Tag Archives: complexity

The Challenges of Complexity

Last night, I attended a dinner in Lafayette. A delightful man at my table turned out to be a retired environmental engineer, and during the conversation, the subject of fracking came up.

I’ve had a good deal of trepidation about the practice, so I was surprised when he said that–done with a reasonable level of care–it doesn’t pose a threat to environmental safety. He also noted that the abundance, and relatively low cost, of natural gas could both lessen our dependence on foreign oil and give the economy a needed boost.

On the way home, I thought about our conversation, and realized that I had absolutely no way to evaluate the accuracy of his observations, or to weigh them against the arguments of those who oppose fracking. I don’t know enough.

The problem is, in so many areas of our communal life, we are all in the position of not knowing enough to make sound, evidence-based decisions. In an increasingly complex world, a world in which none of us can possibly have the knowledge needed to make independent decisions, we have no alternative but to place our trust in experts.

I’ve written a lot about the “trust deficit” in America, and its various causes. This dinner-table conversation focused me on one of the most troubling results of that deficit.

How do we make sound policy decisions when so many of the issues we face require considerable expertise, but we don’t know who has that expertise, who is able to render an unbiased and informed opinion, and who is “in the pocket” of an interest group or otherwise untrustworthy?

What was the old Chinese curse? “May you live in interesting times.”

We are.

Tea and Superficiality

I have this mantra that I am sure annoys the hell out of the students in my policy class: “It’s more complicated than that.” It is part of my effort to explain that policy decisions frequently have consequences beyond those that we can easily identify–beyond the superficial issues that pundits exploit for ratings and politicians employ to agitate their bases.

The auto bailout was a perfect example, and in his column today, Brian Howey does a great job of explaining why the policy choice was not the simple matter of “bailing out losers” that Tea Party activists and libertarians evidently believe it was.

As Howey writes

“In December 2008, I attended a hearing in Indianapolis where economists from the Brookings Institute predicted that a collapse of GM and Chrysler could cost the state 150,000 jobs — not just at GM and Chrysler but also at companies like Cummins and hundreds of auto supplier companies scattered in small towns and large across the state.

The multiplier impact from such a collapse could have been devastating. Not only would toolmakers, engineers, assemblers and molders be jobless, but thousands of restaurants and service businesses would have been devastated. Even foreign automakers in the state such as Honda, Toyota and Subaru would have been negatively impacted, because they draw on the same suppliers as GM, Ford and Chrysler. While Indiana has a troublesome and persistent 9 percent jobless rate today, a collapse of GM and Chrysler would have brought a second Great Depression to Indiana. We easily could have seen the jobless rate double or more.

Indiana Republicans were conspicuous in their indifference. Gov. Mitch Daniels warned of the U.S. government throwing “good money after bad” and said the domestics should emulate the Japanese companies. He later castigated the U.S. Supreme Court for the way it acted on Obama’s forced expedited bankruptcies of GM and Chrysler. Treasurer Richard Mourdock, with Daniels cheering him on, tried to thwart the Chrysler merger with Fiat. Republican candidates up and down the food chain derided the Bush bailout.”

Howey’s larger point was political: that the success of the bailout puts Indiana “in play” this November. (I’d add to that the recent passage of Right to Work legislation, which certainly has energized the Democratic base.) But whether Obama wins or loses the state, Howey’s description provides a “teachable” moment for those open to such lessons.

Modern industrialized societies are complex mechanisms. Very few things are as simple as they may once have been (or seemed). A dim recognition of that reality–and the increasingly obvious cultural changes generated by our growing diversity and rapid technological advances–are a not insignificant reason for the national hissy fit being thrown by folks who don’t want to be confused by the damn facts.

Ideologies of all sorts are increasingly incompatible with evidence and complicated realities. If ideologies win out–and it doesn’t much matter which ones–we’re all going to be in a world of hurt.

This is Not a Bill

I’ve been following the Sunday series in the New York Times in which Ezekiel Emanuel—vice-provost and Professor of Medical Ethics at the University of Pennsylvania, and former White House advisor—has been explaining high healthcare costs.

I particularly appreciated this week’s discussion, “Billions Wasted on Billing.” My husband and I are at the age when doctor’s visits become more frequent, and I have weekly opportunities to open envelopes to read incomprehensible jumbles of medical and financial jargon under the heading “this is not a bill.”  Anyone having experience with mailings of any sort—bills, invoices, reminders—knows that it is impossible to generate and mail anything for less than $5-$7 dollars, once you account for clerical time, stationery and postage. I’ve never understood why the same not-so-informative information can’t be included when the actual bill is sent.

Emanuel’s column was not just about billing, but about all the other repetitive, duplicative paperwork that characterizes our current health care system. How many times do we fill out patient forms with the identical information? How many insurance claims must be completed in different formats by all those white-haired ladies in colorful smocks sitting behind the glass partitions in your doctor’s office?

What does all this cost, and how much of it is really necessary?

According to Harvard economist David Cutler, electronic billing and credentialing could save the system upwards of 32 billion dollars a year. Transitioning to electronic record-keeping would pay other dividends as well: it would allow medical providers to use existing anti-fraud detection methods currently used by credit card companies, and it would minimize the errors that are inevitable when data is manually entered. (No longer getting “this is not a bill” mailings would also have a salutary effect on my blood pressure.)

What Emanuel’s column did not address is the question why medical insurers and providers have been so slow to adapt to the electronic age. I think a part of the answer is the complexity of what passes for a medical system in the U.S.—a complexity that also bedevils efforts to conduct reasonable policy discussions about health care in general.

We’ve all joked about the senior citizen at the Town Hall meeting who shouted “keep government’s hands off my Medicare.”  It’s true that most Americans do know Medicare and Medicaid are government programs. We know that taxpayers fund the (much-lauded) Veteran’s Administration. But how many of us understand the extent to which government currently funds pharmaceutical and medical research? Or how much state governments contribute to the cost of medical education? To public health programs? How many of us know what local government units spend for everything from ambulance service to charity care?

I like to think of myself as informed, but I certainly don’t know the answers to those questions. I was astounded a few years ago when, serving on an academic committee dominated by healthcare professionals, I learned that government at all levels currently funds between 60% and 70% of all healthcare costs.

The real question isn’t whether we should have a government system or a private one. We haven’t had a private, market-driven system for decades, and for good reason. Markets require a willing buyer and willing seller, each of whom has the necessary relevant information and the ability to exercise choice. The real question is how to identify the measures that will reduce healthcare costs and improve patient care and access. Right now, we pay 2 ½ times what the next most expensive country pays for a system that ranks 36th in the world.

That’s a bill we shouldn’t have to pay.