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[Peter Schuck, guest-blogging, May 7, 2007 at 9:50am] Trackbacks
Targeting in Social Programs: Avoiding Bad Bets, Removing Bad Apples

Good morning Volokh Co-Conspirators: To get the ball rolling, here is a recent Boston Globe op-ed about a new book by me and Kennedy School economist and decision theorist, Richard Zeckhauser. I'm looking forward to your comments. Peter Schuck

Good programs vs. bad apples

By Peter H. Schuck and Richard J. Zeckhauser | March 26, 2007

NOW THAT the Democrats control Congress, Americans will see more emphasis on social programs. But voters' reluctance to expand such programs, coupled with a budget deficit, will force legislators to do more with less. Fortunately, better targeting of resources could yield huge benefits. The question is: How?

Society rightly wants to improve the chances of people who have drawn a bad ticket in life's lottery ("bad draws"), yet the government often spends substantial resources on the wrong people. We need to avoid "bad bets" and remove the "bad apples," so our dollars go further and better serve those who will benefit the most. Bad bets are people who will not benefit as much from outside help as would others in equally bad or worse situations.

Pneumonia, once regarded as the "Old Man's Friend," offered the very frail a dignified death. Now we spend millions of dollars per year offering Alzheimer's patients an abysmal existence by keeping them alive on dialysis. Opinion leaders and litigation exacerbate the problem: A leading medical journal recently attacked one of our poorest states for proposing to give extra coverage to its Medicaid patients who join weight-loss or antismoking programs — a cost-effective way to improve health and extend life.

Bad apples are people in a program whose irresponsible, illegal, or immoral conduct harms the far more numerous good apples in the same program. Bad apples also harm the good ones by stigmatizing the group, making voters less willing to support programs to benefit it. The classic bad apple is the chronic disrupter in public housing or schools. Parochial schools, which remove bad apples more readily, outperform public schools in educating equally disadvantaged students at much lower cost.

Misguided laws make it harder than it should be for public schools to transfer these students. Homeless shelters and public housing authorities face worse difficulties. Only after years of litigation can they hope to evict even chronic rule-breakers.

Why do we keep spending on bad bets and bad apples? Healthcare is the most wasteful area for bad bets. Although Americans accept the need for triage medicine on the battlefield, we bridle at rationing healthcare, particularly where a patient is a bad bet through no fault of her own — say, because she suffers from a debilitating, treatment-resistant condition. Advocates for those who suffer from specific diseases fight hard to keep payers from cutting off resources. Critical features of our healthcare system — insurance coverage, professional ethics, doctors' "can-do" spirit, free-rider problems, special-interest groups — push government to place big chips on bad bets.

The bad-apples problem is also endemic. Because the causes of individuals' misconduct are often complex and perhaps beyond their control, society resists condemning them. Especially for youngsters, we do not want to "blame the victim," when the real culprit may be bad parenting, bad brain chemistry, or just bad luck. We try to address root causes so people won't become bad apples in the first place, but this may bear fruit too late to protect the good apples. Finally, our due-process values properly demand a high degree of accuracy before people are classified in disadvantageous ways.

These obstacles can be surmounted. Better information can often defeat fuzzy analysis and parochial interests. The Clinton-era welfare-reform law, which imposed work requirements and time limits for benefits, dealt with bad bets and bad apples among recipients. The public now has a much more favorable view of those still receiving assistance.

Also, Medicare now bases certain payments to providers on a patient's condition, not on the amount of treatment the patient receives. This change has significantly reduced hospital use in the last 90 days of life. In-hospital deaths have dropped sharply, while less costly home-care and other non-hospital treatments have risen, thus saving resources and providing a more humane process of death.

Political courage also helps. The New York City Housing Authority, for example, recently amended eviction procedures to remove disruptive tenants more quickly without sacrificing due process. The public schools should do the same, while also designing separate "second chance" programs for bad apples who should be removed from regular classes until their conduct improves.

To some, these calculations may seem coldly rational. But a compassionate society needs to target its resources carefully. We hope that the new Congress and other policymakers are listening

martinned (mail) (www):
L.S.,

I've always felt that that is the problem with meritocracy. It sounds like a good idea, but in reality it means that those who have nothing also deserve what they've got, meaning that the rest of us are saved from the moral obligation to care about them.

In a related note, recent research (it's an SSRN article I can't find at the moment) shows a correlation between a country's tendency to believe in things like rags to riches, meritocracy, etc. and their tendency to impose severe penalties on criminals. Upon reflection, that makes perfect sense. If you believe that anyone can achieve anything they set their mind to, as long as they work hard, etc., it means that criminals chose their path, and deserve to be punished severely.

LET'S GET RID OF THE BAD APPLES!!!
5.7.2007 11:04am
Justin (mail):
Peter,

Is there any chance you can edit this post by adding paragraph breaks?

While I agree with many of Peter's points, I've always tended to look at it from a utilitarian-aggreagate view. Furthermore, once we've determined that "bad apples" and "bad bets" are human beings and deserve at least that minimal dignity, we must take both their utility into account, as well as their ability to impact others, and we should not focus too much on "dessert" or "fairness" in hurting these people when considering their impact on the latter - i.e., using education, healthcare, and welfare as an effective tool to reduce crime.
5.7.2007 11:13am
Houston Lawyer:
The bad bets area really needs to be fleshed out for the elderly and the terminally ill. When my father had stage 4 brain cancer, the doctors kept pushing for aggressive treatment even though such treatment would only extend his life by weeks. In the end, the treatment significantly reduced his quality of life without significantly prolonging his life. I wish I had those decisions to make over again with a more fully informed perspective.
5.7.2007 11:33am
CaDan (mail):
My eyes! My eyes! The goggles--they do NOTHING!

(In other words, some paragraph breaks would be appreciated)
5.7.2007 11:40am
Randy R. (mail):
The really bad bets are the sloths who are in middle management in government agencies. They usually don't do anything but slow things down and cause problems.

Also, what about the bad bets in private industry? We all know people who work in large corporations and there are people who are bad bets all around.

Then there are bad bet friends. You know them - they are the ones who are energy vampires, and suck the life out of you because of their bad luck. the complain and complain but are unwilling to do anything about it. And then the family members!

This is all so silly. We DO have the ability to but out the bad bets in our own lives. When it comes to policy, though, you will have a tough time. Virtually impossible. It's a great theory, and makes you look like You Are Doing Something. But just like all those doomed-to-fail ideas on making government more efficient, or making businesses more effiicient and user friendly, other considerations are more important.

This whole debate is the equivolent of the medieval thinkers who debated how many angels can dance on the head of a pin. Piffle.
5.7.2007 11:41am
Randy R. (mail):
Houston Lawyer: I feel for you. I understand what a bad situation is when it becomes terminal. However, you did have the opportunity to cut off treatment at some point. So did your father. The answer of whether you should should be a private matter between you, your father, and your doctors. (If you didn't have that choice, well, that is their mistake).

