Insurers finding a clever way to exclude preexisting conditions despite Obamacare rules

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A friend in the healthcare biz told me that insurers have found a way around the Obamacare requirement that customers be welcomed despite preexisting conditions. The government left insurance companies and doctors the freedom of association. For conditions that are expensive to treat the insurance company will limit reimbursement to a handful of specialists with inconvenient locations, hours, and availability.

If it takes more than a year in Massachusetts to see a primary care doctor for a regular exam (see the end of my Bad Pharma review), just imagine how long it will take expensive-to-treat patients who choose one of these carefully crafted plans to see the specialist who can prescribe them a $100,000 per year medication!

The Chicago Garry Winogrand

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If you share a love of Garry Winogrand’s work (see this blog posting and this photo.net book review), you’ll probably enjoy seeing the work of his Chicago-based doppelganger: Vivian Maier (1926-2009). See her online portfolios, for example, and this three-minute BBC video.

[Separately, it seems odd that the folks trying to make money out of this woman's work by selling prints are doing them in a 16x20-inch size (link). A lot of street photography seems to work better if printed smaller, especially if originated with a 35mm film camera.]

Government: Unemployed person = helpless victim or lazy criminal, as situation demands

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A friend’s daughter is doing some research on divorce, custody, and child support litigation. Today I took her over to the Middlesex County Probate and Family Court in East Cambridge so that she could see what was happening. It turned out that we were there on “Department of Revenue (DOR) Day” where the Commonwealth itself sues deadbeat dads on behalf of mothers who had previously been successful custody and child support plaintiffs but hadn’t received the amounts ordered. This saves the moms from having to retain and pay attorneys; the lawsuits are handled by taxpayer-funded attorneys.

The first guy to appear was, not to put too fine a point on it, a genuine bum. He appeared to be in his 50s, with graying hair, shabby clothing, and a physically disabled posture that might have been due to the fact that he was in handcuffs and ankle chains. He had last worked at a biotech company in Massachusetts back in 2010, but it wasn’t clear in what role. He paid child support to a trim, well-dressed plaintiff while he was working and continued to pay child support while collecting unemployment. When that ran out and he still hadn’t found a job he fled to Idaho and worked as a caretaker in exchange for a free place to sleep. “How did you eat?” asked the judge. “Food stamps,” he replied. During this period he called the three children (current ages: 17, 20, and 22 (in Massachusetts it is possible to collect child support for children until they turn 23)) but didn’t send any money to their mother. “Where are you living now?” With his mom in Billerica, it turned out. The DOR attorney railed against this loser who had “abandoned his responsibilities” and “refused to work” and asked that he be imprisoned for 60 days and fined $5000 on top of the $41,000 that he owed his former plaintiff and the money that he continued to owe for the two adults and one minor child. Throughout the proceeding the chained deadbeat was surrounded by five armed sheriffs, each of whom was probably costing the taxpayer $250,000 per year (salary, benefits, pension, etc.). The judge asked him a few questions about the efforts he was making to get a job, e.g., “How many resumes have you sent out?” then lectured him on how it was obvious that he could and should get a job. She ordered that he be imprisoned for 30 days and fined $2000. The deadbeat did not seem surprised by or object to this. The five sheriffs added some additional shackles to his wrists and ankles, then escorted him out.

The second guy was apparently at an earlier stage of the process because he was not in chains. His plaintiff did not appear because, she had written to say, driving made her “anxious”. The subject of the child support obligation was an adult (over 18 but younger than 23). This child lived full time with the father, but the plaintiff mother still had a child support order in place from when the child lived with her at least part-time. It seemed that a second woman had been unwise enough to select this man as the father of her children and he had two preteen girls living at home with him and, due to his lack of employment, there was not enough money to pay the mother of the adult child as well as put food on the table for the adult child (living with him) and the two minor girls. He did not ask for the “adult-child” support to be eliminated going forward, on the grounds that the adult lived with him, but only for it to be reduced and for the judge to order a gradual payment plan for the arrears (more than $10,000). He received a stern lecture on how it should be straightforward for him to find a job and then was allowed to leave without handcuffs.

