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Interactive analysis · August 2026

Where Would a Marginal Dollar Do the Most Good in Kansas City?

Fifteen problems from my KC burden-of-disease analysis, rank-ordered by the effective altruism framework: impact × tractability × neglectedness. Tractability comes from verified intervention cost-effectiveness and Missouri's actual legal room to act. Neglectedness comes from mapping who currently funds what, in dollars. A 10,000-draw Monte Carlo over the uncertainty turns the ranking into rank intervals, and the explorer below lets you disagree with any score I made and watch the ranking respond.

The impact figures are measured; the T and N scores are structured judgment over verified evidence, which is exactly why they are adjustable. Every claim cites its source at the bottom of the page.

1 · P(top 3) = 100%

Tobacco control

Quitlines at $849–2,358/QALY meet the most extreme neglect in the study: Missouri funds tobacco control at 7.4% of the CDC-recommended level.

2 · P(top 3) = 93%

Overdose response

Naloxone at $438/QALY, a 2–5× mortality gap for people in vs out of MOUD treatment, and settlement money sitting undeployed while KC lags the national decline.

3 · P(top 3) = 65%

Elderly falls

Cost-saving interventions, zero dedicated local infrastructure, and the least-funded cause of death in America relative to its mortality.

4 · P(top 3) = 28%

Hypertension control

$2,800–15,000/QALY levers against the region's single largest burden, deliverable through safety-net clinics with no policy fight.

The headline metric: DALYs averted per marginal $10M/yr

One number that integrates all three ITN factors: if an additional $10M/yr showed up in Kansas City, how many disability-adjusted life years would it buy against each problem, through the best verified locally-feasible intervention, at current levels of crowding? Whiskers are the 10th–90th percentile of the Monte Carlo.

Central estimate 10–90% interval

How stable is the ranking?

Each dot is a problem's median rank across 10,000 Monte Carlo draws; the line is its 10th–90th percentile rank range. Tight lines mean the ranking is confident; long lines mean reasonable people can land in different places. Violence has the longest line in the study.

The explorer: disagree with me

Impact is measured (annual DALYs, fixed here). Tractability and neglectedness are 0–10 scores I assigned from the evidence in each capsule; drag them if you read the evidence differently and the ranking recomputes live using the factor-product score (log10 I + T/2 + N/2). "Evidence" expands each problem's reasoning with citations.

Data table (study values)

Three findings that shape everything

The violence caveat deserves its own paragraph. Kansas City ran the celebrated focused-deterrence playbook once already: KC NoVA cut homicides in 2014, was declared a success, decayed to nothing by year three, and was formally rated Ineffective by the National Institute of Justice.[31] SAVE KC, today's version, reports encouraging numbers from exactly the same early stage, with no independent evaluation. The expected-value ranking above already discounts for this; what survives that history is a value-of-information play: fund rigorous independent evaluation of SAVE KC, and watch 2026–27, the window where a NoVA-style decay would first become visible.

What a marginal $10M/yr would buy

A sketch, not a plan. Splitting $10M across the top four: roughly $3M for a quitline and cessation surge (media plus free nicotine replacement, Missouri-side), $3M for naloxone saturation, low-barrier medication access, and settlement-deployment advocacy, $2M for falls programs (CAPABLE and Otago through senior centers and Medicaid waivers), and $2M for self-measured blood pressure and team-based hypertension care through the safety-net clinics. Central estimate on the model's own numbers: 1,500–2,500 DALYs averted per year at scale, with the falls and cessation lines partly cost-saving to Medicare and Medicaid. Every line is deliverable by organizations that already exist here, without a single preempted policy fight.

Method

Impact carries over from the companion burden analysis: WHO Global Health Estimates 2021 US cause rates, localized with county death certificates and CDC PLACES prevalence, with 80% CIs.

Tractability (0–10) anchors to the best locally-feasible intervention's verified cost-effectiveness on a log scale ($500/DALY ≈ 9, $5K ≈ 7, $50K ≈ 5, nothing proven ≈ 1–2), adjusted for evidence strength (CPSTF- or RCT-verified beats contested beats absent), Missouri's legal room to act, and KC-specific precedent.

Neglectedness (0–10) is scored at the prevention margin: annual local dollars aimed at reducing the problem, not treating it, per DALY of burden, from verified budgets (city, county COMBAT tax, settlement flows, HUD awards) and philanthropy (990-verified), benchmarked against national funding-versus-burden residuals. Treatment spending is reported but does not count as crowding for prevention.

The Monte Carlo draws every factor from a triangular distribution over its range, 10,000 times (fixed seed), and records each problem's rank per draw. The full simulation is a 60-line stdlib Python script that reproduces every number in the table above. Two scoring views run in parallel: marginal DALYs per $10M (the headline) and the factor product (the explorer). Where they disagree, the disagreement is the finding: falls leads the factor product but its modest burden caps absolute gains; musculoskeletal disease scores high on burden-times-neglect but has no deployable intervention, making it a research bet, not a program bet.

