Unequal power, public health, and liberalism
A few months ago, Malcolm Gladwell hit on a really interesting but totally counterintuitive set of points about social inequality. (Actually, two.) It stuck in my head, in an “Isn’t that interesting” kind of way, but it wasn’t until I read two other items today that it clicked.
Now, I should note that Gladwell is the closest thing this profession has to a genius. He’s the Platonic ideal of a journalist, someone who finds novel sources for inspiration and does his own amazing number-crunching, just to make the story coalesce. To a certain extent, people like me check the New Yorker’s covers slavishly every week just to see if he has a new article, and read his blog for whatever meager insight he can offer us. I’m a total sucker for numbers and interesting and novel statistical analyses.
In February I read his story about homelessness, and the way in which the problem’s solutions are completely counterintuitive to the conventional two approaches to homelessness in the U.S. Most social phenomena are assumed to have a Gaussian distribution, which is to say that if you were to graph any measurable trait, you’ll get a bell curve. For instance, height fits a normal distribution curve almost totally perfectly; if you distribute those data points with x as height and y as number of people in a given population at that height, you have a bell curve, and if you don’t, you have a data problem.
But Gladwell noted that homelessness, among other things (e.g., complaints of police brutality in the L.A.P.D.), actually fits a power-law distribution, where the data are heavily clustered at one end of the distribution. He writes:
Homelessness doesn’t have a normal distribution, it turned out. It has a power-law distribution. “We found that eighty per cent of the homeless were in and out really quickly,” he said. “In Philadelphia, the most common length of time that someone is homeless is one day. And the second most common length is two days. And they never come back. Anyone who ever has to stay in a shelter involuntarily knows that all you think about is how to make sure you never come back.”
The next ten per cent were what Culhane calls episodic users. They would come for three weeks at a time, and return periodically, particularly in the winter. They were quite young, and they were often heavy drug users. It was the last ten per cent — the group at the farthest edge of the curve — that interested Culhane the most. They were the chronically homeless, who lived in the shelters, sometimes for years at a time. … In the early nineteen-nineties, Culhane’s database suggested that New York City had a quarter of a million people who were homeless at some point in the previous half decade — which was a surprisingly high number. But only about twenty-five hundred were chronically homeless.
It turns out, furthermore, that this group costs the health-care and social-services systems far more than anyone had ever anticipated. Culhane estimates that in New York at least sixty-two million dollars was being spent annually to shelter just those twenty-five hundred hard-core homeless.
[…]
The homelessness problem is like the L.A.P.D.’s bad-cop problem. It’s a matter of a few hard cases, and that’s good news, because when a problem is that concentrated you can wrap your arms around it and think about solving it. The bad news is that those few hard cases are hard. They are falling-down drunks with liver disease and complex infections and mental illness. They need time and attention and lots of money. But enormous sums of money are already being spent on the chronically homeless, and Culhane saw that the kind of money it would take to solve the homeless problem could well be less than the kind of money it took to ignore it.
This goes totally counter to all of our traditional impulses, Gladwell argues. Conservatives say that the homeless should be shoved off the street by whatever means necessary, which may be the impulse the vast majority of the homeless need but which won’t even touch the chronically homeless. And liberals say that the homeless should be shown compassion and given shelters and a hand up, which ends up providing needlessly expensive solutions to the transitorily homeless. The solution, Gladwell finds scattered throughout the country, are programs that essentially provide housing and nursing care for the most chronically homeless.
The reason that that’s so interesting is another one of his articles, from last August, which suggests that medical care probably doesn’t fit a power-law distribution. That’s the foundation of our entire medical system; we assume that because insured people don’t pay for their health care, some people don’t need much medical care but that they over-use the system because it doesn’t cost them anything. In other words, their utilization fits a power-law distribution. We’ve long assumed that there are a lot of people who fit these criteria, so we charge everyone a co-pay for every visit they make to a doctor, and these co-payments are actually going up. The idea is that, by charging people money to see the doctor, they make rational decisions about when to see the doctor and when not to.
We know now that they don’t, thanks to Gladwell (inter alia). All too often, co-payments cause people to cut back on any doctor visits, and the consequence is rotting teeth and lingering health problems.
John Kenneth Galbraith, who died last week, would’ve understood this power dynamic and why it fails, why it basically condemns the poor and the lower middle class to limited health care. Our entire system is predicated on denying them care, the powerful against the powerless, something that Galbraith’s entire philosophy demanded that he oppose. Conservatives who were angered by his philosophy throughout his life, who had the wounds reopened with his death last week, opposed it because of the way that he proposed using the state to redistribute power. (For an example, see Andrew Sullivan’s visceral hatred of Galbraith, and anyone else who advocates using the state as a positive tool.)
But the key to Galbraith’s insight was that the use of power to take power from the masses only hurts them. And that brings us up to today, and Slate’s article about the recent survey which suggests the strange failings of the American health care system. For all the gigantic sums of money that we invest in the U.S. in our health care system, we actually have worse health than even the British, with the painfully dysfunctional National Health System in the U.K., and certainly worse aggregate health than Canada, without any obvious reason to do so.
If we apply Galbraith’s insight, then, our goal should not be to add accountability to our health care system, but to make sure that people whose needs fit a power-law distribution get care instead. Our current system is designed to transform a power-law distribution of needs into a bell-curve distribution of use, and the result is a mismatch, and disastrous health consequences. That’s why basic care is under-provisioned, with the presumption that it is overused, and acute care is over-provisioned and has a very low barrier for utilization. Galbraith would tell us that we should instead dramatically increase access to basic care, by cutting co-pays for preventative care of various kinds and increasing reimbursement if need be, and decrease access to acute (but non-life-threatening) care.
The theory behind this is, to a great extent, the theory that fuels the National Health Service: It was created with the assumption that preventative care would reduce the demand for acute care later, and that eliminating the need for decision-making about care would provide better overall health. The NHS seems to be succeeding.
Of course, the NHS is a disaster area right now. But, without going into too much detail, I would argue that the NHS’ failure is in a to-low entry barrier, and that its systematic over-utilization is related to the only barrier that exists, the challenge of finding a doctor who can actually see patients. Also, they have a significant under-reimbursement problem, relative to the U.S. system. In neither system are doctors adequately reimbursed, but in Britain, at least no one benefits at the expense of doctors and patients, which is more than I can say for us — our insurance companies, like our oil companies, are posting record profits at the expense of ordinary Americans.
Anyway, the take-away point is that the conservative plan for health care, that we should discourage people from using health care, is clearly broken, because for all the extra expense we have, we don’t get better care. The power distribution is utterly broken.
Galbraith’s key insight was that that’s the way it will always be, when you have an unequal distribution of power. And if we have to use the power of the state as leverage on this distribution, to make it equitable and to un-break our health care system (or, per Gladwell’s examples, a small population of chronic homeless, or the L.A.P.D.’s brutality problems), so be it.
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