Drug Related Violence

Drug Related Violence

In his book Chasing The Scream, Johann Hari writes about common misconceptions related to drug violence in the United States. Misconceptions influence drug policy, shape the way people think about drug crimes and drug users, and prevent us from taking real action to help reduce the conflicts and negative externalities related to the American war on drugs.

 

Hari writes, “When we hear about drug-related violence, we picture somebody getting high and killing people. We think the violence is the product of the drugs. But in fact, it turns out this is only a tiny sliver of the violence. The vast majority is … to establish, protect, and defend drug territory in an illegal market, and to build a name for being consistently terrifying so nobody tries to take your property or turf.”

 

What Hari suggests throughout the book is that many of the negative things we relate to drug use is more associated with prohibition against drugs. Making drugs illegal and trying to stamp out any drug use in an all-out war creates negative externalities that justify violence and prohibition. The war on drugs creates a positive feedback loop, making drug use and drug trafficking more dangerous, building support for harsher treatment and destruction of drug users and sellers.

 

When we make something illegal, we create a black market. On the black market, as I wrote about from Brookings Scholar John Hudak’s book Marijuana: A Short History, suppliers don’t have to meet safety and quality standards that would exist in a regulated legal market. This is where the dangers of drug use arise and where drug related violence comes into the picture. Many of the people using drugs directly are non-violent, and don’t want to cause harm to others when using drugs. They harm others when they need to obtain drugs illegally, on a costly and dangerous black market. The sellers create relationships and build territory, and use their own force to control their territory, since relying on police protection and legal backing to defend property and product is not an option in a black market.

 

I don’t know what the world would look like without a war on drugs and with a legal market for obtaining drugs. I don’t know what new externaliteis would arise and how we would face them. But I do think that Hari is correct and that we should acknowledge that much of the drug related violence and crime, and much of the safety concerns related to drug use, stem from the very prohibition and war that we approve of to stamp out drug use. The current approach seems incapable of eradicating drugs, but it does seem to spur substantial drug related violence and safety issues.
Transparent Price Bundles

Transparent Price Bundles

One of the items that Dave Chase calls for in his Fair Trade for Health Care Plan in his book The Opioid Crisis Wake-Up Call is bundled prices. He wants pricing to be transparent and up-front so that patients know what services they are receiving, and he wants prices to be bundled for any procedures that we undergo.

 

As chase writes, “Imagine buying a car and getting a bill for the transmission six months later. You’d be livid, yet this sort of thing happens all the time in the healthcare industry.” If you have ever gone to an emergency room or had a surgery, you likely have experienced what Chase is talking about. You were probably billed for the procedure and the doctor who saw you, but then you might receive a separate facility bill some time later, or you might receive a separate bill from the anesthesiologist months after you thought you had finished paying everything from the procedure or emergency room visit that you had.

 

The amount of additional bills that keep rolling in from a single procedure can be frustrating and overwhelming. You likely get an explanation of benefits that to an ordinary person doesn’t explain much of anything, and then you get multiple bills from multiple entities with no clear explanation of why you are receiving another bill. The confusion can easily frustrated patients and prevent them from being able to contest what many see as unreasonable charges.

 

In Chase’s Fair Trade for Health Care, providers would have to be up front about any costs that patients are going to incur before a procedure or encounter. This would include bundling all prices together ahead of time to reduce surprise billing. A patient can try to anticipate charges, but if they can’t anticipate who will be billing them, they cannot truly have a sense of what a procedure will cost them. This is an unfair practice from healthcare providers and drives up costs for everyone.
The Specter of Rationing Care

The Specter of Rationing Care

American’s fear having to wait for anything. We want to order things from the comfort of our own home and have them delivered in two days. We don’t want to wait behind more than three people in line at the grocery store, and we don’t want to wait for medical care (to be honest these are all examples from my own life – not picking on anyone who isn’t like me here). Our fear of waiting is used as a reason against universal health coverage. We are told about Canadians who cross to the United States to have surgeries that they would have to wait several months to have in Canada. We are told that we won’t be able to schedule an immediate primary care appointment if more people were to have access to health care. And we are told that the high costs of medical care stop unnecessary care from happening, preventing us from having to wait to see a doctor.

 

However, these fears of waiting and the specter of rationing care presented to us in these scenarios is overblown. It is true that some Canadians chose to get care in the United States for elective procedures, but presenting that fact to us in isolation is misleading and done in bad faith. The reality of our waiting for care is much more complex. Dave Chase does a good job of explaining it in his book The Opioid Crisis Wake-Up Call, “People often raise the specter of rationing care. In reality, it’s overuse (i.e., unnecessary and potentially harmful care) that leads to reduced access by squandering enormous financial resources that would be better used for individuals who actually need care and can’t get it.”