But how would you like it if an insurance company or the government made the decision for you? Or anyone else, for that matter? I'm sure you would not like some gov't bureaucrat to decide that your father is now a 'bad bet' and therefore not needing anymore treatment. Because, you know, gov't bureaucrats don'tl always make the right decision.....
5.7.2007 11:45am
Benjamin Davis (mail):
Eliminating the bad apples reminds me of the effort to focus on the truly needy about 25 years ago. It's just a rationalization to mask or make more palatable the willingness to cut out money for the poor.
Best,
Ben
5.7.2007 11:51am
Speedwell (mail):
There have been times in my life when I would have called myself a bad bet. There have been other times in my life when I would have called myself a good bet, but others might have considered my a bad bet. There have certainly been times when I considered myself a bad bet, but I got help or surgery or an investment paid off, and it made the difference. At the moment, I'm doing fine and am considered a good bet, I suppose.

So, what criteria do we use, and how objective can we be? Can we determine this with any level of accuracy, or is the implementation of such a "bet" going to be the usual dreary round of throwing the innocent babies out with the guilty bathwater?
5.7.2007 11:54am
J. F. Thomas (mail):
So once we have decided that a "bet" is bad, what do we do with the "bet".

Isn't it so much easier to talk about this when we refer to living, breathing, human beings as concepts, not even objects.
5.7.2007 12:05pm
New World Dan (www):
The great failure of most (all?) government programs is their desire to try and do too much, to be the complete and total solution to a problem. Government education is a prime example. Rather than simply providing an education stipend to parents and letting them figure out how their child can be best educated, we try to shoehorn everyone into a one-size fits all system. It is a circular failure because the solution to every problem is more government. More testing, more management, more money, and ultimately more failure. Government schools can not filter out bad apples because governement schools are a bad bet to begin with.

Simplicity is a virtue. So is humility. Government programs need to accept that they can not be all things to all people. Nor should they try.
5.7.2007 12:05pm
martinned (mail) (www):
L.S.,

Sorry, but schools are a bad example. The problem with schools is that you can't determine the quality on offer until the teaching has taken place/is taking place. That doesn't mean that the government should be in the business of providing education, necessarily, but it does mean they should be in the business of setting and upholding minimum standards.
5.7.2007 12:10pm
Abe Delnore:
I'm troubled by all of this, but I'm confused by the example bad bets:


Now we spend millions of dollars per year offering Alzheimer's patients an abysmal existence by keeping them alive on dialysis.


Very few Alzheimer's patients are kept alive by dialysis. Most are kept alive by providing food, shelter, and clothing.

Long-term dialysis often causes a form of dementia--dialysis dementia. Ingested aluminum is not effectively eliminated and you get something very similar to Alzheimer's. I suppose this is an argument for not providing dialysis to patients who are likely to need it for the rest of their lives.
5.7.2007 12:28pm
J. F. Thomas (mail):
Government schools can not filter out bad apples because governement schools are a bad bet to begin with.

Universal public education has been the "best bet" western civilization has ever made. I defy you to name one other that has had a bigger and better impact on society for such a relatively small investment. In particular, in this country the land grant colleges were a stroke of pure genius, and the system of public education (primary, secondary and post-secondary) in general led to our domination in science and technology in the latter half of the twentieth century. Most of the great research universities in this country are public institutions. To deny this fact is to deny reality.

Even our hard core libertarian hosts teach at public universities. One of the leading universities for libertarian economic theory (George Mason) is also a public institution (talk about biting the hand that feeds you).
5.7.2007 12:32pm
glangston (mail):
At least one fairly well know Sci-Fi writer, Larry Niven, saw "bad apples" becoming organ donors through increasingly strict laws that added many crimes to the capital list (which included having illegal offspring). The moral dilemma however, did not vanish, it was just re-shaped.
5.7.2007 12:49pm
Houston Lawyer:
Regarding my example above, my father died peacefully at home with us. However, that was after we refused pleas from the surgeons for more surgery.

My complaint is that his doctors oversold the benefits of surgery. I strongly suspect that the mind set of those who deal with terminal ilnesses is first to prolong life. Quality of life issues are not focused on sufficiently.

Patients should be told more often and more quickly that yes, there are things we can do for you, but you probably won't want to live that way. I suspect that as we age as a nation we will address this issue more often.
5.7.2007 12:50pm
Henri Le Compte (mail):
Speaking in generalities (bad bets, bad apples) sometimes clarifies problems, but at the expense of capturing their real world complexity. I mean, of course, people would support ending government payments for ineffective or useless interventions. The problem is accurately identifying those cases! It is not as easy, or obvious, as you may assume. And, say in the case of medicine, when a human life may well be at risk, it can be extremely difficult to procede with anything resembling confidence.

I bring up medicine because it is a field I work in. And, I can assure you that having doctors be the "rationers" of health care is a terrible idea. Why? Because we are simply not experts in the topic of "quality" of life. No one is. Doctors are experts at diagnosing and treating diseases. Period. We have no special insight into who's disability is "too much to bear," or who's life is "costing too much to sustain."

It is superficially appealing to see physicians as respectable "experts" on all matters regarding the end of life. This is simply not the case. In addition, there are no professional ethics or "historical roadmaps" within medicine to guide physicians. Also, and most importantly of all, society has not explicitly given physicians the authority to make these types of decision. There is no consensus out there that physicians are allowed to ration care in any way! Which is why you see doctors routinely recommending that we "do everything possible" to keep someone alive, despite overwhelming odds, and enormous expense. That's what we do. That's all we were ever taught to do.

For doctors to play the role of "resource allocator" there would have to be a Copernican revolution within medicine and the law. I don't see that on the horizon. (And, frankly, I don't want to see it.)
5.7.2007 1:10pm
Latinist:
"we bridle at rationing healthcare, particularly where a patient is a bad bet through no fault of her own — say, because she suffers from a debilitating, treatment-resistant condition."

But there are problems with rationing to people who are bad bets due to their behavior, too -- because that basically amounts to lightly criminalizing the behavior. A lot of people don't mind the idea of Medicare rules that amount to a tax on smokers, or overeaters (since it pays for the coverage they need). But if we extend that principle, it gets a little dicey: what about giving extra Medicare coverage to patients who don't engage in certain risky sex acts? The logic is roughly the same, but it amounts to a tax on sexually active homosexuals (among others).

I'm not saying it's an unavoidable slippery slope; but I hope people recognize that "giv[ing] extra coverage to . . . Medicaid patients who join weight-loss or antismoking programs" is pretty much the same as legally penalizing the opposite behavior. I wonder how many people on this libertarian-leaning site are okay with that.
5.7.2007 1:10pm
Clayton E. Cramer (mail) (www):
New World Dan writes:

Government schools can not filter out bad apples because governement schools are a bad bet to begin with.
They don't have to be a bad bet. Public education was actually working pretty well in much of America until we engaged in a classic "bad bet" mistake. In 1975, Congress decided that all but the most severely disabled children needed to be "mainstreamed." I can understand the motivations for this, and it probably was better for many of the retarded kids to be in a normal classroom, but there was a high cost for the rest of the education system. Children with severe special needs dragged the rest of the classroom down--and public school systems spent an enormous amount of money on a tiny fraction of the kids. I've read that about 25% of New York City's public education spending is spent on a few percent of the most severely disabled kids. I've seen somewhat similar numbers claimed for California K-12 education.

