Ways of getting people to do what you wish they would.

Let's say I have to go to the store for something, and I really want Dave to come with me. He says he doesn't want to.

There are a variety of ways in which I can try to get him to come anyway. (This list is probably not exhaustive.)

• Argument. I could start tallying all the reasons he should want to come to the store with me (the duties of partnership, the fact that he will enjoy the trip outside, etc.)
  
• Bribing. I could promise to buy him a chocolate croissant if he comes.
  
• Lying. I could tell him that he will enjoy the trip outside, even though I'm quite sure that he won't.
  
• Force. I could tickle or punch him until he stops resisting, and cram him into the car.

These same ways of evoking change are available in other contexts, too -- say a high school teacher wants his students to work harder, or a President wants the country to support her declaration of war.

I feel, as I expect most people do, that argument seems like the "best" of these methods, in some sense; the others should be resorted to only in exceptional circumstances, and only when argument is for some reason impossible. But this leaves us with a couple of important questions.

1. What is distinctive about argument? How does it differ from bribing, and from force?
2. In what ways, or for what reasons, is argument preferable to the other methods?

Ok, now that I've gotten to the interesting part I have to quit. If anyone has ideas about these questions, please share! I also have some ideas which I'll try to write down later.

Chanterelle hunt: a success!

Dave and I went to our top-secret chanterelle grounds in Portola Valley. We found a bunch of great stuff, including various mushrooms, a half-dozen well-camouflaged salamanders, and a giant male deer ~40 feet away from us!

You can see some pictures here.

What's The Point of a Debate?

After the republican debate, the tv station airing the debates said some analysis would follow. Their "analysis" consisted of asserting who "won" or "lost" the debate (with little to no reference to the content of the debate), and employed extensive use of sports and boxing metaphors. They might as well have been saying: "Did all those issues confuse you? Let us tell you what to think about the candidates."

What I would prefer the media do is the following:
1). Re-cap the major logical flow of the debate (since that can be unclear in the moment)
2). Try to identify what are the right questions to ask from here.

For example, the commentators summarized the argument between Obama and Clinton with the phrase "experience vs. change" (which itself arguably confuses and obfuscates more than it clarifies). Then they proceeded to discuss how "strong" or "weak" each candidate's performance was (not even how strong or weak their positions were). What I wish the commentators had said was something like this:

"Clinton said she stands on her experience. Her position seems to be that experience is necessary to convert words and ideas into useful action. Edwards, on the other hand, seemed to be suggesting that too much experience could hinder a president's ability to make real change, because they'd be too entrenched in the system. The next step in this debate is for both candidates to explain exactly what kinds of experience are important to a presidency and why. What, exactly, does a president need to do to get support for their program? What can cause their efforts to fail? What personal qualities, or expertise is required for them to succeed?"

Without this focus on what the candidates are actually saying it is, as one commentator approvingly described the event, "pure theater."

Democratic Debates

Last night Jen and I watched the democratic debate in New Hampshire.

The following isn't quite the exchange that took place between them, but I wanted to present my re-phrased version of what I thought were their strongest arguments.

Hillary's major argument has always been experience. I was never terribly moved by it before (because I think we've had, and can have, effective presidents without prior experience), but below is a version of it that gave me pause:

Hillary: All the democratic candidates want change, but we need someone who can deliver it. If you want change, look to what changes each candidate has already made. I have a 35 year record of it. I don't have to remind you of the importance of what the next president will need to do for the country and the world. Obama and Edwards are great people, with real passion and good ideas; the question you need to ask yourselves is, are you willing to take the gamble?
Are we willing to risk a president who can't bring his good ideas into reality? What our country needs is a president who can turn words into action, and I am that president.

What I think would be effective about this (for me) is that, even if you're not totally convinced about the role of experience, the "gamble" argument trades on a widespread conviction that we can't afford anything like that last 4 years.

Here is my re-phrasing of Obama's response:

Obama: Hillary is absolutely right that she's made some important changes in her career. But the kind of changes we need can't be made by the strength of a single person. As Hillary should know, large-scale changes can only be done with broad coalitions.