Post-vetting update (Aug 15). A follow-on pass vetting KC's actual charities fed back into three neglectedness scores: falls down (delivery infrastructure exists after all, small and deficit-funded), tobacco up (no local giving vehicle exists at all), overdose up slightly (the metro's joint federal harm-reduction grant lapsed in May). Re-running the Monte Carlo: the headline View A ranking is unchanged in every number; View B's only change is falls and tobacco swapping #1 and #2. Everything stays inside the published rank intervals. For a donor, note the asymmetry the scores can't hold: tobacco ranks #1 but has nothing to fund without building the channel, while falls has a starving, fundable vehicle today.

What this is not. Local institutions' own priorities entered only as crowdedness data, never as conclusions. The T and N scores are my judgment over the verified evidence, stated openly and adjustable above. A state-level actor's ranking would differ (alcohol and tobacco taxes jump); so would a researcher's (musculoskeletal jumps).

Sources

Numbered as cited in the capsules and text. Flags mark anything that resisted primary verification; those claims are labeled in place.

  1. Community Preventive Services Task Force, tobacco cessation economic reviews: quitline counseling $2,358/QALY (IQI $1,761–$3,156); counseling plus medications $849/QALY (IQI $369–$2,426), 2013$. thecommunityguide.org
  2. KCUR, 2025-07-20: Missouri cigarette tax 17 cents/pack since 1993, lowest in the US; raising it requires a ballot initiative under the Hancock Amendment. kcur.org
  3. RSMo §149.192 (1993), read from the statute: the state "occupies and preempts the entire field of legislation increasing the taxation of cigarettes and tobacco products"; new local tobacco taxes are void and existing local taxes are frozen at their September 30, 1993 levels. revisor.mo.gov
  4. Kansas constitutional home rule (Art. 12 §5); Topeka Tobacco 21 ordinance upheld by the Kansas Supreme Court.
  5. Campaign for Tobacco-Free Kids, Missouri FY2026 state report: $5.4M spent vs $72.9M CDC-recommended (7.4%), rank 39/50, up from dead last circa 2019. Retrieved via archive snapshot. tobaccofreekids.org
  6. CTFK "Broken Promises to Our Children" FY2024: states spend 2.8% of tobacco revenue on prevention (22% of CDC-recommended). tobaccofreekids.org
  7. Coffin & Sullivan, Annals of Internal Medicine 2013;158(1):1-9: naloxone distribution $438/QALY base case (95% CI $48–$1,706), $14,000/QALY worst case; verified from the abstract (no open-access full text exists). PubMed 23277895.
  8. Sordo et al., BMJ 2017;357:j1550 (read from the PMC full text): all-cause mortality 11.3 vs 36.1 per 1,000 person-years in vs out of methadone treatment (rate ratio 3.20, CI 2.65–3.86); 4.3 vs 9.5 for buprenorphine (rate ratio 2.20, CI 1.34–3.61). PMC5421454
  9. Missouri fentanyl test strips legalized effective 2023-08-28; statewide naloxone standing order in place. Syringe services: NOT authorized under Missouri law (RSMo 579.040/579.074 contain no SSP exemption, read from statute; the 2021 legalization bill was SB 64, died in committee; 2026 bills HB 2602/SB 1219 remain in committee; the July 2026 omnibus healthcare law is silent on SSPs). revisor.mo.gov
  10. CDC VSRR provisional overdose deaths: Missouri 12-month-ending Dec 2023 = 2,014, Dec 2024 = 1,482 (−26.4%). data.cdc.gov
  11. MIMH Addiction Science, KC-area medical examiner data: 4-county drug deaths 402 in 2024 (−10%); 65+ deaths +94%; Black male deaths +11%. mimhaddisci.org
  12. The Beacon, 2026-04-15: Missouri opioid settlement ~$900M over ~15 years (roughly double the 2022 estimate); 50+ jurisdictions spent nothing in 2025; Jackson County ~$4M unspent. thebeaconnews.org
  13. ProPublica Nonprofit Explorer, verified filings: First Call $4.1M revenue; ReDiscover $75.6M; Tri-County Mental Health $26.2M; Nurture KC $3.3M; KC Common Good $0.9M (FY2023–24). propublica.org
  14. CHCS profile of CAPABLE: ~$3,000/participant; $22,120 average 2-year Medicare savings (CMMI demonstration); $867/month Medicaid savings in a dual-eligible study.
  15. PLOS ONE 2022 (PMC9020705): Otago in a post-fall cohort, fall-rate reduction 39% (men, significant) / 32% (women, ns); delivery cost $393/person (2019 CAD).
  16. Verified absence: no dedicated Kansas City falls-prevention nonprofit or funder found in a systematic sweep.
  17. Stark & Shah, JAMA 2017;317(1):84-85 (read from the full text): gun violence received 1.6% of funding predicted by mortality ($22M observed vs $1.4B predicted) and 4.5% of predicted publications; falls is the least-funded cause of death relative to mortality, gun violence second. jamanetwork.com