No one wants to tell parents that their disabled kid is a "bad bet"--that the resources that will be spent trying to get him through a conventional high school education are a waste. But there comes a moment when you have to face reality. A kid with an IQ of 90 can certainly benefit from an mainstream education appropriate to his intelligence level. A kid with an IQ of 55? Putting him in a conventional classroom isn't going to do him much good. It will expose him to the cruelty of his normal and above intelligence peers. It will impair the overall progress of the class.
5.7.2007 1:30pm
J. F. Thomas (mail):
The logic is roughly the same, but it amounts to a tax on sexually active homosexuals (among others).

Actually, the tax would be highest on those who engage in anal sex (both men and women) and lowest on those who choose not to have sex with men. So it is incorrect to say it would amount to a tax on homosexuals since exclusive lesbians would have the lowest tax rate under such a scheme (assuming those who abstain completely would have higher mental health costs that would make up for their lower risk of STDs).
5.7.2007 1:30pm
Kasumi Ghia:
There's also the issue that identifying the bad bets has costs. Are you sure that it costs less to identify the bad bets, than to just pay them all? In every benifit program? I'd really rather not have to pay more to be sure that only the deserving get benifits.
5.7.2007 1:30pm
liberty (mail) (www):
Rationing medicine and having the state choose who is and isn't a bad bet is precisely why - or one of two reasons why - socialized medicine is so evil (the other reason is that the state will set prices and make it impossible for firms to profit, hence reducing innovation to near-zero, preventing new medicines and cures from ever coming about).

Do you really want government deciding whether you or your loved ones deserve treatment?
5.7.2007 1:32pm
Special Guest:
We're not yet at the point in this country where we're willing to lock up all the extremely unstable but not dangerously criminal people (the "bad apples") in jail or institutions forever, or let them die on the streets. But if you refuse to give them any social services, they just get worse and worse -- a cycle of addiction, homelessness, prison, mental institutions, then back on the streets again...

In the end, providing the correct amount and type of social services to the "bad apples" ends up being the best solution as a matter of public policy and human decency. One example is the Housing First approach to chronic homelessness, which advocates providing no-questions-asked shelter to the most severely incapacitated homeless people. It's had good success, and has even been embraced by the Bush Admin's Homelessness Czar, Tony Mangano.
5.7.2007 1:42pm
Special Guest:
Sorry, his name is actually Philip Mangano.
5.7.2007 1:43pm
J. F. Thomas (mail):
Do you really want government deciding whether you or your loved ones deserve treatment?

As opposed rationing medicine based on the to ability to pay for treatment? I guess it all depends on how much money I have, doesn't it.
5.7.2007 1:56pm
Bruce Hayden (mail) (www):
Rationing medicine and having the state choose who is and isn't a bad bet is precisely why - or one of two reasons why - socialized medicine is so evil (the other reason is that the state will set prices and make it impossible for firms to profit, hence reducing innovation to near-zero, preventing new medicines and cures from ever coming about).

Do you really want government deciding whether you or your loved ones deserve treatment?
It isn't just whether to get treatment, but what treatment they get.

For example, a friend of mine had a back condition that could benefit from surgery. The insurance company knew that it would be cheaper for them if they just filled her full of painkillers for the rest of her life, which would likely be 40 years w/o the painkillers, but luckily for them, shorter because of that. Luckily for the friend, she had private health insurance, which could be leveraged to get the surgery. And so, she doesn't need to spend the rest of her life on morphine.

In a similar vein, she has very weird drug reactions. So, her stomach is shot because of all the drugs she has had to take. The stomach medicine that does work costs a lot of money. So, they routinely try to swap it out for a generic, which has been tried and doesn't work. Because the insurance company is private, not public, it is open to suit for this sort of thing, and inevitiably backs down.

If you look at things from the view of Mr. Schuck, she is a bad bet through no fault of her own. But a rational socialized medicine administrator would very rationally have prevented much of the health care that she has received because of the cost/benefit ratio. What is $100k of drugs over her lifetime compared to $1000k of surgeries over a couple of years, esp. when the remaining $900k (ignoring the cost of money over time) could be spent helping a lot of others?
5.7.2007 2:17pm
Bruce Hayden (mail) (www):
Do you really want government deciding whether you or your loved ones deserve treatment?

As opposed rationing medicine based on the to ability to pay for treatment? I guess it all depends on how much money I have, doesn't it.
In other words, should health care be a right or a privilege? And, of course, if it is a privilege, how much are we willing to pay for it? How much of GNP should we dedicate to it?

Yes, I am selfish, and am willing to pay so that I can have the health care that I ultimately need, not that which some bureaucrat thinks that, in the entire scheme of things, I need. But, not surprisingly, I value my own life far more than either that bureaucrat or you do. So, I am quite unwilling to sacrifice years off my life so that others can have years added to theirs. You might not be.

You also get into a lot of slippery slopes toward totalitarian control, if you accept the rights theory. As someone pointed out above, it isn't precisely male homosexuality that is the issue for STDs, esp. HIV, but rather anal intercourse, though I still expect that male homosexual intercourse of that type is still more dangerous than heterosexual equivalent due to the number of partners and the likelihood that the one party will be infected. But assumming that that isn't a factor, then the obvious solution would be to have periodic or random anal exams to detect such intercourse, and if detected, then terminate, or at least significantly reduce, health care.

Or, what about the person who abuses his body by drinking, smoking, and not exercising until say 60. Then he finds religion. Should he be cut off now because he was a bad apple back then, but isn't now? Ok, if not at 60, then 50? 40? Where are you going to draw the line? And how do you know anyway? I am getting ready to walk two miles each way to Burger King for lunch. Should I lose coverage because a camera outside catches me walking in there many days? Or just if I drive up?
5.7.2007 2:33pm
AppSocRes (mail):
Before the late 1960s New York City, and some other large cities, had separate "discipline schools" where chronically disruptive students were segregated from the rest of the student population. A perfect case of dealing with "bad apples". And it worked well too. I'm not sure why the system was dismantled.

Doctors I know, have admitted to me on occassion that disproportionate medical resources are expended extending the lives of persons whose ill health is their own fault, e.g. persons who are grossly overweight, sedentary, smokers, heavy drinkers, users of illicit drugs, and who have engaged in criminal activity through much of their lives. Ironically it seems to be such persons - or their family members - who will most likely demand extraordinary medical measures to stay alive even when "living" involves little beyond the mechanical pumping of heart and lungs.

Giving these "bad apples" a comfortable and dignified end without heroic medical interventions would significantly reduce medical expenses in this country. By the way, I'd argue that giving such persons: (1) shelter; (2) freedom from pain; (3) clean bodies, clothes, and bedding; and (4) whatever food and liquids they could ingest without assistance adequately meets the moral requirements of all reasonable ethical or religious system with which I am familiar.)
5.7.2007 2:37pm
Bruce Hayden (mail) (www):
I should add that a society that is unwilling to condemn male homosexual behavior from moral grounds is highly unlikely to penalize it because those participating in it are both bad bets and bad apples. But if our society is unwilling to address this, then how can it hope to morally address health care issues through socialized medicine? Compare someone engaging in homosexual anal intercourse to someone who just doesn't exercise enough? Or eats the "wrong" type of food. Where is the morality in stigmatizing or penalizing the later, but not the former?

