Aging
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Given an increasingly complex web of financial pressures on providers, studies have examined how hospitals’ overall financial health affects different aspects of hospital operations. In our study, we develop an empirical proxy for the concept of soft budget constraint (SBC, Kornai, Kyklos 39:3–30, 1986) as an alternative financialmeasure of a hospital’s overall financial health and offer an initial estimate of the effect of SBCs on hospital access and quality. An organization has a SBC if it can expect to be bailed out rather than shut down. Our conceptual model predicts that hospitals facing softer budget constraints will be associated with less aggressive cost control, and their quality may be better or worse, depending on the scope for damage to quality from noncontractible aspects of cost control. We find that hospitals with softer budget constraints are less likely to shut down safety net services. In addition, hospitals with softer budget constraints appear to have better mortality outcomes for elderly heart attack patients.

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International Journal of Healthcare Finance and Economics
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Karen Eggleston
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Karen Eggleston
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In December 2009, the Asia Health Policy Program celebrates the first anniversary of the launch of the AHPP working paper series on health and demographic change in the Asia-Pacific. The series showcases research by AHPP’s own affiliated faculty, postdoctoral fellows, and visiting scholars, as well as selected works by other scholars from the region.

To date AHPP has released eleven research papers in the series, by authors from China, South Korea, Thailand, Taiwan, Pakistan, and the US, with more on the way from Japan and Vietnam. Topics range from “The Effect of Informal Caregiving on Labor Market Outcomes in South Korea” and “Comparing Public and Private Hospitals in China,” to “Pandemic Influenza and the Globalization of Public Health.”  The working papers are available at the Asia Health Policy website.

AHPP considers quality research papers from leading research universities and think tanks across the Asia-Pacific region for inclusion in the working paper series. If interested, please contact Karen Eggleston.

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Context: The aging of the baby boom generation, the extension of life, and progressive increases in disability-free life expectancy have generated a dramatic demographic transition in the United States. Official government forecasts may, however, have inadvertently underestimated life expectancy, which would have major policy implications, since small differences in forecasts of life expectancy produce very large differences in the number of people surviving to an older age. This article presents a new set of population and life expectancy forecasts for the United States, focusing on transitions that will take place by midcentury.

Methods: Forecasts were made with a cohort-components methodology, based on the premise that the risk of death will be influenced in the coming decades by accelerated advances in biomedical technology that either delay the onset and age progression of major fatal diseases or that slow the aging process itself.

Findings: Results indicate that the current forecasts of the U.S. Social Security Administration and U.S. Census Bureau may underestimate the rise in life expectancy at birth for men and women combined, by 2050, from 3.1 to 7.9 years.

Conclusions: The cumulative outlays for Medicare and Social Security could be higher by $3.2 to $8.3 trillion relative to current government forecasts. This article discusses the implications of these results regarding the benefits and costs of an aging society and the prospect that health disparities could attenuate some of these changes.

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The Milbank Quarterly
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John (Jack) W. Rowe
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Prior to coming to CISAC, Joe was the project director and leader for the Los Alamos National Laboratory’s team in the Reliable Replacement Warhead (RRW) design feasibility study.  He will share his experiences and knowledge from over 25 years at Los Alamos and multiple projects related to nuclear weapons design and maintenance, plutonium storage and disposition, stockpile life extension and plutonium aging.  Following a slide show, he will be available for a question and answer session.
 
This is the second in a series of informal gatherings aimed at providing first hand, in-depth information on a variety of topics.  Different from more a formal research seminar, these informal discussions will provide first hand information and Q&A opportunities to facilitate wider understanding and to catalyze potential unrealized research opportunities.

Dr. Joseph C. Martz is a 25 year employee of the Los Alamos National Laboratory in which he has served in a variety of research, leadership, and management positions.  His career has focused on nuclear weapons and materials, and he has lead and participated on a variety of projects related to nuclear weapon design and maintenance, plutonium storage and disposition, stockpile life extension and plutonium aging.  His early work led to a nationwide evaluation and repackaging of stored nuclear materials, and he was a co-developer of the ARIES system, a means to dismantle and safely recover plutonium from excess nuclear weapons.  Dr. Martz technical focus has been on plutonium surface chemistry and metallurgy, including oxidation, dispersal mechanisms, and plutonium aging.  He is a long-time contributor to the Enhanced Surveillance Program for the stockpile, including the evaluation and predictive assessment of aging effects in stockpile materials and components.   Most recently, Dr. Martz was the project director and leader for the New Mexico team in the recent Reliable Replacement Warhead (RRW) design feasibility study.  Dr. Martz is the author of over 50 papers and invited presentations in these areas.  He holds a Ph.D. in Chemical Engineering from the University of California, Berkeley.

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Joseph Martz CISAC Consulting Professor Speaker
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Sociologists and others studying aging in the U.S. uncover myths that dominate public perceptions of the elderly. Educating our society about the facts on aging is a necessary step to ensure that future policies will promote a more equitable and productive America for all ages.

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John (Jack) W. Rowe
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Joseph C. Martz, a nuclear materials scientist at Los Alamos National Laboratory (LANL), has been named the inaugural William J. Perry Fellow in International Security at Stanford University.