Based on what we heard and saw, for these guys to get a job, America’s employers would have to

  1. hire all 9.5 million currently unemployed people
  2. entice another 6 percent of the population back into the workforce so that the labor force participation rate was up towards a historic high
  3. fund $1 trillion in unsuccessful robotics research
  4. be under the influence of both drugs and alcohol on the day that these two prize specimens came in for their interviews

The human tragedy aspect of the cases was first and foremost in my mind but after we were out of the courthouse, I thought “Hey, wait a minute. If you are a long-term unemployed person one government agency will tell you that this situation could not have been avoided, it is not your fault in any way, and here are some tax dollars so that you can make ends meet. But if the same long-term unemployed person owes child support, even he is at the extreme end of the spectrum of demonstrably unemployable, employees of the same government but at a different agency will tell him that he could easily get off his ass and earn enough money to support himself plus have enough left over to pay $41,000, after taxes, to the person who sued him two decades ago.”

[Separately, we went to the records department and sampled some cases. Here are two parents in the midst of a divorce lawsuit coordinating the exchange of a three-year-old via text message:

20110310-text-messages-about-exchange-time

(background: Ivy League graduate wife sued husband after four years of marriage, ultimately winning a free house, roughly half of her attorney's fees (despite a prenuptial agreement that said each side would pay his or her own), 100% of the child's expenses, including a full-time nanny, paid by husband, $50,000 per year in taxable alimony, and nearly $94,000 per year in tax-free child support through the toddler's 23rd birthday (the plaintiff would take care of said child, with the assistance of the nanny, for slightly more than half time))]

Related: Divorce in Denmark (the scenes that played out in front of us in Middlesex County probably would not have happened in Denmark because when a parent cannot pay the $2200/year minimum child support the government steps in to pay it without expecting to be paid back, a source of irritation to middle-class taxpayers; the text message exchange also might not have happened due to the fact that the maximum child support obtainable is about $8000 per year)

Matt Guthmiller on the last leg of his round-the-world trip

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Check out www.limitless-horizons.org and (FlightAware) to track Matt Guthmiller in his single-engine Bonanza on his final leg home (16 hours from Kona to San Diego). [See my earlier posting on this project for more background.]

Separately, it looks as though my idea (in that original posting) of a record-breaking around-the-world trip in an airplane that can do the job effortlessly has been adopted. A 31-year-old woman named “Amelia Rose Earhart” took a Pilatus PC-12 NG and a co-pilot and, on July 11, 2014 became the “youngest female ever to circumnavigate the globe in a single-engine airplane” (keep in mind that the “single engine” is a $1 million Canadian-built Pratt and Whitney turbine and that this pressurized airplane, fully equipped with autopilot and lavatory, can climb up to 30,000′, crack any ice off its wings, melt ice off the prop and windshields, etc.). See Wikipedia for more about the modern-day Amelia Earhart and the Pilatus factory site  to learn more about the Swiss-made PC-12.

[Separately, note that Pilatus is the company whose engineering and production prowess, combined with the superior efficiency of Swiss aviation regulators, put Beechcraft, founded in Kansas in 1932, into bankruptcy in 2012. The Beechcraft King Air could not compete with the PC-12. The Beechcraft military trainers could not compete with the Pilatus PC-7 , PC-9, and PC-21 (though Beech licensed the Swiss design and produced a plane called the "Texan II" for the U.S. military to buy at a substantial markup).]

Update: He made it! We need to give him a hero’s welcome when he returns to East Coast Aero Club.

Killing oneself for career, English-style

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I’m reading The Silkworm by J.K. Rowling under the pen name of “Robert Galbraith” (I was not a fan of the Harry Potter books and thought that I should give the world’s most successful writer a second try). The plot concerns a private detective who takes a break from his usual work of helping women turn their marriages into cash by searching for a missing writer: “Strike had recently helped several wealthy young women rid themselves of City husbands who had become much less attractive to them since the financial crash. There was something appealing about restoring a husband to a wife, for a change.” The prose style can be peculiar: “And by the same power of will that in the army had enabled him to fall instantly asleep on bare concrete, on rocky ground, on lumpy camp beds that squeaked rusty complaints about his bulk whenever he moved, he slid smoothly into sleep like a warship sliding out on dark water.”