Of course then, we get into another problem with socialized medicine - that what is paid for and who it is paid for ultimately becomes a political issue. The solution to the above? Pass a law that prevents insurers from stigmatizing those who are both bad bets and bad apples in that respect. And do it because homosexuals are an authenticated victim class (who got there due to their outsized political power as compared to their class size). Whichever group that manages to organize the best and screams the loudest gets the coverage.
5.7.2007 2:45pm
SeaDrive:
We hold this truth to be self-evident that all men are created either good bets or bad bets, and the good bets are endowed by their Creator with certain inalienable rights, and among these rights are life, liberty, and not spending any money on the bad bets.
5.7.2007 2:48pm
Special Guest:
Sigh. Must this become yet another gaybashing thread? Really, it seems quite uneccesary.
5.7.2007 2:48pm
Randy R. (mail):
Let's see: Maybe this is a good idea afterall. I'm sure that the authors had in their minds that the first ones to identify as bad apples and bad bets are those corporations that receive generous amounts of federal aid, particularly those in the Farm Bill, and defense contractors that overbill the US, such as Halliburton, and so on.

As for individuals, the first people the authors would identify are those trust fund kids that drink all day and all night and don't take their education seriously and basically just live off the fat of their parents wealth.

After we have purged our society of these bad apples, or 'undesirables', who do nothing to contribute to our innovation, but rather suck at the teat of our society, then we can move down to retirees who do nothing but play golf and shuffleboard. What good are they? And they are bad drivers, to boot.

As for the 'immoral' bad apples, the first to go with be Christain fundamentalists, since they are by far the most immoral group I've ever encountered, especially people like Pat Robertson and so on. Next up -- those who practice Islam, because we all know how immoral THAT religion is! Atheists, too, since all good religious people have declared atheists to be immoral. After that, all homosexuals need to go, since they are prima facie immoral. Sorry Lord John Browne! You built up BP to a world class oil company, but your immorality makes you a 'bad bet.'

I'm sure that blacks, the poor and other minorities won't be identified as 'bad bets' until all of these others are weeded out, right?
5.7.2007 2:49pm
Ramza:

Special Guest:
Sigh. Must this become yet another gaybashing thread? Really, it seems quite uneccesary.

Americans love talking about sex in quote theoretical discussion unquote, especially if it isn't sex they are getting. It doesn't matter if they would personally not enjoy that type of sex, it is the principle *wink* (Finally substitute American with any nation population it isn't something limited to Americans it is human nature)
5.7.2007 2:56pm
Waldensian (mail):
Clayton Cramer:

No one wants to tell parents that their disabled kid is a "bad bet"--that the resources that will be spent trying to get him through a conventional high school education are a waste. But there comes a moment when you have to face reality. A kid with an IQ of 90 can certainly benefit from an mainstream education appropriate to his intelligence level. A kid with an IQ of 55? Putting him in a conventional classroom isn't going to do him much good. It will expose him to the cruelty of his normal and above intelligence peers. It will impair the overall progress of the class.

I've got two kids in special ed, and they have very significant disabilities. As a preliminary matter, this situation has altered my perspective. As just one example, I view our lot in life as a "bad draw," while you might see it as a "bad bet" situation.

As another preliminary matter, you're wrong that nobody wants to tell parents that their kids are "bad bets." For one thing, you're now telling me that. And in fact, administrators in charge of special ed, and thus responsible for meeting enormous needs with meager resources, have been telling that to parents for years. Ask me how I know.

There's certainly a lot of room for reform in special ed, but it's not as simple as merely "facing reality." Like a lot of people, you generalize about special ed by discussing IQ levels, and where kids with X IQ can and ought to be educated. But the situation on the ground is actually far more complex.

As just one example, children with autism, one of the most common disorders now seen in special ed classes, typically have a "scattering" of skills -- high in some areas, low in others. (A small percentage are even savants, but that's much more rare than the public perception would suggest.) Moreover, we now know that the right educational intervention -- intensive one-on-one behavioral therapy, or the closest thing you can get to that -- CAN actually make a HUGE difference in the lives of SOME of these children. Such therapy is enormously expensive, however, as is the litigation that is sometimes necessary for parents to obtain that education.

Who will get this therapy? Who will pay for it? What level of benefit is necessary to justify it? How many kids must show significant improvement before the courts will mandate it? These are the kinds of difficult questions that must be answered day after day in the special ed context.

Another problem is deciding upon what, exactly, is a disability requiring special ed. Note that a great deal of growth in the special ed burden has come not from new kids entering the system, but from much older kids being classified with disabilities. A lot of these kids would not strike the average person as significantly disabled. In my day, parents would have avoided having their kids so "labeled" like the plague, and of course this view is still out there. But increasingly, parents are eager to get special services to help kids with disabilities that are not particularly profound. What counts? What doesn't?

The special ed system needs to get much better at answering those and other kinds of questions. *But they are very very hard questions to answer.* You can't just segregate by IQ and write off the kids below a certain level. If it were that simple, it would have been done years ago.

It's true that special ed is a major resource strain on schools. But I don't think that's because special ed is a waste, or because lots of parents need to "face reality" -- I think it's simply because special ed is the ultimate unfunded mandate. Keep in mind that prior to IDEA, we weren't really doing ANYTHING for these kids. The situation was a scandal. I don't believe many thinking people want to go back to those days.

I've had a lot of experience in the special ed world. There's a story to match every preconception. But in the main, I believe that what you're seeing is not a system catering to "bad bets," in which parents need to "face reality." Instead, it is a system where we finally decided to do something about special ed and children with disabilities, but just plain didn't come up with the money to do it. That part actually is simple.

Finally, I'd be very interested to read your references indicating that putting special ed kids into mainstream classes has impaired mainstream class performance. As you can imagine, this is a topic that concerns me. :)
5.7.2007 3:14pm
logicnazi (mail) (www):
Ughh, it seems like everyone here is focusing on emotional associations they have to the word 'bad bet' rather than engaging with the proposal in a serious fashion.

All the poster is saying is that we ought to spend our money in a cost-effective manner. He is not asking people to make some moral or value judgement about who is a 'bad bet' or who deserves to pay more. It is also not about making people pay for any risk they incur. Latinist remark about making active homosexuals pay more in taxes is totally unrelated since the suggestion is that we use money where it is the most beneficial which may often be among those who incur the most risk (prevention programs) not among those who are the most responsible.

Perhaps some hypothetical examples will clarify they problem. For instance suppose we find out, as I suspect is true, that educating children to really understand mathematics requires a totally different approach than what works to give math phobic kids a minimal level of competence in doing mathematics. That is we discover that rote arithmetic and addition problems discourage kids from going into math and science and generally fail to challenge or interest the small percent of kids who might otherwise be interested but that kids who resent mathematics just give up when confronted by problems that actually require thinking and don't respond to a rote algorithm. Supposing society gets a much greater benefit from having more engineers and scientists than from having the average student be able to solve algebra problems this sort of thinking would argue that we should use the intelligent and challenging mechanism for teaching math even if it abandons the students who resent the subject. Alternatively this proposal might urge us to take funding from normal inner city schools and give it to magnet schools in the area if we find out that normal schools (because of the corrosive effect of other students uninterested in learning) don't improve much with extra money. Similarly of course this approach says we ought to deny someone an expensive and likely to fail medical procedure if that same money could save many more lives used elsewhere.

I think most of the moral objections to this view are simply the result of a biased viewpoint. If one phrases the question as, "Is it justified to deny some students really helpful resources so that we can give other students nearly useless resources?" the moral intuition shifts (at least for me).

