Risk Literacy Builds Trust

Risk Literacy Builds Trust

In his book Risk Savvy Gerd Gigerenzer writes about a private medical panel and lecture series that he participated in. Gigerenzer gave a presentation about the importance of risk literacy between doctors and their patients and how frequently both misinterpret medical statistics. Regarding the dangers this could pose for the medical industry, Gigerenzer wrote the following, recapping a discussion he had with the CEO of the organization hosting the lectures and panel:

“I asked the CEO whether his company would consider it an ethical responsibility to do something about this key problem. The CEO made it clear that his first responsibility is with the shareholders, not patients or doctors. I responded that the banks had also thought so before the subprime crisis. At some point in the future, patients will notice how often they are being misled instead of informed, just as bank customers eventually did. When this happens, the health industry may lose the trust of the public, as happened to the banking industry.”

I focus a lot on healthcare since that is the space where I started my career and where I focused most of my studies during graduate school. I think Gigerenzer is correct in noting that risk literacy builds trust, and that a lack of risk literacy can translate to a lack of trust. Patients trust doctors because health and medicine is complex, and doctors are viewed as learned individuals who can decipher the complexity to help others live well. However, modern medicine is continuing to move into more and more complex fields where statistics and risk play a more prominent role. Understanding genetic test results, knowing whether a given medicine will work for someone based on their microbiome, and using and interpreting AI tools requires proficient risk literacy. If doctors can’t build risk literacy skills, and if they cannot communicate risk to patients, then patients will feel misled, and the trust that doctors have will slowly diminish.

Gigerenzer did not feel that his warning at the panel was well received. “The rest of the panel discussion was about business plans, which really captured the emotions of the health insurers and politicians present. Risk-literate doctors and patients are not part of the business.”

Healthcare has to be patient centered, not shareholder centered. If healthcare is not about patients, then the important but not visible and not always profitable work that is necessary to build risk literacy and build trust won’t take place. Eventually, patients will recognize when they are placed behind shareholders in terms of importance to a hospital, company, or healthcare system, and the results will not be good for their health or for the shareholders.

The Cost of the Status Quo in Policing

The Cost of the Status Quo in Policing

It is not always clear exactly what the cost is of the status quo. Policing is an area that is getting more attention now, and hopefully calls to defund the police are met with serious consideration as to how much money our police forces really need. The status quo in policing is that we spend a lot of money to lock up people we determine to be criminals, but not a lot of money on things that help rehabilitate criminals or prevent crime in the first place. We argue that tight state and federal budgets don’t leave us with enough money for anything other than incarceration, but when we consider just how costly policing really is, we can see that changing the status quo would open a lot of funding for other avenues.

 

Johann Hari addresses this reality in his book Chasing the Scream from 2015. At the time Hari wrote the following about a block in Brooklyn, NY, “In Brownsville, Brooklyn, the state spends one million dollars for every five people it arrests and convicts of midlevel drug offenses.” Our priority for our police has been to go after drug criminals and place steep penalties against them. The harsh costs, society thinks, should go to drug dealers and addicts, but the reality is that the costs fall on society itself. The current movement of defund the police is as much about how we prioritize our resources as it is about stripping the police from their ability to cause physical harm to those they encounter.

 

“In the United States,” Hari writes, “90 percent of the money spent on drug policy goes to policing and punishment, with 10 percent going to treatment and prevention.”

 

We complain about limited resources and being unable to introduce policy to truly make the lives of our fellow citizens better. But we spend huge amounts of money ($5 million dollars on five people) in the costs of arrests, trials, and incarceration. We are willing to pay huge amounts of money to round up the problem and remove it from our sights, but we are not willing to pay money to work with people and help address the problems that spiraled into the even worse problems that we arrest people for having. There are other ways to address crime, drug use, and the dereliction of the lives of the people we incarcerate. Shifting away from an arrest first and police first mindset can open up new resources to better address these problems and challenges.
Steel, Coffee Beans, and Healthcare

Steel, Coffee Beans, & Healthcare

“GM spends more on health care than steel, just as starbucks spends more on health care than coffee beans.” Dave Chase writes in his book The Opioid Crisis Wake-Up Call. “For most companies, health care is the second largest expense after payroll. This puts you in the health care business.”