I don't think Obama could elaborate in a debate about why he's better suited for this task. Here's why: it seems to me that building a broad coalition requires charisma, and it requires that people like and and trust you. I don't believe (though I'm willing to be convinced) that Hillary is widely liked or trusted. Therefore she's going to have a lot more trouble building coalitions.

Review of four candidates on healthcare

Apparently, the Democratic plans are all similar because they have all taken counsel from MIT economist Jonathan Gruber, who is at the center of an group of analysts who agree that the best way forward is with minimal disturbance to current players (Working Californians, July 2007) Others (not including any of the Dem front-runners) prefer a single-payers system. (Huffington Post, October 2007)

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Obama's Plan
(in this section, text not in [brackets] is taken directly from Obama campaign materials, found here)

• Guaranteed eligibility. No American will be turned away from any insurance plan because of illness or pre-existing conditions.
• Comprehensive benefits. The benefit package will be similar to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have. The plan will cover all essential medical services, including preventive, maternity and mental health care. [This plan will be available to all Americans.]
  
• Subsidies. Individuals and families who do not qualify for Medicaid or SCHIP but still need financial assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan.
• National Health Insurance Exchange: The Obama plan will create a National Health Insurance Exchange to help individuals who wish to purchase a private insurance plan. The Exchange will act as a watchdog group and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible. Insurers would have to issue every applicant a policy, and charge fair and stable premiums that will not depend upon health status. The Exchange will require that all the plans offered are at least as generous as the new public plan and have the same standards for quality and efficiency. The Exchange would evaluate plans and make the differences among the plans, including cost of services, public.
• Mandatory Coverage of Children: Obama will require that all children have health care coverage.
• Reducing Costs of Catastrophic Illnesses for Employers and Their Employees: Catastrophic health expenditures account for a high percentage of medical expenses for private insurers. The Obama plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers' premiums.
• Lower Costs by Modernizing The U.S. Health Care System. [A variety of measures, including mandatory electronic recordkeeping, disease management programs, emphasis on prevention, and incentives for using proven best practices, are purported to reduce an average family's annual costs by "up to $2,500".]

Total Funding Figures

• $55-60 billion annually, after fully phased in, to be paid for by efficiency improvements and repealing the Bush tax cuts for those making over $250K/year. (Obama Health FAQ)

Jen's Commentary on Obama's Plan

• Does not mandate coverage. Obama's plan does not require that everyone have health insurance. Though insurers will be required to cover everyone, and the government will provide an unspecified level of subsidy for poor people not covered under Medicaid or SCHIP, economists estimate around 15,000,000 Americans will choose to remain without insurance. (The New Republic June 2007; Cohn blog post)
  
• Claims about efficiency gains seem contentious. Jonathan Cohn, who I trust knows more than I do about this, calls the proposal "detailed and well thought-out" in this area (The New Republic June 2007). But the Obama campaign's numbers for administrative overhead in healthcare are at the very highest end of what's out there; and John Mongan has convinced me that replacing medical recordkeeping systems is very hard to do (although I mostly remember arguments about doctor personalities, which may matter less in national policy than in private campaigns). I remain unconvinced that these predictions are realistic.
  

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Clinton's Plan
(in this section, text not in [brackets] is taken directly from Clinton campaign materials, found here)

• The Same Choice of Health Plan Options that Members of Congress Receive: Americans can keep their existing coverage or access the same menu of quality private insurance options that their Members of Congress receive. In addition to the broad array of private options that Americans can choose from, they will be offered the choice of a public plan option similar to Medicare.
• Individuals: will be required to get and keep insurance in a system where insurance is affordable and accessible.
• Insurance and Drug Companies: insurance companies will end discrimination based on pre-existing conditions or expectations of illness and ensure high value for every premium dollar; while drug companies will offer fair prices and accurate information.

• Reducing Costs: By removing hidden taxes, stressing prevention and a focus on efficiency and modernization, the plan will improve quality and lower costs.
• Provide Tax Relief to Ensure Affordability: Working families will receive a refundable tax credit to help them afford high-quality health coverage.
  
• Limit Premium Payments to a Percentage of Income: The refundable tax credit will be designed to prevent premiums from exceeding a percentage of family income, while maintaining consumer price consciousness in choosing health plans.

