John Harvard's Journal
Health by the Numbers
"How many of you agree with the statement, 'Health is priceless'?" A robust show of hands.
"How many of you went jogging this morning?" No hands.
"Now what if I tell you that each hour spent jogging extends your expected life by an hour? So health does have a price: you didn't want to give up that extra hour of sleep, so you didn't value that hour of healthy life very highly."
With that gentle exchange on September 21, the first morning of fall-term classes, in a newly renovated classroom in Harvard Hall, David M. Cutler '87 helps launch the new quantitative reasoning component of the undergraduate Core curriculum. By artful indirection, by frequent engagement, and by quick resort to humor, Cutler, professor of economics and Loeb professor of social sciences, will lead a couple of dozen students through the substance of "Health Economics," as the course is titled. Along the way, at breathtaking speed, he will take them on a get-acquainted tour of quantitative, economic, and statistical analysis, the lingua franca of the Journal of Health Economics, which he edits.
A student emerging from the semester, Cutler hopes, will be able to make sense of the New England Journal of Medicine, or to listen to public-policy debates--the class follows Bill Bradley's and Al Gore's healthcare plans--and to evaluate differing claims of their efficacy and cost. The underlying theme is learning "how to deal with a number and not be afraid of it."
To that end, Cutler has overhauled an economics department course, tossing out his assumptions about concentrators' command of statistical analysis. Using the course website, he has created an anonymous electronic survey of the students' smoking behavior and academic performance; used the data gathered to introduce notions of survey design and statistical significance before scaring the students off by lecturing about the underlying concepts; elicited evidence that the class distinguishes correlation from causation; and taken everyone on a forced march through the thickets of regression analysis so that the budding health analysts can sort out the effects of age, income, gender, or any other factors they can identify in probing the links between smoking and grade point averages--or any other problems they care to attack.
It's an ambitious agenda, but it works. Just before the midterm, Cutler risks calling on a quiet student to explain the implications of the data resulting from a regression. Line by line, she nails every finding, and the whole class seems to enjoy seeing what they have learned. Mike Housman '02, who is pursuing a special concentration in health policy, reports expecting the course to be too "simplistic," but instead finds it challenging. Compared to the "very dry statistical methods" that students "simply regurgitated" from memory as part of the former mandatory quantitative reasoning examination, he says, "this course applies them to modern-day examples in healthcare and forces you to think."
At the other end of the spectrum, Adair Dammann '79--now a mid-career student at the Kennedy School of Government after working for 20 years as a labor organizer, most recently at Nevada hospitals--says, "I love the clarity with which Cutler lays out questions such as, 'What are the determinants of health?' I have never, ever, had anyone explain economic terms, or statistics, so simply and understandably."
Cutler's decisions in designing the course apparently contribute to its success in holding students' interest across that spectrum of experience. First, it is unlike a pure economics course, where, he says, "They spend a lot of time on the market for doctors and the market for hospitals." Here, gleefully using the classroom's new electronic equipment and a laser pointer, he projects from his laptop a graph showing the price of health services, and the number of office visits patients avail themselves of each year. He then reveals, "That's the fundamental diagram in economics, supply and demand. Everything interesting happens where the lines cross." That said, to the especial amusement of the teaching fellows seated in the front row, he's launched on an introduction to the healthcare system, insurance, and, ultimately, "the public-policy issues in healthcare about which economics has a lot to say." In this, he teaches from his own background in public economics, and his experience at the Council of Economic Advisers and the National Economic Council in 1993, during the drafting of President Clinton's healthcare plan.
From that decision follows another: to consciously shy away from the thicket of formulae that now characterize economics. Economics concentrators, he says, "confuse mathematical rigor and conceptual difficulty. You lose very little without the math, compared to what you can do." What you can do, in the readings, is offer very demanding papers, like Robert W. Fogel's Nobel lecture, which challenges the assumption that improved health is principally the result of medical care. (Fogel and other analysts make the students think about the roles of nutrition, body size, and income.) Deep within Cutler's own recent--and mathematically rigorous--paper with Richard J. Zeckhauser, Ramsey professor of political economy at the Kennedy School, on "The Anatomy of Health Insurance," students are asked to consider that "Managed care partly represents a price club. In exchange for an up-front fee, the patient gets to purchase goods at a significant discount...secured in part through bulk purchase bargaining, or by directly hiring the sellers."
And to help them pull together the diverse strands of analysis and substantive readings on health and medical care, Cutler employs every tool in the teacher's kit. In the computer-illustrated lectures, static graphs are brought to life by moving curves into place to make a point--complete with canned computer-generated applause. To reinforce basic skills, the weekly discussion sections are supplemented by sessions on the use of spreadsheets, economics, and statistics. Problem sets force students to use the tools introduced in readings and lectures. By early November, they have grown comfortable with all the analytical tools they will need to tear apart knotty issues of insurance and health policy in the semester's second half. And always, there are questions, yielding unexpected riches: a query about how health systems operate in other nations brings forth student responses from Brazil, France, and Ireland, illuminating the distinctive features of American healthcare. Biology concentrator Brian Kim '01 says simply, "It's my favorite class." He cites "a great reading list" and lectures based on "a lot of thinking."
Apparently, the process is reciprocal. "Teaching undergraduates is very interesting and good for research," says Cutler, who himself looks closer to his college days than to the end of nearly a decade professing at Harvard. When designing a course, he says, "You learn where there are no good papers to assign." In his case, that means research on the definition and value of health and what--if anything--medicine has to do with securing it.