 

We act as though our healthcare system is following good market incentives to find a good balance between wait times and receiving the right care. But we often fail to acknowledge that our healthcare system isn’t performing like an ideal market, and that it often pushes people to too much of the wrong type of care. Chase details this in his book with unnecessary back surgeries. Those who have a legitimate need for a back surgery might have to wait, because primary care providers get a bonus when they refer patients to orthopedic surgeons who are paid to operate. The right path for a patient might be physical therapy, but the money for the providers is in the surgery.

 

We should not raise the specter of rationing care when we are so wasteful with the care we provide through our current system. We waste a lot of money when we don’t have a concern about rationing care, and when we reward providers for doing more surgeries, prescribing more pills, and offering more treatment, even if the efficacy isn’t proven. In his book, Chase doesn’t advocate for a universal coverage system with healthcare covered by the federal government, but he does show how employers today can do more to ensure their patients get more of the good care (the effective PT and preventative check-ups) for free. This reduces the demand on the expensive and unproven treatments later on, and actually reduces the demand on the system for services that we are afraid of rationing.
Black markets and Marijuana

A Thought About Black Markets

A line from John Hudak’s book Marijuana: A Short History is worth thinking about if we are someone who frequently thinks about public policy. Hudak writes, “The black market just has to deliver marijuana; the legal market must meet consumer demand.” 

 

Hudak’s line comes from an early paragraph in his book where he discusses historical trends in the strength of marijuana overtime. Marijuana strength is often measured by the amount of THC in the final product to be consumed. Dr. Mahmoud ElSohly, a researcher with the University of Mississippi, has been analyzing the THC content in seized marijuana since the 1970’s and has found that THC content has increased overtime from about 3% to 7-8%. However, marijuana that can now be purchased in dispensaries in states that have legalized marijuana often has a much higher THC content, closer to 20% or more.

 

My interest is not so much in the marijuana itself, although the plant and product is interesting (Note: I have asthma and can’t smoke and I have never tried any edible forms of marijuana). What is really interesting is the degree to which the black market under-served those who wanted to purchase marijuana from 1970 to today. Marijuana that could be purchased from a drug dealer or a friend was not as potent as people would have liked. If people were intent to buy marijuana, their only option was a product that we would consider inferior to the options available in states that have legalized marijuana today, a product that many likely wouldn’t chose if they’d been able to chose an alternative product.

 

The point I want to highlight is not that people were purchasing weak marijuana from the 1970’s until 2019 when Hudak’s book was published. Instead, the point I am trying to make is that the black market delivers sub-par products to people who use them. In the case I am writing about, illegal supplies of marijuana were simply less potent, not something that non-marijuana users are likely to care much about. However, if we think about other black markets, we should be more concerned about the products that people purchase illegally. Other black market products, that people cannot obtain legally and that cannot be regulated by a true market mechanism, likely come with more dangers than just being weak. Other illicit drugs can be even more dangerous and harmful when purchased on the black market. Health products, purchased on the black market where they might be cheaper than licensed and regulated products obtained legally, could also pose serious risks of harm.

 

This creates an argument for reasonably regulated markets, even of things we find deviant and would rather people be unable to purchase. We want some type of government oversight to ensure that products and services are safe, effective, and authentic, but we should be concerned about government regulation that drives a product or service into a black market. The market itself will find a way  to deliver the service or product, but it may do so in a dangerous and illicit manner. Government and regulation can be forces for good and bad within this dynamic. What is important is that we think critically of how regulation relates to markets, and consider the impact on people’s lives, including the lives of those who will still pursue a product or service once it is forced to a black market.

Markets & Civil Society Organization

I tend to be a bit hard on the idea of free markets. I grew up learning about the invisible hand and in a family that started a business and did well. I (mostly because of my family’s business) appreciated the idea that setting up a market and running a business was a good thing from the standpoint of finding an efficient point at which to price a product or service. Today however, perhaps as a result of my healthcare interests, I see numerous examples of markets falling short of the goal we establish in our minds based on the idea of the invisible hand.

 

Rather than seeing markets find an efficient point where competition drives efficiency and provides everyone with better products at better prices, I see too many externalities from free markets and unfettered competition. We are producing a lot of greenhouse gasses that harm life on the planet. CEOs are getting better (maybe deservedly so) at capturing greater salaries from their companies, driving economic inequality, and straining social stability. Private health insurance markets seem to drive overall healthcare costs up at every turn, and no one seems to be able to understand how health insurance actually works. The free market, and open competition, does not appear to function as clearly and organize as succinctly as my simple understanding from high school would have suggested.