  18. Administration for Community Living: ~$53M cumulative falls-prevention grants since 2014, against $50–80B/yr in fall-related medical costs. acl.gov
  19. CPSTF economic reviews: self-measured blood pressure monitoring $2,800–$10,800/QALY (2014$); team-based hypertension care $15,202/QALY (2020$) with median health-system ROI of −80% (cost-effective, not self-funding). thecommunityguide.org
  20. Health Forward Foundation: $905.3M assets, $50.3M expenses (FY2023, ProPublica raw filing data); current purpose framework (People/Power/Place/Platform) names no disease areas. propublica.org · healthforward.org
  21. SHADAC/TFAH state public health funding, FY2023: Missouri $6.67/capita (50th of 50); Indiana $15.16 (49th); Kansas $31.78. Cross-referenced against America's Health Rankings' broader $92/person measure (different definition: 2-year average including federal pass-through, rank 41st). americashealthrankings.org
  22. Tupper v. City of St. Louis (Mo. banc 2015); St. Louis Automated Camera Enforcement Act (2024, driver-face capture); statewide camera-ban bills HB658/SB196 not passed as of mid-2026.
  23. KCUR Vision Zero series: KCMO traffic deaths 102 (2023) → 97 (2024) → 68 (2025). kcur.org
  24. KCUR, 2026-04-02: KCMO FY2026-27 budget: Vision Zero $4M (earlier reporting cited $8M for FY2025-26; unreconciled). kcur.org
  25. Wu, Dean, Rosen & Muennig, J Health Care Poor Underserved 2017;28(4):1578-97: Nurse-Family Partnership at $14,642/QALY offered to all first-time mothers (CI spans cost-saving to $71,877); net benefit $2,764/child targeted to high-risk mothers. PubMed 29176115
  26. Verified hospital CHNA priority lists: University Health 2025-28 (behavioral health #1, violence named); Children's Mercy 2022-25 (mental health, violence named); Saint Luke's 2023 (behavioral health). Infant/maternal health appears in none.
  27. CPSTF economic review: multicomponent colorectal cancer screening interventions $1,651–$3,817/QALY (2016$).
  28. Nguyen et al., Lancet Regional Health – Americas 2024 (NIH RCDC 2021): cancer $6,520M (highest non-HIV $/patient); neck pain funded at 0.83% of DALY-predicted (a 120× gap); low back pain 13.88%; COPD $5.56/patient. PMC10788788
  29. Braga, Weisburd & Turchan, Campbell systematic review of focused deterrence (24 quasi-experiments): statistically significant moderate effects, smaller in more rigorous designs (via OJP abstract).
  30. University of Chicago Crime Lab, READI Chicago RCT (n=2,456): null on the pre-registered primary outcome; outreach-referred subgroup −79% shooting/homicide arrests (significant); benefit-cost 4:1–18:1. crimelab.uchicago.edu
  31. Fox & Novak, Police Quarterly 2018 (KC NoVA time-series evaluation); NIJ CrimeSolutions rating: Ineffective. KCPD withdrew 2018. SAVE KC (2024–): self-reported −40% group-member homicides, no independent evaluation. crimesolutions.ojp.gov
  32. RSMo 21.750, read from revisor.mo.gov: complete state preemption of local firearms regulation; SAPA struck down (8th Cir. 2024). revisor.mo.gov
  33. Jackson County COMBAT: ~$30M/yr quarter-cent sales tax; $4.8M violence-prevention grants (2024); KCMO Department of Community Safety ~$20M (KCTV5). jacksoncountycombat.com
  34. PMC2826303: collaborative care for depression, systematic review of 8 RCTs: $21,478–$49,500/QALY. PMC2826303
  35. The Beacon, 2026-04-02: Missouri 988 funded from general revenue; ~$18.5M (988) + ~$22.3M (crisis services) proposed FY2027; dedicated telecom-fee bill stalled. thebeaconnews.org
  36. Diabetes Care 2025 real-world NDPP cost-effectiveness: −$4,552 two-year medical costs (CI crosses zero), no significant 2-year QALY gain, 84% probability cost-effective at $100K/QALY.
  37. Gillum et al., PLOS ONE 2011: NIH funding vs burden: depression (−$719M), injuries (−$691M), COPD (−$613M) most underfunded; AIDS (+$2,474M), diabetes (+$390M), perinatal research (+$297M) overfunded. doi:10.1371/journal.pone.0016837
  38. Wagenaar, Salois & Komro, Addiction 2009;104(2):179-90 (verified from abstract + full text): 112 studies / 1,003 estimates; elasticities beer −0.46, wine −0.69, spirits −0.80, overall −0.51, heavy drinking −0.28. PubMed · full text (PDF)
  39. Suicide means-restriction: PMC11450421 (full bridge barriers −63/−74%; partial measures ineffective); PMC7514406 (lethal-means counseling: feasibility evidence only). KC's method mix is firearm-dominant, and firearm policy is preempted.
  40. Verified absence: no CPSTF-recommended city-scale musculoskeletal intervention found; MSK is a research opportunity, not a deployment target.
  41. RSMo 67.1571 (local minimum wage preemption, read from statute); Prop A paid sick leave repealed by HB 567, effective 2025-08-28, ~9 months after voters passed it.