 

It is incredible to think that major companies like Starbucks and GM spend more on healthcare than on the products they produce that make them stand out. It feels incredibly troubling and a bit counter to our American pro-business narrative for our companies to spend so much on something that is not a key part of their business and that is not part of their core competency. But as a quote from Warran Buffett that Chase uses to open the 11th chapter of his book says, “GM is a health and benefits company with an auto company attached.” 

 

I am among those who think that one of the greatest failures in America’s healthcare past was to allow businesses to provide health benefits with a tax break for the company. Rather than paying employees more money, which would come with higher tax rates, companies have been allowed to provide health benefits, which instead come with tax breaks. This is how we have fallen into a system where the quality of care, the structure of access to healthcare, and what you pay is largely determined by how well your employer does with navigating the complex healthcare landscape. You might work for someone like Harris Rosen who has figured out how to provide large amounts of preventative services with low costs, or you might work for a cash strapped organization with a random HR person trying to make healthcare plan decisions while also dealing with that employee who won’t take down the inappropriate calendar in their office and is simultaneously trying to review several applications for a new position.

 

The reality of healthcare spending by companies shows us that they cannot reasonably expect to have an inexperienced HR person handle healthcare benefits. The spending is too high for someone who is not completely focused on industry trends and changes, someone who doesn’t understand how insurance companies and PBMs work, and someone who has multiple other responsibilities to manage. If we want to keep private health insurance tied to our jobs, then we need to demand better from our employers and our public policy.

 

When we discuss the costs of healthcare in our nation, and when we consider whether a single entity (the Federal Government) should provide health insurance versus having everyone either buy private insurance through individual markets or receive health insurance through their employer, we need to consider the reality of business spending on healthcare. We need to ask whether GM should be producing cars and accountable to so many employees for their basic health needs. Maybe there is still a space for GM to be involved with the health of their workforce, but should they be the entire determining factor, spending more on healthcare than the steel that goes into the cars they produce? These are the questions I would like to focus on when we think about how we should access and pay for the care we receive.
Medical Technologies

The Problem with Healthcare Technology

In my last post I wrote about hidden costs of the healthcare system in America. I wrote about tax breaks for employers who offer health benefits, and I wrote about third party insurance preventing the healthcare system from working like a pure market. This post introduces one consequence of the hidden costs of our system and the ways in which our system fails to act like a market: the high cost of medical technologies.

 

In The Opioid Crisis Wake-Up Call, Dave Chase writes, “We ended up focusing on a certain type of high-technology, acute medical care – which we financially reward far more than lower-level preventive and chronic care – without regard for the quality of the outcomes or value of the care.”

 

When I took a healthcare policy and administration class along with a healthcare economics class for my graduate studies, I was surprised to see a critique of advancing medical technologies as part of the problem of American healthcare costs. I live in Reno, under the sphere of influence of the Bay Area, where technological solutions to global problems are hailed as the cure-all, deus ex machina that we need for a peaceful and prosperous world. I always thought that better medical technology saved lives, made us healthier, and ultimately reduced cost by being more efficient and precise than older technologies.

 

As it turns out, new medical technologies are incredibly expensive, and often times the benefits that patients receive are only marginally better than what existing technology offers. In some instances those marginal improvements make the difference between life and death, but in many instances, the new technologies might only add a few months of life to a terminal diagnosis, a few additional months lived in pain and fear. In other instances, the new technologies might add a little more comfort or certainty in a patient’s procedure or diagnosis, but it is fair to question whether its really necessary and worth the additional cost.