On the other hand I have to say that it's not always clear that the goal of the health system is really to maximize health or years of life. Often the benefit from these programs is more psychological than actual. We will all die at some point and it's not clear improving the life expectancy by 1 year really increases overall utility by that much. However, many people receive a direct psychological benefit from thinking that everything plausible to help them will be done if they get sick. In other words treating the sick even when it is inefficient is much like offering everyone a lotto ticket. Our irrationality about risks might make it a net benefit despite the negative expectation in terms of pure life years.
5.7.2007 3:17pm
Special Guest:
Good point, Logicnazi, but it's one I don't see myself in Schucks essay. He doesn't seem to present any way to distinguish between bad apples (which he plainly categorizes as a kind of moral judgment) and bad bets.
5.7.2007 3:20pm
FC:
logicnazi

He is not asking people to make some moral or value judgement about who is a 'bad bet'


Of course he is. He called pneumonia a "dignified death." I have to wonder if he has ever seen someone die of pneumonia. Or of anything.
5.7.2007 3:22pm
Bruce Hayden (mail) (www):
All the poster is saying is that we ought to spend our money in a cost-effective manner. He is not asking people to make some moral or value judgement about who is a 'bad bet' or who deserves to pay more. It is also not about making people pay for any risk they incur. Latinist remark about making active homosexuals pay more in taxes is totally unrelated since the suggestion is that we use money where it is the most beneficial which may often be among those who incur the most risk (prevention programs) not among those who are the most responsible.
Once the subject of socialized medicine comes up, I don't think that you can exclude the subject of male homosexual behavior here. Unprotected male homosexual behavior is one of the behaviors that is easiest to tie to a significant increase in probable health care costs, esp. over the relatively short run.

I am not coming at it from a moral point of view, but rather from a bad apple point of view - the behavior is extremely risky from a health care point of view. And if the decision is made to make the system more efficient by penalizing bad apples and bad bets, then up near the first in line should be those who participate in that behavior.

Of course, they won't be, because, as I noted above, they are a certified victim class with outsized political power.

So, maybe the answer to this is to not use the bad apple / bad bet theory in medicine...
5.7.2007 3:35pm
JBL:

The fact that a particular question is difficult is a very poor reason to avoid asking it.

Removing support from the bad apples has a significant cost. But so does providing support. Especially when the support we are providing uses a lot of resources to produce relatively little value.

The fact is that the public education system, though historically extremely valuable, is not currently doing a good job of educating children.

Health care is extremely expensive in this country, outcomes are debatable, and many of the underlying factors are affected by individual behavior.

Identifying a bad bet and placing a good bet might mean not spending money to educate the unintelligent or medicate the chronically ill.

Or, identifying a bad bet and placing a good bet might mean stopping programs that do not effectively accomplish their goals and putting more effort into programs that do.

The idea of separating the problem children from the rest of the students is not necessarily a claim that we owe them less, especially if the reason you are separating them is because it enables you to provide a better education to both groups.

Developing a health care system that reflects the cost of individual choices might leave some people without alternatives, or it might mean that the net efficiency gain is enough to provide all (or almost all) groups with better care than the current system offers.

It's certainly worth taking some time to flesh out the possibilities.
5.7.2007 3:41pm
J. F. Thomas (mail):
Developing a health care system that reflects the cost of individual choices might leave some people without alternatives, or it might mean that the net efficiency gain is enough to provide all (or almost all) groups with better care than the current system offers.

I would just love to see this assessment. How would we rate the risk of a male homosexual extreme skier against a celibate (although not by choice), alcoholic, non-exercising couch potato.
5.7.2007 4:25pm
Special Guest:

Once the subject of socialized medicine comes up, I don't think that you can exclude the subject of male homosexual behavior here. Unprotected male homosexual behavior is one of the behaviors that is easiest to tie to a significant increase in probable health care costs, esp. over the relatively short run.


I don't know whether to laugh or cry.
5.7.2007 4:38pm
liberty (mail) (www):
"How would we rate the risk of a male homosexual extreme skier against a celibate (although not by choice), alcoholic, non-exercising couch potato."

And what kind of KGB-style intrusiveness would it take to accurately distinguish between the two?

Please, lets just go private. Retain a little bit of the dignity of our American heritage.
5.7.2007 4:47pm
Houston Lawyer:
Question who had to die because he didn't get the liver transplant that Mickey Mantle received. There are costs to providing subsidies to bad behavior or pretending that bad behavior doesn't matter.
5.7.2007 5:01pm
J. F. Thomas (mail):
Question who had to die because he didn't get the liver transplant that Mickey Mantle received.

And the Mickey Mantle highlights the pitfalls of a private system. Because he was a rich celebrity he was able to obtain a liver that should have gone to a candidate who had a much better chance of survival.
5.7.2007 5:40pm
Brian K (mail):
Henri,


In addition, there are no professional ethics or "historical roadmaps" within medicine to guide physicians.


Umm...yes there is. I know for a fact there is since I just finished the medical ethics class in med school. I recommend reading "Principles of Biomedical Ethics" by Beauchamp and Childress. There is also a nurses code of ethics...i'm pretty sure there is also a physician's code of ethics produced by the AMA (but i can't say for certain since it wasn't assigned reading for the class)
5.7.2007 5:43pm
American Psikhushka (mail) (www):
There's also the ever-present chance that those judging "good" and "bad" are wrong. Look at the Atkins diet and natural fats, for instance. Look at moderate drinkers living longer than both alcoholics and teetotalers. Can I charge you extra because you don't drink?

This the problem with socializing anything. It's a license for those who would love to tell everyone else what to do to run people's lives, and often these people are pathological, hypocritical, ignorant, prejudiced, corrupt, incompetent, biased, and often downright wrong.
5.7.2007 6:05pm
Brian K (mail):
Bruce,


[homosexual] behavior is extremely risky from a health care point of view. And if the decision is made to make the system more efficient by penalizing bad apples and bad bets, then up near the first in line should be those who participate in that behavior


Driving is even more risky...why aren't you advocating penalizing drivers?
5.7.2007 6:24pm
J. F. Thomas (mail):
This the problem with socializing anything. It's a license for those who would love to tell everyone else what to do to run people's lives, and often these people are pathological, hypocritical, ignorant, prejudiced, corrupt, incompetent, biased, and often downright wrong.

I don't know what you mean here by "socializing". In a general sense, any insurance is socializing risk in that you are taking a risk and spreading it over a large pool of people. If you have health insurance through your employer, it is affordable because the risk pool has been spread across all employees. In fact many employers make it difficult to opt out of company provided health insurance to ensure that the good risks (i.e., those that are not going to use the full value of their benefits) do not opt out of the system and leave only the frequent users in. The larger the pool, the less the cost per person is. This is one of the potential benefits of a "single payer system". Another advantage would be the simplification of paperwork requirements.
5.7.2007 6:53pm
JBL:

"How would we rate the risk of a male homosexual extreme skier against a celibate (although not by choice), alcoholic, non-exercising couch potato."

That would be silly. We could:

1. Come up with a broad measure of the two or three largest risk factors, such as drug addiction and BMI (or whatever other standards are germane and easy to measure), and tie them to a relatively small adjustment to insurance premiums. It's entirely possible that much of the benefit of a stratified risk system could be acheived without much more than that.