Total Funding Figures

• $110 billion, to be paid for by efficiency improvements and repealing the Bush tax cuts for those making over $250K/year. (Full, detailed breakdown in Clinton Health Plan)

Jen's Commentary on Clinton's Plan

• The only substantial criticism I found is that even with the mandate, some people -- perhaps ~1.5%, or 4.5 million -- will go uninsured, given realistic levels of subsidies. (Washington Post blog, November 2007)

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Edwards's Plan
(in this section, text not in [brackets] is taken directly from Edwards campaign materials, found here)

• Requiring businesses and other employers to either cover their employees or help finance their health insurance.
• Making insurance affordable by creating new tax credits, expanding Medicaid and SCHIP, reforming insurance laws, and taking innovative steps to contain health care costs.
• Creating regional "Health Care Markets" to let every American share the bargaining power to purchase an affordable, high-quality health plan, increase choices among insurance plans, and cut costs for businesses offering insurance.
• Once these steps have been taken, requiring all American residents to get insurance.
• Edwards claims he will "use [his] power as president to take [Congress's] healthcare away" (TV ad, cited by factcheck.org) unless his plan is passed. This seems like an empty threat, since Congressional healthcare is provided for by legislation, and the only legal way to revoke it would be with more legislation. Written campaign materials make the weaker claim that he will "submit legislation" to achieve this end (which, presumably, would be voted down by Congress). And Edwards has defended this plan, saying "The most powerful tool that the president has is the bully pulpit. And that means making the case to America, submitting legislation to support exactly what I just said, and then making the case to America in any place--any congressional district or any state where a senator is opposing it--saying `your senator, your congressman is defending their health care at the same time that they're not providing health care for you.'" (Face the Nation, quoted in Mike Kuykendall's blog)
  

Total Funding Figures

• Maybe I'm just tired, but I didn't see this on the webpage or in the detailed plan PDF. Elsewhere, "Campaign estimates cost to be $90-$120 billion a year. Would finance the plan by rolling back tax cuts for those earning more than $200,000 a year." (KFF)
  

Jen's Commentary on Edwards's Plan

• This appears to me to be esentially the same as Clinton's plan, though less specific (and with the addition of the Health Care Markets, and the Congressional bribe). So, again, the only criticism is that an individual mandate is less likely to provide truly universal care than a single-payer system would be.
  
• Announced in Feb 07, Edwards was the first of the candidates with identical plans. Obama announced in May, and Clinton May-Sep. (KFF)
  

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Paul's Plan
(in this section, text not in [brackets] is taken directly from Paul campaign materials, found here)

• Making all medical expenses tax deductible.
• Eliminating federal regulations that discourage small businesses from providing coverage.
• Giving doctors the freedom to collectively negotiate with insurance companies and drive down the cost of medical care.
• Making every American eligible for a Health Savings Account (HSA), and removing the requirement that individuals must obtain a high-deductible insurance policy before opening an HSA.
• Reform licensure requirements so that pharmacists and nurses can perform some basic functions to increase access to care and lower costs.

Total Funding Figures

• not provided.

Jen's Commentary on Paul's Plan

• This plan seems unlikely to substantially alter the current situation.
  

Healthcare Background Info

I spent today researching health care in preparation for a discussion about the presidential candidates. Here are my findings.

Healthcare Spending

We're spending a lot, and the spending rate is growing.
- In 2005, the U.S. spent $2 trillion on health care, which is 16 percent of GDP and $6,697 per person. (KFF August 2007)
- Health care costs have grown on average 2.5 percentage points faster than U.S. gross domestic product since 1970. (KFF August 2007)
- Health care costs are also rising in other OECD countries, at somewhat slower rates (KFF January 2007)


Two other surprising figures.
- Almost half of health care spending is used to treat just 5 percent of the population. (KFF August 2007)
- In 2005, nearly half of US health expenditures were public (just under $3,000 per capita). US public health expenditures per capita (in terms of USD PPP) are among the top in the world (behind only Luxembourg and Norway) (OECD)


Where the money goes.

(from KFF)
A note: "Program Administration" here means marketing and billing by health insurance plans. Other administrative costs are included in other categories. One study on 1999 data estimated total administrative costs at $1059 per capita (or almost 31% of total expenditure that year), compared with $307 per capita (for 16.7% of total expenditure) in Canada. (NEJM August 2003) A response in the same journal says this gap is overestimated by 25%. (NEJM August 2003) Also, much of the gap appears to be attributable to Canada's public health insurance program; Canadian private insurers have slightly higher administrative costs than their American counterparts, but make up a much smaller share of the health market.