So far the paragraph that has struck me the most is this one, about what it would mean to have a demanding job in England: “Robin was twisting her engagement ring on her finger, torn between her desire to follow Matt and persuade him she had done nothing wrong and anger that any such persuasion should be required. The demands of his job came first, always; she had never known him to apologize for late hours, for jobs that took him to the far side of London and brought him home at eight o’clock at night.” [emphasis added]

Can Google Chromecast do a simple slide show?

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Folks:

We’re hosting a Glastonbury Festival party at our apartment tomorrow evening (music by Kasabian, Dolly Parton, Massive Attack, et al; “hog roast” and Strongbow cider, which the beer expert at the Fresh Pond liquor store said is better than the American brands despite being one third the price). The photos that I want to show are in a Google Plus directory so I thought that it would be simple to show them on a Samsung “Smart TV” (perhaps it is a bad sign when a product includes the word “smart” as part of its name). As soon as I turned the TV on, however, the software updated itself and removed the Picasa app that can grab photos from Google Plus. I thought “no problem; I will use Chromecast from my Android phone.” The Google “Photos” app sort of works except that it doesn’t tie in with the TV remote for going to the next slide and, more distressing, the pictures are terrible quality (low res? oversharpened?). So I’ve reverted to exported JPEGs 1920 pixels wide to a USB stick and plugging that into the back of the TV.

Am I missing something simple? Can it be that Google Chromecast is incapable of doing this with reasonable image quality?

Thanks in advance.

[Update: pork roasting photo gallery; the 14.4 lbs. was all consumed by 9 pm so I think we can declare victory on the roasting front.]

Peter Orszag beats the child support rap

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Back in March I wrote a post with some details about former Obama Administration official Peter Orszag, whose ex-wife had hoped to tap him for $264,000 per year in tax-free child support revenue. Backstory: following a brief marriage, about 10 years ago, Cameron Kennedy got a luxurious house and a few million dollars in cash by suing Orszag for divorce and, as part of settling that lawsuit, signed an agreement that they would split the children’s expenses going forward (she may have earned more than he did at the time, though now he is cashing in from our revolving door system between government and finance). The judge has ruled and it seems that Cameron Kennedy will get two free kids, with the father paying for all of their private school tuition, summer camps, medical expenses, and extracurricular activities. But she won’t be able to turn a cash profit on the children. In fact she will have to provide them with at least some meals on at least half of the days of the year, paying for the food out of her $350,000 per year income, mostly from working at McKinsey. (She also has to give them a place to sleep, but I am pretty sure that is in a house that got as part of her divorce lawsuit.) She has to pay her own attorney’s fees, according to the Washington Post. And the judge refused to accept the idea that $350,00/year was right at the poverty line:

“Ms. Kennedy is also a high-earning party, capable of providing a more than comfortable lifestyle and many advantages for her children, even in the absence of any assistance from Mr. Orszag,” the court ruled Thursday.

More: Read the Kennedy Decision (64 pages)

Book review: Bad Pharma

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I’ve finished Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients,a well-researched effort presented in overheated language by Ben Goldacre. With all of the trillions of dollars spent on drug development and drugs themselves, have you ever wondered why people don’t seem to feel better than they did back in the 1970s? There have been so many new painkillers, for example, but none seem to work much better than aspirin, a remedy known to Hippocrates (Wikipedia).

Here’s the main thesis of the book:

Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques which are flawed by design, in such a way that they exaggerate the benefits of treatments. Unsurprisingly, these trials tend to produce results that favour the manufacturer. When trials throw up results that companies don’t like, they are perfectly entitled to hide them from doctors and patients, so we only ever see a distorted picture of any drug’s true effects. Regulators see most of the trial data, but only from early on in a drug’s life, and even then they don’t give this data to doctors or patients, or even to other parts of government. This distorted evidence is then communicated and applied in a distorted fashion. In their forty years of practice after leaving medical school, doctors hear about what works through ad hoc oral traditions, from sales reps, colleagues or journals. But those colleagues can be in the pay of drug companies – often undisclosed – and the journals are too. And so are the patient groups. And finally, academic papers, which everyone thinks of as objective, are often covertly planned and written by people who work directly for the companies, without disclosure. Sometimes whole academic journals are even owned outright by one drug company. Aside from all this, for several of the most important and enduring problems in medicine, we have no idea what the best treatment is, because it’s not in anyone’s financial interest to conduct any trials at all. These are ongoing problems, and although people have claimed to fix many of them, for the most part they have failed; so all these problems persist, but worse than ever, because now people can pretend that everything is fine after all.