2. Encourage wider use of something like the HDHP/HSA plans that require people to assume the first n dollars of their health care expense. That way we get at least some of the efficiency and innovation of market dynamics while still protecting people from catastrophic expenses. And if some people dont have the n dollars to meet the deductible, we could correctly identify the problem as poverty, not health care.

Of course, neither one of those is a complete solution. But more to the point, I'm not sure I understand your question. If we don't make some determinations about treatment, do we just give everybody all the treatment they want? If so, how do we pay for it? How do we ensure that funds are wisely spent? Would it really work like that?

I understand what is distasteful about trying to make value judgements about other people's lives. And also what is distasteful about letting people suffer while the technology exists to prevent it. What I don't understand is what else is being proposed.

The only good arguments I've heard are from people who explicitly acknowledge the costs - those who want to completely privatize the system even though they recognise that doing so will have a tremendous cost due to leaving large numbers of people without coverage, and those who want a single payer system even though they recognise that it would still leave many conditions uncovered and leave very little room for individual players to improve the market.
5.7.2007 8:04pm
Randy R. (mail):
Clayton: "As just one example, children with autism, one of the most common disorders now seen in special ed classes, typically have a "scattering" of skills -- high in some areas"

I actually know of a very famous successful classical pianist who is autistic. You wouldn't know it from his playing, but when you meet him in person, you can see it immediately. (I also got confirmation from his family).

I'm sure he would have been a 'bad bet." And that bet would have been wrong.

Logicnazi: "He is not asking people to make some moral or value judgement about who is a 'bad bet'

Actually, that is exactly what they authors are arguing, to wit: "Bad apples are people in a program whose irresponsible, illegal, or immoral conduct harms the far more numerous good apples in the same program"
5.7.2007 9:17pm
ReaderY:
Because of interaction factors, profit and loss is not a zero sum game. In any society, it is necessary for some people to operate at a loss so that they themselves and society as a whole may win.

One simple example involves carriers of genes vital to permit human survival under harsh conditions, but which create difficulties under artificially good conditions.

One shouldn't readily assume that the good times will last forever and that we won't someday be dependent on those genes and therir carriers for survival. Perhaps we can sustain things, perhaps not.

Sir Ronald Fisher wrote the ability of a society to adapt to new conditions is inversely proportional to the variance of its adaptation to current conditions. A society of people perfectly adjusted to present conditions would be wiped out under systemic changes. This is why preversing diversity, and the survival of those maladjusted malcontents, is valuable.
5.7.2007 10:00pm
ReaderY:
This is, of course, not to say that there are no limits or no place for personal responsibility. It is to say that that isn't the whole picture.
5.7.2007 10:01pm
markm (mail):

A lot of people don't mind the idea of Medicare rules that amount to a tax on smokers, or overeaters (since it pays for the coverage they need). But if we extend that principle, it gets a little dicey: what about giving extra Medicare coverage to patients who don't engage in certain risky sex acts? The logic is roughly the same, but it amounts to a tax on sexually active homosexuals (among others).

This sounds to me more likely to function as a tax on telling the truth - or else a license for a government agency to be more intrusive than Big Brother (which would often work out as a tax on not being politically connected).


And the Mickey Mantle highlights the pitfalls of a private system. Because he was a rich celebrity he was able to obtain a liver that should have gone to a candidate who had a much better chance of survival.

Give a public system long enough, and the the transplants will be going to those with political pull. At least Mantle earned his money...
5.7.2007 10:03pm
Clayton E. Cramer (mail) (www):

As another preliminary matter, you're wrong that nobody wants to tell parents that their kids are "bad bets." For one thing, you're now telling me that.
I'm not running for office.


You can't just segregate by IQ and write off the kids below a certain level. If it were that simple, it would have been done years ago.
I used IQ as an example; I know that the situation is often much more complex than that.


Finally, I'd be very interested to read your references indicating that putting special ed kids into mainstream classes has impaired mainstream class performance. As you can imagine, this is a topic that concerns me.
My wife has a bit of experience teaching in elementary school classrooms. Even though the school had a full-time aide for each of these children, they definitely slowed the pace of instruction for the class as a whole. Nor would I expect it to be any different. To the extent that one student is substantially less able to learn material, a teacher either has to keep moving, or leave some kids behind. There's a great reluctance to leave some kids behind.
5.7.2007 11:18pm
Clayton E. Cramer (mail) (www):

Clayton: "As just one example, children with autism, one of the most common disorders now seen in special ed classes, typically have a "scattering" of skills -- high in some areas"

I actually know of a very famous successful classical pianist who is autistic. You wouldn't know it from his playing, but when you meet him in person, you can see it immediately. (I also got confirmation from his family).

I'm sure he would have been a 'bad bet." And that bet would have been wrong.
I don't think you understand the concept here. A "bad bet" means that when you get 100 people with a particular category of problem, you have to guess what the return is by betting that all 100 of those people are going to be a good investment of resources. Sure, there are going to be a few kids with autism who are going to be a great investment. But is it two out of 100? Is it is three out of 100? It almost certainly isn't going to be 95 out of 100--or you would start to wonder if autism is really that much of a problem.

I don't expect the parents of autistic children are going to be happy about this. They see a child that is precious to them, and they want the best for that child. They also believe, probably more based on hope than evidence, that their child will benefit from spending $15,000 a year giving them an education. But there comes a moment when a dispassionate analysis is going to say, "There's a limit to what we can do for your child, at the risk of impairing the education of the 85% of kids who don't have significant problems impairing their education."
5.7.2007 11:25pm
Clayton E. Cramer (mail) (www):


Developing a health care system that reflects the cost of individual choices might leave some people without alternatives, or it might mean that the net efficiency gain is enough to provide all (or almost all) groups with better care than the current system offers.
I would just love to see this assessment. How would we rate the risk of a male homosexual extreme skier against a celibate (although not by choice), alcoholic, non-exercising couch potato.
Take a look at the mortality rates and the costs of providing medical care. That's actually pretty easy to do. That's why homosexuals would prefer that you not do it.

Yes, there are homosexuals who don't have 40 different unprotected partners a month. But there's a reason that syphilis is primarily a gay men's disease in America, and it isn't because fundamentalists are sneaking up behind them in gay bars with hypodermics.
5.7.2007 11:30pm
Henri Le Compte (mail):
Brian K.
Small point, but perhaps I didn't make myself clear.... I was not suggesting that there is no historical system of professional ethics in medicine. Of course there is! I was saying that there is no element of medical ethics that makes doctors specifically qualified to make "medical resource" decisions about who lives, who dies; who costs too much, who doesn't; whose live is worthy of life, whose is not.*

At least there wasn't back in the moldy old days when I was in school. But then perhaps they've remedied that... oversight in the years since, eh?

