phosphorous is a non-renewable, but essential, element for life and has many industrial uses,” explains Huan Liu, a doctoral student with UBCO’s School of Engineering and lead author of a new study investigating this method.
Phosphorus is a natural mineral crucial for human health and essential to food security as a commercial fertilizer; however, it's also listed as a critical raw material because many countries rely on imports.
“The uneven distribution of phosphate rock has created political and economic risks,” he says. “On the other hand, phosphorus discharge from waste sources, such as wastewater, is a major contributor to aquatic eutrophication, causing severe environmental challenges including algae blooms and dead zones in lakes.”
Liu and his supervisor, principal investigator Dr. Cigdem Eskicioglu, are investigating a promising process that integrates hydrothermal liquefaction.
The process converts organic components of the municipal wastewater sludge into a petroleum-like bio-crude and concentrates the phosphorous into a solid residue called hydrochar. The hydrochar can have 100 times higher total phosphorus than raw sludge, making it comparable to the phosphate rock used in commercial fertilizers.
Liu describes the extraction process as mirroring what happens when you mix minerals and acids. “We were able to identify, for the first time, the kinetic reactions of phosphorus leaching from hydrochar to optimize the recovery of useful materials, such as what is needed for fertilizer,” says Liu.
According to Dr. Eskicioglu, their latest findings are essential for wastewater utilities aiming to develop a process to recover usable nutrients from the system.
“At a time when we are seeking to be more sustainable and looking for alternative fuels, extruding useable materials from waste is essential,” she says. “Recovery and recycling is the solution that also provides the double benefit of providing a secondary source of phosphorus that can be globally distributed and also help with environmental conservation.”
This latest study appears in the journal Water Research and was funded by the Natural Sciences and Engineering Research Council of Canada and the Metro Vancouver Industrial Research Chair Program in Advanced Resource Recovery from Wastewater. Liu also conducted six months of studies in France in collaboration with Dr. Ange Nzihou’s team at the Research Centre for Particulate Solids, Energy and Environment at the IMT Mines Albi-Carmaux engineering school.
IMAGE: “WE’VE GOT YOU COVERED,” A BOOK CO-AUTHORED BY MIT ECONOMIST AMY FINKELSTEIN, DESCRIBES A WAY TO REVAMP HEALTH CARE IN THE UNITED STATES.view more
It’s not exactly what he’s best known for, but Alexander Hamilton helped develop the first national, compulsory health insurance policy in the world: a 1798 taxpayer-financed plan Congress approved to cover sick and disabled seamen.
“The interests of humanity are concerned in it,” Hamilton wrote.
And they still are, as MIT Professor Amy Finkelstein notes in a new book. The U.S. has repeatedly tried to provide medical care for those who need it and cannot afford it. These efforts may have started with Hamilton, but they have continued through modern times, with policies that have mandated emergency-room care for all, and have extended insurance to those with certain serious illnesses.
Then again, no policy has fully addressed the needs of the U.S. population. About 30 million U.S. citizens lack health insurance. Even for the insured, costs routinely exceed a plan’s benefits. Americans have $140 billion in unpaid medical debt, more than all other personal debt combined, and three-fifths of it is incurred by people with health insurance.
That’s why Finkelstein is calling for a total overhaul of the U.S. health insurance system, in a new book with economist Liran Einav of Stanford University, “We’ve Got You Covered: Rebooting American Health Care,” published by Portfolio. In it, the scholars envision an approach with one layer of free and automatic health insurance for everyone, and another layer of private insurance for those seeking additional care amenities.
“In the U.S., we have always had a commitment to do something when people are ill, so we might as well do it effectively and efficiently,” says Finkelstein, the John and Jennie S. MacDonald Professor in MIT’s Department of Economics. “I don’t think anyone would argue we have a wonderful, well-functioning health care system.”
Patchwork programs
Finkelstein has won the John Bates Clark Medal and received a MacArthur fellowship for empirical studies of health insurance and health care — including work on Medicaid and Medicare, the financial impact of being hospitalized, geographic variation in medical costs, and more. Finkelstein and Einav are also co-authors, with Ray Fisman, of the 2023 book, “Risky Business,” about the insurance industry.
Through two decades of intensive research, Finkelstein and Einav have also never advocated for specific health care policies — until now.
“We feel we do have something to say to the wider public about the problems, and also about the solution,” Finkelstein says. “We emphasize the problems of the insured, not only the uninsured.”
Indeed, around 150 million Americans rely on private employer-provided insurance. Yet they risk losing that insurance if they lose or change their job. Those with public health insurance, like Medicaid, face nearly the opposite problem. If a family member earns enough money to lift a household above the poverty line, they can lose eligibility. The net result: About one in four Americans under the age of 65 will be uninsured at some point in the next two years.