Potential reasons for increasing health costs.

• increases in expertise and technology have made more (and more expensive) care possible (KFF August 2007)
• US population is aging (KFF August 2007)
• US population's health is worsening (Michael Pollan claimed in a recent interview that our health care spending has been inversely correlated with our spending on food during the last half century)
• improving insurance coverage encourages higher rates of care access (KFF August 2007)

Potential reasons which are clearly not large factors (at least not directly).

• medical malpractice suits: Total costs of defense, awards, and settlements is less than 1% of total health expenditure in US. [This figure does not include malpractice insurance costs, which appear to total $2 billion, less than .5% of total health expenditure (Healthcare Financial Management 2002 )]. This is not far out of step with other countries' malpractice costs. (Health Affairs 2005)
• greater basic access, no queues: The US has less healthcare availability (in terms of hospital beds, doctors and nurses, and MRI and CT scanners per capita) than the OECD median. Procedures for which some countries have queues (i.e. some elective surgeries) account for only 3% of US expenditures. (Health Affairs 2005)

The Uninsured
Total US population: 301,000,000 (CIA World Factbook July 2007)
Uninsured population: 46,500,000 (Kaiser Commission on Medicaid and the Uninsured. "The Uninsured and Their Access to Health Care," Oct. 2007)
Uninsured as proportion of total population: 15.4%
Uninsured as proportion of nonelderly population: 18%

Estimated undocumented immigrant population: 11,500,000 (Pew Hispanic Center Factsheet April 26, 2006)
Estimated uninsured undocumented population: 7,800,000 (inference from above and below)
Estimated uninsured as proportion of undocumented population: 68% (RAND Corporation November 2005)

(from KFF)

A Problem with Individual Health Insurance Markets

From my somewhat dusty memory of a lecture by Peter van Doren; similar points are made in an article by Paul Krugman. The problem stems from the fact that, unlike in many other insurance markets, many of the costs being insured against in health insurance are known in advance.

Imagine that there is only one health insurance company in the US, offering full-coverage plans to everyone at the average annual health costs per capita (plus a little extra for overhead). These plans cost *a lot* more than the healthiest Americans expect to get back in terms of benefits, so most of the healthiest don't participate. The very sick, on the other hand, are eagerly joining up. Now, the company is charging average rates and providing care for a group with higher-than-average costs.

The company can increase rates, but the same thing will happen -- the healthiest of the old participants now prefer to take their chances in exchange for much lower average costs, while the sickest are eager to participate. This cycle will not end unless the insurance company is allowed to exclude the sickest from buying its coverage. Insurers have no incentive to insure the sick, unless the sick are included in a large, varied population as part of a group plan (in which case their higher costs are offset by healthy participants with lower costs).

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General Resources
Kaiser Family Foundation (KFF)
OECD Health data
RAND health
A collection of links to Paul Krugman's NYT articles on health
An econ professor draws and discusses various charts about national health spending.

"Automatic Behaviors"

I just read a CDC report on obesity. It poses the question "Why [do] people continue to consume more calories than they need when the consequences are so apparent, stigmatizing, and widely understood to be unhealthy?”

If you look at what we've done as a nation up to now (education about nutrition, better labeling on food products), there's a clear assumption at work: eating is a conscious choice people make. If that's true, then educating Americans should allow them to make better choices for themselves. In the light of day, it doesn't sound all that plausible, and indeed it doesn't seem to be working.

This report suggests that eating (as Americans practice it, anyway) isn't mainly something we deliberately choose to do. It suggests instead that it's an "automatic behavior"; a behavior that's more controlled by environmental factors than individual choices. The report cites various studies which show that we will eat more whenever food is more visible, more available, or given in larger portions. Not only that, but those who eat more due to these environmental factors are unaware they've eaten more or of the cause. In short, we're usually not in control when we eat, even if we think we are.