 

The quote from Chase reveals that when we are shielded from the costs of care, and when we remove market aspects from the healthcare system, we adopte a mindset that healthcare equals expensive interventions with high cost technology. I had clearly bought into this narrative prior to my graduate studies. The alternative that Chase highlights in his book, which we have underdeveloped in the United States, is to move upstream, and take care of people at a preventative level before they are sick and before they need expensive technological interventions. Developing systems, structures, and norms for healthy lifestyles will do more to reduce costs than the development of new magical cures and technological fixes. Our priorities and the focus of our system is flawed, and a as a result we focus on high cost interventions within a system no one is happy with. Rather than develop a system that actually supports healthy living, we have fished around for quick, high-cost technological solutions to our health woes.
The Costs of High Healthcare Costs

The Costs of High Healthcare Costs

Dave Chase believes that healthcare costs have stolen the American Dream. Beyond that, Chase believes that our high healthcare costs have cost us more than just money. People stay in jobs they don’t like so that they can afford healthcare, people feel a wage stagnation as employers have to spend more on healthcare, and up to 70% of people who file bankruptcies due to healthcare costs have insurance. The high costs of healthcare come at a substantial emotional, psychological, and aspirational cost to Americans.

 

In his book The Opioid Crisis Wake-Up Call, Chase writes, “Had health care costs paralleled the Consumer Price Index, rather than outpacing it, an average American family would have had an additional $450 per month – more than $5,000 per year – to spend on other priorities.”

 

The money that families are spending on increased healthcare is not the only money that could be redirected toward other priorities. Employers are spending more on healthcare, which means they have less to use for business investment, less to use for retaining great talent, and less money for expanding into new areas.

 

The stagnation for individuals and companies is real, and it has serious costs beyond just the money going toward healthcare. Individuals who don’t see their take-home pay increase will feel discontent. If inflation picks up, and the amount of goods that can be bought diminishes, people will channel their frustration into social unrest. If businesses cannot invest in R&D because too much money is going to the healthcare costs of their employees, then the United States will not see new innovations inside our boarders, and the dynamic companies that we depend on for our jobs will not be able to compete on a global scale. The costs of our high costs of healthcare go beyond a loss of spending money for some people. The costs are real, and threaten our economy, our global standing, and our social contracts with each other and our institutions.
The Cost of Marijuana Prohibition

The Cost of Marijuana Prohibition

“Tremendous sums of money are spent on enforcing federal and state marijuana laws every year,” writes John Hudak in his book Marijuana: A Short History, “A 2010 study by Harvard economist Jeffrey Miron puts that total cost at around $14 billion annually for federal and local law enforcement, judicial, and correctional costs.”

 

A common refrain in the public policy world is that government budgeting reveals a society’s priority. In the United States, our system of incarcerating individuals and enforcing laws that often disproportionately impact individuals from racial minorities does not reveal something that many American’s would be proud of. The amount of money that our country, our state governments, and our local municipal governments spend on law enforcement and incarceration is enormous, and the amount we spend on actual rehabilitative programs and preventive efforts is comparatively small. We seem to be a nation that is all about punishing bad guys, but not as concerned about preventing crime and helping people avoid lives that lead toward illegal behavior in the first place.

 

There is still a lot we don’t know about how marijuana use will impact the human body, and we don’t know the full costs of legalizing marijuana, but I think it is fair to question whether $14 billion dollars is worth the cost of prohibition. Keeping people in jail for low level drug charges doesn’t seem to be worth the cost to many people, and that is why some libertarian and conservative groups (such as the Koch brothers), have begun to support marijuana legalization. The question is whether our priority really should be policing and arresting people for using marijuana, or whether we should be investing that money toward other purposes.

 

Police and law enforcement resources could be redirected toward other crimes. Reduced judicial and correctional costs might allow for smaller local budgets, meaning lower taxes for citizens. And in states like Nevada, legalized marijuana has meant tens of millions in new revenue specifically for schools and rainy day funds. Ultimately, where our government decides to put money reveals what our preferences are as citizens and voters, and for a long time our preference has been to pay to remove people we don’t like from society, even if the cost is huge and overwhelms our state and local budgets.

Balance and Dimensionality

In our society we like to talk about balance. Everyone seems to be on a quest to find the perfect balance between work, family life, and personal interests and hobbies. We talk about a work-life balance as if there is some absolutely perfect way for us to do all the things we want to do and to live a full life. This is an idea that I gave up long ago because it doesn’t really fit with the reality of the world we live in.