We’re nearly 30 years into Prozac Nation. The pills are cheap and published research shows that they work well. Is everyone cheerful?

In 2008 a group of researchers decided to check for publication of every trial that had ever been reported to the US Food and Drug Administration for all the antidepressants that came onto the market between 1987 and 2004. The researchers found seventy-four studies in total, representing 12,500 patients’ worth of data. Thirty-eight of these trials had positive results, and found that the new drug worked; thirty-six were negative. The results were therefore an even split between success and failure for the drugs, in reality. Then the researchers set about looking for these trials in the published academic literature, the material available to doctors and patients. This provided a very different picture. Thirty-seven of the positive trials – all but one – were published in full, often with much fanfare. But the trials with negative results had a very different fate: only three were published. Twenty-two were simply lost to history, never appearing anywhere other than in those dusty, disorganised, thin FDA files.

How about the efforts at reform? Goldacre shows that they’ve failed on both sides of the Atlantic.

The 1997 FDA Modernization Act created clinicaltrials.gov, a register run by the US government National Institutes of Health. This legislation required that trials should be registered, but only if they related to an application to put a new drug on the market, and even then, only if it was for a serious or life-threatening disease. The register opened in 1998, and the website clinicaltrials.gov went online in 2000. The entry criteria were widened in 2004. But soon it all began to fall apart. … But the first problem for the US register, which could have been used universally, was that people simply chose not to use it. The regulations required only a very narrow range of trials to be posted, and nobody else was in a hurry to post their trials if they didn’t have to.

In 2007 the FDA Amendment Act was passed. This is much tighter: it requires registration of all trials of any drug or device, at any stage of development other than ‘first-in-man’ tests, if they have any site in the US, or involve any kind of application to bring a new drug onto the market. It also imposes a startling new requirement: all results of all trials must be posted to clinicaltrials.gov, in abbreviated summary tables, within one year of completion, for any trial on any marketed drug that completes after 2007. Once again, to great fanfare, everyone believed that the problem had been fixed. But it hasn’t been, for two very important reasons. First, unfortunately, despite the undoubted goodwill, requiring the publication of all trials starting from ‘now’ does absolutely nothing for medicine today.  … But there is a second, more disturbing reason why these regulations should be taken with a pinch of salt: they have been widely ignored. A study published in January 2012 looked at the first slice of trials subject to mandatory reporting, and found that only one in five had met its obligation to post results.62 Perhaps this is not surprising: the fine for non-compliance is $10,000 a day, which sounds spectacular, until you realise that it’s only $3.5 million a year, which is chickenfeed for a drug bringing in $4 billion a year. And what’s more, no such fine has ever been levied, throughout the entire history of the legislation.

The search functions on the FDA website are essentially broken, while the content is haphazard and badly organised, with lots missing, and too little information to enable you to work out if a trial was prone to bias by design. Once again – partly, here, through casual thoughtlessness and incompetence – it is impossible to get access to the basic information that we need.

So: let’s say we want to find the results from all the trials the FDA has, on a drug called pregabalin, in which the drug is used to treat pain for diabetics whose nerves have been affected by their disease (a condition called ‘diabetic peripheral neuropathy’). You want the FDA review on this specific use, which is the PDF document containing all the trials in one big bundle. But if you search for ‘pregabalin review’, say, on the FDA website, you get over a hundred documents: none of them is clearly named, and not one of them is the FDA review document on pregabalin. If you type in the FDA application number – the unique identifier for the FDA document you’re looking for – the FDA website comes up with nothing at all. If you’re lucky, or wise, you’ll get dropped at the Drugs@FDA page: typing ‘pregabalin’ there brings up three ‘FDA applications’. Why three? Because there are three different documents, each on a different condition that pregabalin can be used to treat. The FDA site doesn’t tell you which condition each of these three documents is for, so you have to use trial and error to try to find out. That’s not as easy as it sounds. I have the correct document for pregabalin and diabetic peripheral neuropathy right here in front of me: it’s almost four hundred pages long, but it doesn’t tell you that it’s about diabetic peripheral neuropathy until you get to page 19. There’s no executive summary at the beginning – in fact, there’s no title page, no contents page, no hint of what the document is even about, and it skips randomly from one sub-document to another, all scanned and bundled up in the same gigantic file. …  unlike almost any other serious government document in the world, the PDFs from the FDA are a series of photographs of pages of text, rather than the text itself. This means you cannot search for a phrase. Instead, you have to go through it, searching for that phrase, laboriously, by eye.