Many of them will actually be eligible for free or heavily discounted coverage. About 18 million Americans who are eligible for public health insurance remain unenrolled due to a lack of information and complicated signup procedures. And even Medicare, the workhorse public insurance program for many seniors, has out-of-pocket expenses with no cap. A quarter of people on Medicare spend a quarter of their income on health care.
Some reforms have brought better coverage to more people. As the scholars note, the Affordable Care Act of 2010 (which MIT economist Jonathan Gruber helped develop) has allowed 10 million formerly uninsured Americans to gain coverage. But it didn’t change the risk of losing insurance coverage or of incurring large medical debt due to highly incomplete coverage.
The book contends the U.S. has used a long series of piecemeal policies to try to fix problems with health coverage in the U.S. One long-standing approach has been to create disease-specific care subsides, starting with a 1972 law extending Medicare to everyone with end-stage kidney disease. More recently, similar programs have been passed to cover patients with tuberculosis, breast and cervical cancer, sickle cell anemia, ALS, HIV/AIDS, and Covid-19.
Finkelstein and Einav are skeptical of this approach, however, due to its patchwork nature. Passing separate laws for different illnesses will always leave holes in coverage. Why not just automatically include everyone?
“When you think about covering all the gaps, that’s what universal basic coverage is,” Finkelstein says.
Land of the free
As “We’ve Got You Covered” notes, the current U.S. approach to health insurance is hardly etched in concrete: Employer-provided health care really only dates to the 1950s. And, the authors emphasize, the way the U.S. keeps instituting policies to make basic care available to anyone — open emergency rooms, subsidies for severe disease treatments — is telling us that the country has a bottom-line expectation of providing humane care when most needed.
“The reason why we have all these patches is that, hard as it is to believe, in the United States there is in fact a strong social norm, an unwritten social contract, that we don’t let people die in the streets,” Finkelstein says. “When people are in dire medical situations and don’t have resources, we inevitably as a society feel compelled to try to help them. The problems of the insured and the uninsured represent failures to achieve our commitments, not the lack of those commitments.”
To Finkelstein and Einav, then, the solution is to provide free, basic health care for everyone. No sign-up woes; enrollment would be automatic. No charges for basic care. No losing insurance if you leave your job. No falling off the public-insurance ranks if you climb above the poverty line.
At the same time, they envision, the U.S. would have another layer of private health insurance, covering health care amenities — private hospital rooms, say, or other elective elements of medical care. “You can pay to upgrade,” Finkelstein says.
That would not lead to the system of absolutely equal, universal care that some envision, but Finkelstein still believes it would improve the status quo.
“We have inequality in all aspects of our lives, and this is another,” Finkelstein says. “The key is to provide essential basic coverage.”
Could the U.S. afford a system of free, basic, automatic-enrollment health care? The book’s surprising answer is: Yes, absolutely. In the U.S., 18 percent of GDP is spent on health care. Half of that goes to public health care, and half on private care. As it happens, 9 percent of GDP is how much European countries spend on their public-care health systems.
“We’re already paying for universal coverage in the United States, even though we’re not getting it,” Finkelstein says. “We’re already spending 9 percent of GDP on publicly financed health care. We certainly could do it at the same price tag as all these other countries.”
“We’ve Got You Covered” even comes out against modest co-pays (despite studies showing they reduce visits to doctors), finding them “in conflict with the rationale for universal coverage, namely, access to essential medical care without regard to [financial] need,” as Finkelstein says.
Until the impossible becomes inevitable
If the Finkelstein-Einav health insurance system makes sense on the merits, though, does it have any chance of existing?
“One thing that makes me, if not optimistic, then at least not unduly pessimistic, is that this is an argument that will and does appeal to people across the political spectrum,” Finkelstein contends. Expanding health insurance is usually associated with progressive politicians, but the book points to a series of conservatives who, even into the 21st century, have supported universal coverage.
Even if a change to a free system of basic care is not immediately in the offing, Finkelstein and Einav suggest in the book that their role, in writing “We’ve Got You Covered,” is something economist Milton Friedman suggested: Develop ideas and keep them in the public sphere until “the politically impossible becomes the politically inevitable.”
And in the meantime, Finkelstein and Einav firmly suggest people take more seriously the way U.S. health care policy implicitly assumes we should help everyone. And for the same reasons Hamilton wanted to help seamen, namely, “to protect from want and misery” in their lives.
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Written by Peter Dizikes, MIT News
Book: “We’ve Got You Covered: Rebooting American Health Care”
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