 

Instead of balance I like to think about packing a suitcase and leaning toward one item or another. We have a limited amount of time in a given day, and we must give priority to things we think are the most important. We must decide what we are for sure packing in our suitcase, and what things we are leaving out. Once we have identified those things that are the most important and valuable to us, we end up leaning heavily into one thing or another. We may lean heavily into our career, leaving little time or space for a significant other or for exercise. We may lean heavily into our family, making us less likely to put in extra hours on the job. Or we may live for a hobby and rearrange our lives to provide for more time and opportunity to focus on our personal interests.

 

A short section in Colin Wright’s book Becoming Who We Need To Be brought these thoughts of balance back to my mind. He writes, “There’s nothing inherently unhealthy about working long hours, or working hard on something you care about or think will benefit you in the long term. It only becomes potentially harmful when, in doing so, you neglect other aspects of your life that require attention. When you start to lose density and become less three-dimensional.” What Wright is saying is that there is no correct way to pack your suitcase, as long as you do it intentionally.

 

In the same way that we would be very thoughtful about everything we pack for a week long trip to Hawaii, we should be very thoughtful about what we decide to include in our lives on a daily and weekly basis. If we are going to put in extra hours at work then we should be thoughtful about how we spend the rest of our time so that we don’t just operate as a zombie and ignore family, friends, or our own health. We should recognize that we won’t ever be perfectly balanced if we chose to focus heavily on one thing, but we can at least be intentional with how we use the rest of our time. If we don’t, then we will find that our suitcase has haphazardly filled itself with things we don’t really need, like Facebook, Game of Thrones, and late night trips to Wendy’s. If we think about what we want to pack into our suitcase of life, we can make sure our lives are still dimensional and interesting, even if we are spending a majority of our time and focus on a single thing. We can give up activities that simply distract us in favor of activities that help us be more thoughtful, healthy, or engaged with our loved ones. We don’t have to completely cut out Facebook or TV, but we should be intentional about how much time those activities receive. Going through life on autopilot or trying to find a perfect balance will ultimately end up with us in a frustrated spot as we can’t seem to do everything we want and can’t seem to make our lives fulfilling.

Depart Contentedly

Within Stoicism there seems to be a healthy focus on death. Seneca, Aurelius, and other Stoic philosophers constantly reminded themselves that each day they were drawing closer to their death, and that before their death both their bodies and minds would atrophy. The focus on death was meant to be a reminder, that time on earth for any one of us is short, and if we don’t use the time accordingly, we will fail to do the most with the opportunities we have.

 

Seneca writes, “No man can have a peaceful life who thinks too much about lengthening it.” Recognizing that we are mortal is scary. Knowing that we will die, we will no longer experience the world, no longer engage in relationships, and that the earth will keep spinning whether we are here or not is terrible. It is hard to imagine a world without us and the fear of missing out on amazing new things in the world is enough to keep one up at night. But striving to stay alive forever and being afraid of death at every moment is also terrible. The constant worry that one might die is likely to elevate stress hormones and bring death a little closer. Trying in vain to do nothing but extend ones life creates an unhealthy focus on death, rather than a focus that helps us engage meaningfully with our loved ones, friends, and community.

 

Seneca continues, “Rehears this thought every day, that you may be able to depart from life contentedly; for many men clutch and cling to life, even as those who are carried  down a rushing stream clutch and cling to briers and sharp rocks.” We should try to live a fulfilling and meaningful life so that if we die at any moment, we can die proud of what we have done in the last 24 hours or over the course of our life. This sense brings an awareness of our actions and how we are spending the moments of our lives. Are we on autopilot meandering around through the world, or are we truly present with our friends and loved ones? Have we just been trying to accumulate more stuff, take the coolest Instagram photos, and drive the most fancy car? Or have we tried to find ways to give back, to encourage those who are close to us, and to improve some tiny piece of the world not just for ourselves but for others as well? We all want the first set of things I mentioned, the ones that feel good and make us look cool, but we know the second set will help us sleep better at night. Remembering our death will help us shift our priorities and do more so that we can one day pass one with content instead of fear.

Seneca’s Reminder to Get Stuff Done

As I was waking up this morning and getting my coffee going, I was thinking about some things that I have recently needed to do, but have not worked on. I’m usually not too much of a procrastinator, but a few things have slipped by the last couple of weeks. A quote from Seneca’s Letters from a Stoic returned to me this morning with perfect timing.