*(Assuming, of course, that you are not practicing on a friggin' battlefield, or in some other specialized environment of artificial scarcity.)
5.8.2007 1:53am
K Parker (mail):
Randy R.
I actually know of a very famous successful classical pianist who is autistic. You wouldn't know it from his playing, but when you meet him in person, you can see it immediately...I'm sure he would have been a 'bad bet.' And that bet would have been wrong.
Well, that depends on how much the bet cost, doesn't it? At a billion dollars (to use an obviously too-high figure) even you would agree it was a bad use of funds, wouldn't you?
5.8.2007 2:01am
fasdbfh (mail):
I don't remember the priest telling me when I went to Confession when I was a kid, "Well, Lance, it was wrong of you to disobey your mom and talk back to her like that, but since you set the table every night and do your homework and sent your aunt a birthday card, what the heck! You're a good kid. Your sins are forgiven automatically. No need for you to do any penance." 文秘 心脑血管 糖尿病 高血压 高血脂 冠心病 心律失常 心肌病 心肌炎 中风 偏瘫 低血糖 And maybe it's happened a few times and I haven't heard about it but I can't recall a judge ever letting somebody walk on the grounds the crook was a good guy and his friends really like him.
5.8.2007 4:46am
Waldensian (mail):

My wife has a bit of experience teaching in elementary school classrooms.

Okay, we're still in anecdote land then.
5.8.2007 10:35am
Waldensian (mail):

I don't expect the parents of autistic children are going to be happy about this.
No, we actually love hearing the broad policy pronouncements of people who aren't all that familiar with the situation.

They also believe, probably more based on hope than evidence, that their child will benefit from spending $15,000 a year giving them an education.

Actually the evidence is there, although it isn't particularly deep yet. I read the evidence as follows: The likelihood of SOME meaningful benefit is really pretty high. The likelihood of MASSIVE benefit, e.g. returning the kid to a regular ed track and having him or her able to live independently at adulthood, is significantly lower. But it does happen, I've seen it with my own eyes (since anecdotes apparently count here).

And most importantly, we don't know beforehand what will happen in any individual case. So we are left to decide this difficult question. When do we declare a bad draw to be a bad bet? Is there simply a financial cutoff?

On that point, $15,000 -- you're joking, right? Try more like $60,000 or more to do it right. Annually. Per kid. Not covered by insurance, although it is at least deductible as a medical expense to the extent it exceeds 7.5 percent of your adjusted gross income. Ask me how I know.


But there comes a moment when a dispassionate analysis is going to say, "There's a limit to what we can do for your child, at the risk of impairing the education of the 85% of kids who don't have significant problems impairing their education."

The only "impairment" we can show at this point is that money that could be spent on the regular ed kids will be spent on the special ed kids instead. That's not an insignificant fact, of course, but it's really the result of the fact that special ed is an unfunded mandate. We long ago decided that we're going to have special ed; until we decide to pay for it, it will always be a financial strain on regular ed.

Meanwhile, despite my challenge, you have presented nothing but weak anecdotal evidence that educating special ed kids otherwise "impairs" academic performance of regular ed students. Your attitude is typical of many regular-ed parents I run into; at base they simply don't like thinking about special ed, or having their kids around special ed kids. Their lack of evidence of impairment doesn't slow such parents' claim-making (or yours) but perhaps it ought to.

I wouldn't wish autism on anyone's kids. But from what I glean of your mindset in these posts, I guarantee you that you would find it the most educational experience of your life.

Frankly, I don't think you'd last two weeks.
5.8.2007 11:11am
Clayton E. Cramer (mail) (www):
Waldensian writes:

Actually the evidence is there, although it isn't particularly deep yet. I read the evidence as follows: The likelihood of SOME meaningful benefit is really pretty high. The likelihood of MASSIVE benefit, e.g. returning the kid to a regular ed track and having him or her able to live independently at adulthood, is significantly lower. But it does happen, I've seen it with my own eyes (since anecdotes apparently count here).
Actually, you were the one who first raised your own experiences, which is definitely anecdotal. And your raising of it is part of why there is a reluctance to draw lines on this. No one wants to be in your shoes, and no one wants to tell a parent in your shoes, "I'm sorry, but there's a limit that we can't exceed to help your child." Why? Because very, very few people are so heartless as to not feel compassion for your situation. But there are social costs to that compassion.


And most importantly, we don't know beforehand what will happen in any individual case. So we are left to decide this difficult question. When do we declare a bad draw to be a bad bet? Is there simply a financial cutoff?
I'm not sure of the right way of making that call, and that's the point of the original post here--how do we decide what constitutes a "bad bet" and who is a "bad apple"? (These are two very different situations, but with similar hard choices involved.)

On that point, $15,000 -- you're joking, right? Try more like $60,000 or more to do it right. Annually. Per kid. Not covered by insurance, although it is at least deductible as a medical expense to the extent it exceeds 7.5 percent of your adjusted gross income.
I was thinking of the average annual expenditure of Sausalito, California schools, which has an extraordinarily high percentage of severely retarded children. (If you know where Sausalito is, and you are wondering? What? The overwhelmingly upper class whites that live in the district have no kids, and certainly none in public schools. The kids are overwhelmingly from a public housing project/heroin shooting zone called Marin City.)


The only "impairment" we can show at this point is that money that could be spent on the regular ed kids will be spent on the special ed kids instead. That's not an insignificant fact, of course, but it's really the result of the fact that special ed is an unfunded mandate. We long ago decided that we're going to have special ed; until we decide to pay for it, it will always be a financial strain on regular ed.
The impairment that I am referring to is that resources spent on special ed kids are not available for regular ed kids. And yes, you are correct that this is a problem because it is an unfunded mandate. But whether funded or unfunded, we still have to ask the question: at what point does a society draw a line and say, "There's a limit to how much we can spend."
5.8.2007 11:27am
Clayton E. Cramer (mail) (www):

There's also the ever-present chance that those judging "good" and "bad" are wrong. Look at the Atkins diet and natural fats, for instance. Look at moderate drinkers living longer than both alcoholics and teetotalers. Can I charge you extra because you don't drink?

This the problem with socializing anything. It's a license for those who would love to tell everyone else what to do to run people's lives, and often these people are pathological, hypocritical, ignorant, prejudiced, corrupt, incompetent, biased, and often downright wrong.
When insurance companies set rates, there is a very real possibility that they will make decisions based on prejudices and ignorance. But more likely, they will make decisions based on loss experience. If company A sets rates for group X because group X has a very high loss experience, group X will be incensed about it. If company B decides that group X really isn't that expensive to insure, group X will move from company A to company B. If company B is correct about this, they will make a pile of money, and company A will lose. If company A is correct, however, company B will lose a pile of money because group X is very expensive to insure.

Where I lived in the San Francisco Bay Area, the individual health insurance rates for single men skyrocketed in the early 1990s for a very simple reason: a relatively small number of single men were dying of AIDS. The insurers weren't going to ask, "Are you gay?" (very unPC and not likely to get honest answers) so they used single man as the closest approximation.

When the government is the insurer, however, and has no competition, there is no way for competition to correct this ignorance or prejudice.
5.8.2007 11:55am
Don Callaway (www):
It is easier to find and focus on the good bets than it is to identify the "bad bets". Unfortunately such common sense doesn't play well in public policy.

Take a barrel of apples, for example, and start picking out the apples one by one. Normal behavior, and I think empirical evidence obtained from any produce stand will bear this out, is to pick out the best apple available. The biggest, juiciest, reddest, sweetest-smelling apple. Repeat. Once you reach the bottom of the barrel, there will be all the bad apples.

