Showing That You Care The Evolution of Health Altruism

Showing That You CareThe Evolution of Health Altruism Robin Hanson RWJF Health Policy Scholar U.C. Berkeley/San Francisco (8/99: Economics, G.M.U.)

Think different.

Talk Outline • Medicine has little net health value • Idea: loved ones push, to show care • Theory Approach • seek few assumptions explain much • evolutionary psychology • Non-obvious results inform policy

“our best summary of health” 5pts = hypertension G.H.I. 95% copay 25/50% 95%/Free Free Spend $/Year RAND Health Insure Experiment • 20K person-yrs ‘74-82 • Random vary copay • Free (vs. pay): • More glasses, fillings • Less days fully active • Lower blood pressure? (1% less mortality?) • Same: satisfaction, appropriateness

“The RAND H.I.E. documented that patient copayments led to underuse of preventive care services and to a lower proportion of patients whose hypertension was adequately controlled.” [M. Chassin ‘98 Milbank Quarterly 76(4)]

Evolutionary Psychology • Our preferences, behavior adapted to hunter-gatherer environment • Illuminates mating, parenting … • eat too much fat, sugar, salt • women live longer than men

Old Ways to Show Allegiance Groom, gossip, share food, visit, host visitors, adopt customs, make home, wedding/funeral, revenge kill, injury care, ... • Many signals lost, substitution hard • Evolved focus on long-term signals

1. Ally Concern 2. Allies Protect 3. Private Info Altruism for show Assumptions Explain Phenomena • group = correlated allies • status = more better allies • want alliances to seem real • Paternalism • esp. low status • Status Healthy • placebo effect • Medicine Not • esp. high status • neglect quality

Two Types of Signals • Individual to Group • I care, so you should keep me. “If I thought I’d leave or be dumped, doing this wouldn’t be worth it.” • Group to Individual • We care, so calm down. “If we thought you’d leave or be dumped, doing this wouldn’t be worth it.”

Individual to Group Signals • Pay/push docs like funerals, visit sick? • Recipients want to “be cared for.” • Predicts more care if • recipient high status (e.g., elderly) • giver insecure, has fewer other signals • long-term allies (e.g., married with kids)

Group to Individual Signals • Needs want calmer allies (e.g., stress). • Nations, companies seek allegiance • individuals signal via push group choice • Predicts no international health care • Stress version predicts • placebo effect (argues against?) • rich not get more care than “rest of us”

Predictions & Implications • Neglect private quality signals • Spend more due to luxury, not new tech • Insure min/subsidy helps if signal risk, but hurts if signal care • Care no longer says about long-term • Need review all allegiance signals

help? A B help? Cost to A of care Dc A B = seen by ignorant? G q p q p offer taken? Value to A of being in Value to A of being in G / c’(q) / c’(q) Benefit to B of Dc if in wpq Less stress helps B if in B lowers stress if p higher / c’(p) wpq All Three Assumptions Imply Signal Via Over-Care + (b/g)

Medicine as luxury Leisure as luxury Assume More, Explain More Allies matter more when all richer • Rich have few kids • No famine morals

Showing That You Care The Evolution of Health Altruism