Clinical research trials is increasingly outsourced to private companies and increasingly done on patients outside the U.S. and EU. How much money is involved when a trial is done in the U.S.? And what’s the cost savings for going offshore?

In the US, meanwhile, the use of private community doctors to conduct trials has expanded enormously, with incentives approaching $1 million a year for the most enterprising medics.

As the former chief executive of GSK explained in a recent interview, running a trial in the US costs $30,000 per patient, while a CRO can do it in Romania for $3,000.

In the past, only 15 per cent of clinical trials were conducted outside the USA. Now it’s more than half. The average rate of growth in the number of trials in India is 20 per cent a year, in China 47 per cent, in Argentina 27 per cent, and so on, simply because they are better at attracting CRO business, at lower cost. At the same time, trials in the US are falling by 6 per cent a year (and in the UK by 10 per cent a year).

One problem with these trial is that they generally use patients who have only one condition and who may not be getting any treatment for it. Goldacre asks “Are those findings really transferable, and relevant, to American patients, on all their tablets?”

What does it take to get a drug approved by the FDA?

In general, however, a company would expect to have to provide two or three trials, with a thousand or more participants, showing that its drug works. This is where the smoke and mirrors begin. Although the notion of a simple randomised trial should be straightforward, in reality there are all kinds of distortions and perversions that can come into play, in the comparisons that are made, and the outcomes that are measured for success. For me, ‘What works?’ is the most basic practical question that every patient faces, and the answer isn’t complicated. Patients want to know: what’s the best treatment for my disease? The only way to answer this question when a new drug comes along is by comparing it against the best currently available treatment. But that is not what drug regulators require of a treatment for it to get onto the market. Often, even when there are effective treatments around already, regulators are happy for a company simply to show that its treatment is better than nothing – or rather, better than a dummy placebo pill with no medicine in it – and the industry is happy to clear that low bar.

A paper from 2011 looked at the evidence supporting every single one of the 197 new drugs approved by the FDA between 2000 and 2010, at the time they were approved.15 Only 70 per cent had data to show they were better than other treatments (and that’s after you ignore drugs for conditions for which there was no current treatment). A full third had no evidence comparing them with the best currently available treatment, even though that’s the only question that matters to patients.

This same perverse problem of inadequate comparators also exists in the EU.17 To get a licence to market your drug, the EMA does not require you to show that it is better than the best currently available treatment, even if that treatment is universally used: you simply have to show that it is better than nothing. A study from 2007 found that only half the drugs approved between 1999 and 2005 had been studied in comparison with other treatments at the time they were allowed onto the market (and, shamefully, only one third of those trials were published and publicly accessible to doctors and patients).

Goldacre identifies some subtler problems with drug trials, e.g., the cancer drug Bevacizumab being tested in 1000 trials on different kinds of cancer. Some of those trials showed a statistically significant benefit, but by running so many trials it was of course statistically likely that at least some would show a benefit just due to pure random variation.

Goldacre suggests using massive health care systems with computerized records, such as the UK’s, to run experiments on different drugs where currently physicians have no reason to prefer one versus the other and he has built some software toward this end.

What about all of those drug ads? They’re illegal in most countries.

When ads were first made legal again in the US, they could only appear in print, because of a requirement to include all the side-effect information from the drug label. Since 1997 the rules have been relaxed, and now the side effects can be abbreviated (they are read out at jabbering speed over the end of the TV ads). After this change the pharmaceutical industry’s annual advertising budget rose from $200 million to $3 billion in the space of just a few years.

One study observed patients visiting their doctors in Canada, where direct-to-consumer drug advertising is still banned, and the US. It found that those in the US were more likely to believe they needed medication, more likely to request specific drugs that were advertised on television, and more likely to receive a prescription for that drug.