The biggest obstacle in realizing a decent return on public monies spent helping the losers of life's lottery is that the politicians and bureaucrats are obsessively compelled to help "those who need it most" instead of those who will put any resources received to the best use, thus earning a bigger return on investment. In other words, the entire "welfare" program in all its forms is operated by picking the apples from the bottom of the barrel.

If there was a 10% dividend--compounded daily--on all the billions invested in social entitlement programs instead of the black hole effect that currently exists, I doubt the payers would have a problem with increasing the amount invested.

The bottom of the barrel could also be addressed more effectively because the bad apples are sitting in the bottom of the barrel all by themselves.

Competitive market forces will ensure the success of the apple barrel methodology of identifying the bad bets and improving the effectiveness of social spending. If in order to receive assistance one has to be picked from the top of the stack of apples, then one must be prepared, willing, and able to fight to get to the top of the stack before the top reaches the bottom.
5.8.2007 11:59am
Clayton E. Cramer (mail) (www):

It is easier to find and focus on the good bets than it is to identify the "bad bets". Unfortunately such common sense doesn't play well in public policy.

Take a barrel of apples, for example, and start picking out the apples one by one. Normal behavior, and I think empirical evidence obtained from any produce stand will bear this out, is to pick out the best apple available. The biggest, juiciest, reddest, sweetest-smelling apple. Repeat. Once you reach the bottom of the barrel, there will be all the bad apples.
This is why analogies only take you so far. Most people don't spend a lot of a time combing through for the best apples; they pick the ones that are acceptable quality from the top of the pile.

Another flaw in this reasoning: the "bad apples" of a society--those people whose misbehavior greatly aggravates their own problems and that of others, is a tiny percentage of the population, perhaps 5-10% at most. The "bad bets"--those who from either genetics or bad early environment are going to be expensive investments for the return, are also a small fraction of the population, again just a few percent of the population.

We should also remember that the "bad bets" don't have to be scrapped or ignored. One of my concerns about mainstreaming of the severely disabled is that we may be trying to make them into something that they can't be. My employer has a small group of what seem to be severely retarded workers, some of whom also seem to have severe physical deformities as well. I'm not sure exactly what they do for us, but they seem to have some job that they are capable of doing.

Would it have been a worthwhile investment for the society to have tried to get them through a standard high school education, with the expectation that they would have the same opportunities as everyone else? No, of course not. But they do have jobs appropriate to their limitations, and that has to be a lot more satisfying to them than simply being dependent.
5.8.2007 12:40pm
Blake Wind:
Remember also, Mr. Cramer, that the definition of "severely disabled" is fluid. I can say with near certainty I would have received very scant education were it not for that "classic bad bet", much less function effectively as an undergraduate. I recognize that mentally disabled students may be forced through the system, although having been educated for some time in such settings I've seen less of that than might be supposed. I am "severely disabled" but, for obvious reasons, prefer an expansive definition to the reliance on a patchwork of charities and legal aid.
Aside from eugenicists, I've been able to argue fairly well from the principle of comparative advantage, myself.
5.8.2007 1:01pm
dejapooh (mail):

the system of public education (primary, secondary and post-secondary) in general led to our domination in science and technology in the latter half of the twentieth century.


I think you can put a lot of that on the wide access offered by the GI bill to Vets of WWII. Never before (or since) have you had a generation as well educated. The breadth of education is one more thing that made them the "greatest generation." We poked our heads out from under religious ignorance and accepted truth (especially scientific truth) where we found it... how we found it.

Nice to see those good old dark ages coming back to the point where we have to teach our children that Science isn't Science.
5.8.2007 1:11pm
BladeDoc (mail):

And the Mickey Mantle highlights the pitfalls of a private system. Because he was a rich celebrity he was able to obtain a liver that should have gone to a candidate who had a much better chance of survival.

Very true -- except for the fact that the organ donor/allocation pool is very specifically NOT PRIVATE. It is highly regulated, and governmentally controlled, co-ordinated on a national scale by UNOS Mantle didn't get an organ b/c he had good insurance or was rich , he got one because either he knew someone or some bureaucrat with power thought it would be good press for the transplant agency i.e. he got it because he was famous.
5.8.2007 2:21pm
Peter Schuck (mail) (www):
My next research bearing on bad apples is to look at the NYC system to see what happens to the chronically disruptive student who, under our view, should be more readily removed from the classroom and perhaps from the school unless and until he/she is reformed and no longer harms good apple students. There does not appear to much good information about the nature and quality of the alternative programs to which they are sent, how long they remain, what happens to them there and once they leave those programs, and the like. Any ideas?
Peter Schuck
5.9.2007 12:34pm
naftali (mail):
Far more conservative minded people would support government
social programs if they believed the effects of the programs would be studied rationally and tailored or discarded as necessary.But alas, every program creates a constituency and a lobby,added to the perennial constituency for bad apples of all sorts.
5.10.2007 9:56am
Peter Schuck (mail) (www):
I agree with Naftali.

In our book, we make the point (first developed by Tom Schelling) that policymakers and voters tend to respond more to (1) identifiable victims (e.g., the girl, Jessica McClure, who fell in the well, or workers trapped in a mine) even though helping them comes at a very high cost per victim, than to (2) statistical victims (Schelling's term), whose very costly plights could be prevented at a relatively low expenditure per victim (e.g., pre-natal care for low-income women).

This tendency may be rational if the number of situations like (1) is quite low; society can feel good about being generous and affirming the attractive but plainly false idea that life is infinitely precious and we will pay any price to preserve it. But in a very large range of cases, this bias against prevention is irrational and very, very costly to society.

In today's NY Times, p. A33, Nicholas Kristof, in a column entitled "Save the Darfur Puppy," takes this point a step farther -- a step too far, in my view. "The human conscience," he says, "just isn't pricked by mass suffering, while an individual child (or puppy) in distress causes our hearts to flutter."

Tell that to the Americans (and others) who contributed astonishing sums of money to a multitude of utterly anonymous, unidentifiable, and for all intents and purposes statistical victims of the Asian tsunmai, Hurricane Katrina, and countless other instances of mass suffering. It is true that some disasters are more telegenic than others, and that the media today plays a large role in triggering this philanthropic response in some cases more than others.

None of this is to deny the importance of the identifiable vs. statistical victims distinction. Indeed, I discuss this in a new unpublished paper on the different ways in which catastrophe is understood by science, by law, and by politics. But Kristof's well-intentioned column fails to mention some important factors that affect the response to human disasters like Darfur.

One factor is the difference between individual philanthropic responses and geopolitical responses, which are -- and must be -- based on different considerations. Another is the sense that once we get into certain rescue situations, we'll never be able to get out, or that our intervention will be ineffective or make matters worse. (Can you think of a current example??) Yet another is the free rider problem -- the hope that someone else will bear the costs, with the result that no one intervenes.

My point is NOT that we shouldn't do more to stem the suffering in Darfur. In fact, Kristof's earlier columns have made a strong case that we could and should do more, including a no-fly zone, stronger sanctions against Sudanese officials, and more effective pressure on their Chinese and Russian sponsors.

But our failure to take these steps does not mean that mass suffering does not prick our consciences. It manifestly does. Our failure to put more of our energy and resources into protecting statistical victims has something to do with psychology and media, but probably has more to do with the tragic choices presented by geopolitics in a world win which great evil and cruelty create immense human suffering.
5.10.2007 12:24pm