 

What is missing is something that ties markets and capitalism back into civil society. Bruce Katz and Jeremy Nowak, in their book The New Localism, suggest that shifting political power and decision making back to local contexts within cities and metropolitan regions can help correct these problems. They write, “New Localism is a mechanism for converting the self-organizing power of markets and civil society into structured fiscal and financial resources, and ultimately, political power.”

 

National and multinational sized corporations often have a responsibility to maximize profits for shareholders or top executives. Their huge scale means that any local or regional place is less important for them, since there are always markets in other countries and other states. However, when local governments exert more control over such companies, the local contexts begin to matter more. When CEOs and executives from these companies are invited in to help shape policy beginning at the local level, and are held accountable to the local individuals in the places where their markets are strong or where their employees actually live, the business motives that encourage negative externalities are shifted. The dynamic becomes one where civil responsibility is elevated, and ultimately political power is shifted in a way to help organize business in a more responsible manner in relation to the local context.

 

The lesson that Katz and Nowak share is that businesses on their own are encouraged to organize themselves in a way that maximizes profit at the expense of the local communities in which they operate. By giving localities more power and better networked governance structures, big businesses can instead be a cooperative part of the political and social structure, re-organizing themselves within society in a way that helps make Adam Smith’s invisible hand dream a little more plausible. The Invisible hand in this model is not so invisible, but more of a structured handshake creating a commitment to more than just profits.

A Critique of Our Current Markets

A lot of people today feel that capitalism is failing them. They feel left behind and they believe that the system is rigged against them. This will undoubtedly be a major driving factor in the next presidential election and there will be many candidates who offer their own diagnosis as to why people feel the way they do. A key reason, I believe, as to why people feel the system is failing them is highlighted by Colin Wright in his book Becoming Who We Need to Be. Wright addresses the way that many people seem to be creating businesses, making money, and becoming successful through trickery and rent-seeking behavior. He writes, “…this means that if we can find a clever way to extract money from the system, even if we don’t create anything of value, or we sap value from society in the process, we’re still doing it right.”

In a recent podcast episode for his show Against The Rules, Michael Lewis described the way that many financial companies exist not to serve customers better, but to operate in a way that makes money seemingly by fooling customers into making decisions that benefit the company without benefiting the consumer. I’m sure that for many of us, our healthcare or health insurance has felt that way. Also for a lot of us, we probably felt that we got a little ripped off on one of the first times we tried to purchase something on Ebay, and ended up not quite getting what we expected.

A lot of aspects within our economic system at the moment seem to reward people even if they don’t give us what we expected. There are incentives to create systems and products that sound clear, but end up being hard to access and ultimately don’t seem to make us or anyone except the seller any better off.

On our own, we all want to get the most money and reward from doing the least amount of work. At times it is true that we all want to bust our bums and do great work, but if we could just set something up where we made money no matter what and didn’t have to do any real work, on some level we would be happy. On an individual level this is not a big deal, but when it is combined, multiplied, and turned into a corporation it can become a problem for society, and that is what we are seeing in the national mood today. People sense that the system is not fair and doesn’t produce fair outcomes. The individual instance of being ripped off might not be the thing that makes them the most angry, but rather the fact that the system allows for people to pull out money and become successful without creating value makes people lose faith in institutions. At a certain level, no matter what our individual incentives are, we should recognize and accept that this is a bad way to operate long term, and we would be better off within a society that seemed to operate more fairly because it would create less anger and more stability on a societal level.

What Race Are You Running?

In his book Ego is the Enemy, author Ryan Holiday helps us look at competition in a more meaningful way. It is hard, at least in the United States, to feel as though one can be successful without comparing oneself to everyone else. Our entire society is based around consumption and markets, creating daily competitions and providing us with a million opportunities to purchase shiny new trophies as emblems of our success. The markets we live within have driven human ingenuity forward, given us phones that replace a thousand products in a 2.5 X 5 inch rectangle in our pocket, and have risen the living standards for people across the globe, but our markets have also put us in a place where purchasing power and wealth are the standards we use to measure the value and success of people. This can be very dangerous, especially since competition is not always the best way to unify a society or bring meaning to most individuals. Holiday writes,

 

“Only you know the race you’re running. That is, unless your ego decides the only way you have value is if you’re better than, have more than, everyone everywhere. More urgently, each one of us has a unique potential and purpose; that means that we’re the only ones who can evaluate and set the terms of our lives. Far too often, we look at other people and make their approval the standard we feel compelled to meet, and as a result, squander our very potential and purpose.”

