Tag Archives: Democracy

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Guest Post: Efficiency Is Not Always Effective, Rick Meyer

[Header Photo by John Cameron on Unsplash]

Below is a guest post by Rick Meyer

My mother was extremely smart and had a remarkable sense of humor. Even at the worse moments in her life, she found humor and insight. One day, as my sisters and I were playing (and fighting) in the house because of rainy weather, she called out to none, some or all of her three children, “Hey, do you want to know a way to lose twenty pounds of ugly fat?” We stopped our bickering and turned to her, waiting for her to reply to her own question. “Cut off you’re your head,” she said and quietly continued making dinner. Her remark cut through the tension and led to some whole-hearted laughter.

I think of my mom today as I try to understand what it means for a country to work on becoming more efficient. My mom was right: your body would be twenty pounds lighter if you removed your head. That’s an efficient solution to a weight problem. The problem is the effect: you’d most certainly die. Indiscriminately removing something that’s weighty may not be good for the body of the whole.

In a country striving to be a democracy, the tension between efficiency and effect is crucial. Tom Paine said that in a democracy, law is king, and in a monarchy, the king is law. The latter is an efficient way to get laws made and enforced, with the king having power  over both the laws and their implementation. The problem is the effect on the people living within the country in that they all work for the king, for  the perpetuation of the monarchy, and suffer at the king’s whims, desires, moods, needs, and temperament. The effect on the people is that they are essentially enslaved.

In contrast, in a democracy, when the law is the king—meaning it’s the center of organization, structure, and power—things are much more complicated because the government is obligated to consider its impact on all the people. In a representative democracy, like the one in our country, those that represent us are morally, ethically, and legally bound to the good of all. A democracy is organic, meaning that it changes over time as our understandings of life, liberty, and the pursuit of happiness are informed by our deepening understanding of what it means to be a human being. We learned about, understood and acted upon slavery, putting Japanese people in internment camps, workers’ rights, women’s right, voting rights, civil rights, and so much more.

Our growing knowledge also causes tension as, for example, outlawing the owning of slaves affected the economy and led to war. But we adjust because of our deep-rooted belief in and commitment to a country that offers the potential for every human being to realize and act upon all that they can do. In other words, a democracy is not always efficient because the effects that efficiency has matter.

Cutting Medicaid is efficient: money is saved. The effect is that people without economic means lose access to medical care that keeps them alive.

Cutting social security is efficient: money is saved. The effect is that people lose their earned deferred income—money they were forced by law to set aside for their future and their quality of life deteriorates to the point of losing their homes, dignity, and peace in their later years.

Cutting the department of education is efficient: money is saved. The effect is that schools lose essential aid, programs that protect health and civil rights, support for reading instruction, research programs, and even statistical analyses of progress.

Cutting funding of scientific research is efficient: money is saved. The effect is that research that can save lives, improve our food and water, keep our air clean, make communities safer, improve mental health and so much more is lost.

Cutting funding for the arts is efficient: money is saved. The effect is that beauty does not matter, expression is marginalized, and the voices that push our thinking and being are silenced.

Cutting support for programs in other countries is efficient: money is saved. The effect is that more people die of AIDS and other diseases, more children die of starvation, countries are left unprotected against radicals, and oppressed people no longer hear voices of hope.

We should not fall prey to chaos, attacks on a free press that expose chaos and selfishness, and the push to simplify the complexity of our democracy. We need to demand that every member of our government safeguards our well-being, demands that programs for the good of all are replenished, and uncovers who is getting the money that is supposedly being saved. We need to make sure that our heads are not being cut off to reduce our weight.

Rick is an activist and retired literacy researcher.

Democracy, Equity, Incentives, Merit Pay

Welcome, Doctors, to the Brave New World of Corporate Reform!

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What are the problems?

What is the evidence the problems exist?

What is the quality of that evidence?

Who are the stakeholders in the problems and solutions?

What are the perspectives of those stakeholders?

What are the perspectives of the stakeholders with experience and expertise in the problems and solutions?

Who stands to gain personally, professionally, and financially from the problems and solutions?

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In the pursuit of any sort of reform, the right questions are essential—as is credible evidence—before solutions can be identified as valid, useful, and potentially effective. The great failure of democracy is that it appears those elected to power have neither the ability to ask the right questions nor the propensity to seek credible solutions. Those leaders are, however, eager to claim problems and support solutions that benefit them.

“In a bold experiment in performance pay, complaints from patients at New York City’s public hospitals and other measures of their care — like how long before they are discharged and how they fare afterward — will be reflected in doctors’ paychecks under a plan being negotiated by the physicians and their hospitals,” announces the lede to “New York City Ties Doctors’ Income to Quality of Care.”

“Bold” apparently means “making decisions based on ideology and not a shred of evidence.”

The article makes no case that doctor pay currently poses any sort of genuine problem—just that doctor pay is “traditional.”  Further, the article does acknowledge two important facts:

“Still, doctors are hesitant, saying they could be penalized for conditions they cannot control, including how clean the hospital floors are, the attentiveness of nurses and the availability of beds.

“And it is unclear whether performance incentives work in the medical world; studies of similar programs in other countries indicate that doctors learn to manipulate the system.”

For those of us struggling against a similar baseless current of teacher evaluation and pay reform, these details are all too familiar: (1) Concerns about accountability being linked to conditions over which a worker has no control (or autonomy), and (2) A complete disregard for the mountain of evidence that merit pay of all kinds proves to be ineffective and triggers for many negative unintended consequences:

“‘The consequences in a complex system like a hospital for giving an incentive for one little piece of behavior are virtually impossible to foresee,’ said Dr. David U. Himmelstein, professor of public health at the City University of New York and a visiting professor at Harvard Medical School, who has reviewed the literature on performance incentives. ‘There are ways of gaming it without even outright lying that distort the meaning of the measure.’ …

“Dr. Himmelstein also said doctors could try to avoid the sickest and poorest patients, who tend to have the worst outcomes and be the least satisfied. But physicians within the public hospital system have little ability to choose their patients, Mr. Aviles said. He added that he did not expect the doctors to act so cynically because, ‘in the main, physicians are here because they are attracted to that very mission of serving everybody equally.'”

The medical profession is poised to experience the complete failure of democracy that has been the fate of educators for at least three decades now. Democracy has spawned a legion of people with power but no expertise, and the result is a template for reform that ignores clearly identifying problems, fails to gather credible evidence, bypasses a wealth of experience and expertise, and imposes the mechanisms of inequity that brought those in power to that power.

As a result, buried late in this article on doctor pay reform is a cautionary tale:

“But Dr. Himmelstein said there were still hazards in the city’s plan. He said that when primary-care doctors in England were offered bonuses based on quality measures, they met virtually all of them in the first year, suggesting either that quality improved or — the more likely explanation, in his view — ‘they learned very quickly to teach to the test.'”

Educators, sound familiar?