Trained actors, posing as depressed patients, were sent to visit doctors in three American cities (three hundred visits in all).5 They all gave the same background story, about the problems they were having with low mood, and then were randomly assigned to act in one of three ways at the end of the consultation: to ask for a specific named drug; to ask for ‘medicine that might help’; or to make no specific request. Those who did what ads drive patients to do – ask for a specific drug, or ‘medicine’ – were twice as likely to receive a prescription for an antidepressant pill.

If we relaxed the rules forbidding UK- and European-trained doctors to practice here, would they find the salaries attractive enough to make it worth the trip? (A Massachusetts woman recently called her primary care doc to get an appointment for an annual physical. She was offered one in 2015, about 18 months from the time of her phone call.)

The UK [pay] scales are all publicly accessible: junior doctors are paid between £25,000 and £40,000 per annum for the first five or ten years, and then consultants go on to around £70,000. [That's $43,000 to $68,500 per year for the junior docs.]

Given the massive size of the industry, the huge quantity of tax dollars that are spent on pills (many of which are useless or harmful), and the fact that intense regulation doesn’t seem to have accomplished anything, the book is worthwhile reading for any citizen.

More: read Bad Pharma.

Sample bias in Thomas Piketty’s book is worse than I thought

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In this blog posting from May 23, I pointed out an obvious flaw in Thomas Piketty’s Capital in the Twenty-First Century, i.e., that he calculates investment returns for the uber-rich by looking at different people who happened to make the Forbes list at different times. It turns out that a careful analysis by Stan Veuger in U.S. News and World Report was published a week earlier. Veuger follows the top 10 folks (a.k.a. “rich bastards”) from 1987 and finds out that they earned only about a 0.5-percent real return on their investments, i.e., less than what a consumer who bought and held an S&P 500 index fund would have earned. Piketty’s call to action is premised on the idea that rich people and/or rich organizations can get exceptionally good investment returns, but he has not put forth any good data to support that idea. (And even if he were right, he would have to adjust for the fact that a lot of middle class people have their money in pension funds and other professionally managed aggregations that should, in theory, have the same access to investments as the wealthiest individuals.)

[One of the largest investors in the U.S. is CalPERS, with more than $250 billion in assets and 2600 employees. Their year-end 2013 report shows that they achieved a 7.91% annual return over a 20-year period. What about a regular Joe who parked his money in a Vanguard S&P 500 fund? This calculator shows an investment held from January 1, 1994 through December 31, 2013 would have grown at 9.22%.]

Separately, Martin Feldstein published an article in the Wall Street Journal about how changes in the tax code led people to tear down Schedule C corporations and build S corps and LLCs instead. The real economy and real income/wealth distribution didn’t change that much, but individual tax returns changed dramatically in response to dramatic Reagan-era changes in the tax code.

More bad news for American schools: social skills taught aren’t useful in adulthood

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This Business Insider piece covers a longitudinal study by Joseph P. Allen from the University of Virginia. As noted in The Smartest Kids in the World: And How They Got That Way (see my review of the book in these postings: Finland; Poland; American Public; American Private; What can a Parent do?; Korea), Americans like to comfort themselves that though our schools perform poorly on things that are easy to measure, such as educational attainment, they perform well on things that are hard to measure, such as socialization and sports team building: “Instead of the apprenticeship/mentoring environments that prevailed throughout most of human history, we decided to put hundreds of teenagers together all day every day. What could go wrong?” Allen’s study, however, found that teenagers who were experts at impressing other teenagers did not have superior skills for impressing adults. As adults have most of the power in this country, the “cool kids” from high school struggled upon reaching their 20s.

My personal experience in this area comes from following the most popular kid from my 5th grade class. He had long blond hair, was good at sports, and got invited to every birthday party. My parents lived in the same house for more than 45 years so I thought that perhaps they might know how he was doing as an adult. My mom said “I know exactly what he is doing. He’s living in his parents’ basement, smoking dope, drinking beer, and watching TV all day.”

Separately, to celebrate the World Cup, here’s a story from 10 years ago: I was walking past a youth soccer game with a friend from Massachusetts. She said “This is wonderful. By playing on a team these kids are learning everything that they will need to succeed in business.” I replied “Yes, I’m sure that you’re right. That’s why Nigeria, Argentina, and Cameroon have the strongest economies.”

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