Stanford established the fellowship in 2007 to celebrate the 80th birthday of William J. Perry, the 19th U.S. Secretary of Defense from 1994 to 1997 and co-director of Stanford's Center for International Security and Cooperation (CISAC) from 1988 to 1993. Perry, the Michael and Barbara Berberian professor, and CISAC Co-Director Siegfried S. Hecker currently lead the center's Preventive Defense Project, which seeks to forestall dangerous security developments before they require drastic military intervention.

In a statement announcing Martz's selection as the first Perry Fellow, Hecker said CISAC supports scholarship on nuclear disarmament and nonproliferation, particularly at the intersection of science and policy-making. "Your background in understanding the configuration, manufacturing, design and certification of nuclear systems [that] support deterrence and the accompanying weapons complex is of timely relevance to the evolving policies in these areas," Hecker wrote. "Of particular interest is your evaluation of the elements of agility and confidence of the weapons complex and nuclear stockpile that will facilitate further reductions in nuclear weapons, and what effect these may have on international arms control initiatives."

The new Perry Fellowship honors an early or mid-career researcher from the United States or abroad with a record of "outstanding work in natural science, engineering or mathematics...who is dedicated to solving international security problems." Martz, 44, will spend a year at CISAC conducting research on how the United States might be able to reduce the size of its nuclear arsenal by configuring the nation's weapons stockpile more securely and strategically.

"I am honored to serve as the first Perry Fellow, in particular to salute Dr. Perry's extraordinary career and dedication to making the world a safer place," Martz said.

The scientist said his work dovetails with Perry's efforts to reduce and eliminate nuclear weapons around the globe. Perry, alongside former secretaries of state George Shultz and Henry Kissinger, former U.S. Sen. Sam Nunn and Stanford physicist Sidney Drell have joined together to promote this far-reaching objective, which President Barack Obama and the U.N. Security Council endorsed in a unanimous vote last month. "Dr. Perry's focus is a world with fewer weapons," Martz said. "My goal is to find a roadmap to that world."

At LANL, Martz led projects related to nuclear weapons design and maintenance, plutonium storage and disposal, stockpile life extension and plutonium aging, nuclear operations and nuclear systems analysis. He also directed New Mexico's team in the 2005-2007 nationwide Reliable Replacement Warhead (RRW) design competition sponsored by the federal government.

Martz said he was first drawn to nuclear issues during his senior year of high school. He grew up in Los Alamos -- his father worked at the lab. In 1983, Martz and a group of science-minded students were invited to join a gathering marking the lab's 40th anniversary. For three days, renowned scientists from the Manhattan Project, which developed the atomic bomb, returned to Los Alamos. Martz said one of them, Nobel-winning physicist Hans Bethe, told the students about his generation's atomic legacy and that it was up to Martz's generation to find a way out of what he characterized as the nuclear trap.

Today, Martz is interested in what he calls "capability-based deterrence." As he explained in the March 2008 issue of Currents, LANL's employee magazine: "If we are extremely competent and demonstrate the capability to reconstitute nuclear weapons -- convincing both allies and adversaries that the capability is assured and agile -- that capability in and of itself becomes a component of deterrence. It's a compelling idea. Our security rests not so much on the products of our work, but on our work itself." Martz, who has worked at LANL for 26 years, plans to pursue and refine this argument at CISAC and produce a manuscript during his year in residence. Martz holds a doctorate in chemical engineering from the University of California-Berkeley.

William J. Perry and the Perry Fellowship
Perry earned bachelor's and master's degrees in mathematics from Stanford in 1949 and 1950, and a doctorate from Pennsylvania State University. He went on to found the Silicon Valley electronics company ESL, build a venture capital company and pursue a distinguished career in public service. At the heart of Perry's work is a commitment to bring the rigors of science to international security issues. The William J. Perry Fellow in International Security at Stanford University will pursue this commitment.

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BACKGROUND: It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD). METHODS: Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty). RESULTS: The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis. CONCLUSIONS: Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status. 2009 Massachusetts Medical Society

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New England Journal of Medicine
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An equilibrium search model of the Malawian HIV/AIDS epidemic is presented. Individuals engage in di¤erent types of sexual activity, which vary in their riskiness. When choosing a sexual activity, such as short-term sex without a condom, a person rationally considers its risk. A simulated version of the model is parameterized to match some salient facts about the Malawian epidemic. Some topical policies (e.g., male circumcision, treatment of other STDs, and promoting marriage) are studied and found to have potential to back…re: Moderate interventions may actually increase the prevalence of HIV/AIDS, due to shifts in human behavior and equilibrium e¤ects.

Assistant Professor Michele Tertilt is one of three Stanford scholars awarded a two-year Sloan Research Fellowship.  The Sloan Research Fellowships support the work of exceptional young researchers early in their academic careers.  Michele's research focuses on  family economics, consumer credit, growth and development, and demography.  The Economics department congratulates Michele on the prestigious fellowship.

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Michele Tertilt Assistant Professor Speaker the Department of Economics, Stanford University
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