 

Seneca wrote, “Lay hold of today’s task, and you will not need to depend so much upon tomorrow’s. While we are postponing, life speeds by.” There are a couple of things I would like to work on, but that I have not managed to prioritize in my life. I continuously end up feeling more pressure as I delay what I intend to do and waste time with things that I like but that I know are not as valuable. Seneca’s quote, I hope, will help me refocus where my attention is and what my priorities are.

 

Seneca is one of the Big Three in Stoicism which generally focuses on being present in the moment through building our self-awareness. When we take a moment to really think about where we are, what our situation is, what we are doing, how we are feeling, and what pressures we or others have placed on ourselves, we can understand ourselves and approach the world more objectively. This type of self-awareness can become a feedback loop that helps us set our priorities and identify what is working well and what is not working well in our lives. Self-awareness and a well grounded sense of presence can help us separate from the story we tell about who we are and refocus on the daily actions we can take to move forward in the best way possible.

 

Seneca’s advice is not anything special, but if you consider his advice within the larger stoic context of self-awareness and presence, you can see that he is correct. We continuously have less  time left in our lives to do the things we want or to make the world a better place. We can spend our time doing easy and self-serving activities, or we can take advantage of the time we have now to do the things that matter to make our lives and the lives of others better. The choice is ours and with some attention and focus we can make the most of the situation we find ourselves in.

Budgets Reveal our Priorities

Last summer my class at the University of Nevada, Reno for my Masters in Public Administration was public budgeting. What we discussed in that class was the fact that budgeting in the political process is always political, and never based on completely rational principles. We can do our best to include data and think objectively, but a the end of the day we must make political decisions and judgement calls when we decide where we will allocate funding. How we make those decisions and where we choose to spend money reveal our priorities. This is particularly helpful to understand when we look at our nation’s problem with mass incarceration. A lot of people understand that there are problems with the number of people we arrest and that we underfund a lot of social services, but I don’t think people fully recognize the costs of mass incarceration in purely financial costs, and how those costs relate to other programs or areas where the government could spend money.

Michelle Alexander provides examples of the budget being used to arrest black people in her book The New Jim Crow. Rather than using money for services and programs upstream, before we ever arrest an individual, our resources over the years have shifted toward our police and prisons, making it easier to arrest people and providing funding to keep people incarcerated. Alexander writes, “During Clinton’s tenure, Washington slashed funding for public housing by $17 billion (a reduction of 61 percent) and boosted corrections by $19 billion (an increase of 171 percent)”. She continues by quoting Loic Wacquant, “effectively making the construction of prisons the nation’s main housing program for the urban poor.”

What the funding of public housing and prisons in the United States during the 1990s shows us is where our priorities lied regarding race, incarceration, and public housing. Alexander throughout the book demonstrates how a lack of affordable housing can lead to crime, particularly low level drug dealing charges. By taking away funding for public housing we set up a situation where poor people can barely afford a place to live and turn to illegal forms of earning money. Down stream this leads to more arrests and greater prison costs. Getting ahead of the drug dealing and arrest cycle in some cases is as simple as providing better housing (or any form of housing at all) so that an individual can work a basic job and afford housing.

Ultimately, our nation’s priority has been to punish those who we decide are bad apples rather than help those individuals create a situation where they don’t have to resort to illegal activity in the first place. We have conveniently told ourselves that success, failure, crime, and opportunities are the results of individual actions. The role of the collective and the importance of our position within society are downplayed when we look at success versus criminality, and as a result, we seek punishment for those who mess up and find it unacceptable to help those who are poor, struggling to avoid drug use, have slight mental health issues, and those who lack the education, skills, and abilities to become more successful in the low level jobs that we undervalue. If our priorities were truly aligned around helping people get a step ahead, or if our priorities were on creating a society where one could pull themselves up by their boot straps, our priorities would be reflected in a budget that did not decimate social services and public housing for those who needed some form of stability to help them get on the right path. Our nation has decided that directing ever greater funding toward police, prisons, and incarceration is a better use of our money as opposed to establishing a budget to fund upstream interventions to prevent crime and help build stability in people’s lives.