 

The competition of the markets in our lives make it seem like we are all racing against each other all  the time. I feel this when I check the stats for my blog, when I post a run to Strava, and when someone I know pulls up next to me in a brand new car. I often feel that I am doing well or not doing well based on how I look relative to others, which is dangerous because it is something I do not control. I cannot compare my blog to people who are professional bloggers and have the time and energy to put all of their focus into their blog. I cannot compare my running to friends of mine who have the time to do multiple workouts every day with a coach who can help them run really fast. And I do not know if the person in the new car next to me is just borrowing the car from a family member, paid for it outright, or is leasing a new car they really can’t afford. In my examples above, each of us is in a different race, and it is a mistake to think that I am somehow competing against all of them in these areas that really do not matter at the end of the day.

 

A while back I wrote about the pitfalls of using money and wealth as our default measurement for success. Financial success does not always translate into a well rounded and truly successful life. There are many factors that contribute to someone’s wealth, and very often those factors don’t really have anything to do with the hard work, value, or skills of a person. Trying to outrun that person and achieve greater wealth than them might be a mistake, because you are running a different race, and you might be competing in an entirely different sport. Assuming that everyone is just like us, that they have had the same experience as us, the same advantages and obstacles in their lives, and experience the same desires and goals as us is a mistake if we are trying to compete with them to have more things or more of what ever it is we decide makes someone successful. At the end of the day we can use elements of competition to encourage us to make good decisions like eating healthy, writing every day, and working hard to be productive, but we should not do these things simply to be better than everyone else and show our dominance over them.

Political Monopolies

Throughout his book Political Realism: How Hacks, Machines, Big Money, and Back-Room Deals Can Strengthen American Democracy, Jonathan Rauch argues that our government needs a little less sunlight and transparency to allow for good governance. His ideas are that too many rules and restrictions, too many provisions for transparency and clearness, and too many changes to make our system more democratic have led to a point where necessary parts of politics cannot take place, and as a result, our government cannot function effectively. Politics (thinking about human behavior dating back to our first human ancestors) is about coalition building, creating alliances, and cooperating for safety, growth, and group survival. When a government’s political activities have to be entirely out in the open these types of activities are hindered, and as a result, we get showmanship and political battles as acts of public coalition building. Real governance, compromise, and negotiation become impossible.

While Rauch thinks that we need more of a cover in our system for these political behaviors, he does understand how we got to this point and he does examine some of the shortcomings of our old political system which compelled people to impose such restrictions on modern day politics. When looking at political machines specifically, Rauch highlights some of the negative aspects of organized political coalitions. He writes,

“Machines seek monopolies. In order to preserve power, they will seek to manipulate rules and rule-making (redistricting, voting rules, and the like) to shape the political battlefield in their favor—often with the goal of raising barriers to entry for would-be political competitors. They also will try to get their hands on as many formal levers of power as they can, using each to reinforce the others.”

This description of political machines reminds me of modern day corporations. Rather than simply looking to out-compete and out-innovate their sector and competitors, many firms today seem to prefer gaming the system and industry to limit competition. Often corporations will argue for increased regulation and requirements because it makes it harder for new firms to enter the market and disrupt current markets. Firms also look to build monopolies and diversify across different sectors to capture markets and establish a status quo that favors their bottom line rather than the interests of society or the furthering of new products and technology. Rauch argues that the danger of our old political system of machine politics mirrors the danger of modern markets. The political landscape in one sense becomes an economic landscape, with different political coalitions competing for greater market-share (vote share) and influence.

What I find interesting and revelatory about this point of view is that ideology and beliefs take a back seat to group dominance and interests. When we operate in machines, what we favor is the preservation of our coalition, not necessarily any specific ideology. Just like in a market we may prefer a specific brand and gravitate continuously toward that brand even if competitor brands introduce better products. Often we will stick with our familiar brand and highlight the good things about the brand we like while downplaying the shortcomings. Rauch’s demonstration of machine politics reveals that we do this in our political alliances as well, favoring rules and power grabs that help our side while remaining critical and opposed to any actions taken by our competitors.

What Rauch highlights here is part of why we have implemented rules that make politics more transparent and clear. The political actions of machines are not about issues but rather power, and we are uncomfortable with that. Unfortunately however, we humans operate in this tribal manner, and without these political power games, we don’t seem to be able to coalesce around issues to foster good governance. Somewhere in the middle of where we are now and the machine politics of the past is where good governance can live and thrive, addressing our political issues while engaging the public and building teams to move government policy forward.