We're used to thinking of ourselves as controlling what we do; of thinking, deciding, and choosing. In other words, we think of ourselves in exactly the way the CDC report suggests we aren't insofar as our eating is concerned. What if it's more than just eating? My understanding is that research for a wide variety of our everyday behavior are coming to the same conclusions. I think this research also accords with experience. Most of what I do most of the time is "automatic"--I respond without deliberate thought.

Obviously, with enough effort we can overturn any particular automatic behavior; we can refuse dessert. But it does take an effort, and that effort is hard to sustain (the term of art for this in psych. studies is "ego depletion"). This is no surprise to dieters. Fighting constant environmental temptations is difficult, and often a loosing battle.

Dieters also have a familiar alternative strategy: don't tempt yourself. If you know you're tempted by unhealthy foods, make sure you don't have any in the house; or, better yet, make sure there's a healthy alternative readily available so you won't feel a craving and drive to get some.

This seems obvious, but the way of thinking about yourself that makes it work seems to be restricted to a few types of behavior (like eating). A college friend of mine was living alone, and in a long-distance relationship. He took care to put lots of pictures of his girlfriend in his room, and told me at the time that they would make it virtually impossible for him to "make a mistake" that he, presumably, was worried was possible without them (they're now married). I don't know if he ever explained his reasoning to his girlfriend, but I can image the scene turning out badly. Why? Because, if he really loved her (she might say to herself), he wouldn't be tempted, or he would be strong enough to resist.

What seems obvious when dieting may seem very counter-intuitive in other situations, but the same point applies. Her imagined response would be like saying to the dieter that if he really wanted to be thin, he wouldn't be tempted, or he would be strong enough to resist. Clearly someone's weakness for chocolate doesn't show they don't want to be thin; and my friend's weakness for women doesn't show that he doesn't want to be faithful. All it shows in both cases is that they're weak. We all have our weaknesses, and, if we're honest with ourselves, I think we all have levels of temptation that we can't say with certainty we could resist.

The lesson I take from this is that people think of themselves as behaving automatically sometimes (like when they're snacking), but think of themselves as in control most of the time. We need to switch those. We behave automatically *most* of the time, and can only sometimes be in control.

Most of us have a daily routine that is, with some minor variations, consistent. One metaphor I use is to imagine the daily routine of my life as going down the same stretch of rapids, day after day. From the moment my day starts, the currents of the river determines the course my day will take, and I can only have small, local influences over it.

Imagine that one day, I become unhappy with my course, and every day try paddling with all my might to reach a different, parallel, current. Maybe some days I make it, but the effort is always exhausting, and I feel disappointed and generally terrible on the days I don't.

This is what dieting is like for some people. Their daily effort is spent in resisting the draw of what's around them every day. Some days they make it, some days they don't; but it's hard, inconsistent, and seemingly endless.

Now imagine that, one day, right before I head in the direction I try daily to avoid, I notice a rock that's dividing the current at that point. The next day I kick it, and it budges. The day after that, I bring a rock of my own to drop beside the first. On the third day, I notice that the rock I brought has shifted the currents, and now it's easy for me to divert my course.

After I discovered where to apply my effort, it seemed foolish to struggle with the prevailing current every day. All I needed to do was to direct my effort to change my environment so I didn't have to struggle. The more we can think about our lives this way, I believe, the better we will be able to effect change.

The other metaphor I like is thinking of myself as a broken robot. Most of the time I'm not me; I'm a robot that's more or less competent, but can definitely go astray. At the end of each day, I need to review the robots logs (where it records everything that happened to it), and find the places where it didn't behave as I would have wanted. I can't really fix my robot, but I can tell it to do specific things; so I have it add and remove things from its daily surroundings, and I tell it to change the order it does things, or the lengths of time it does things, until it's behaving more the way I want.

The trick, either way, is to stop struggling so hard with something that's not working, and start watching yourself. Try to figure out exactly when you start to go wrong, and how you might avoid it. It may not work the first time, but if it doesn't, you don't need to feel bad because you were too weak to resist temptation again. You just know that you need to adjust your environment even more.

I'd like to end with a few examples that Jen and I have noticed from our lives:

* When we have a tv, we both can't stop watching it. Our solution was to get rid of it entirely. Had that seemed to extreme, I might have considered looking into a way to lock ourselves out of watching after a fixed time-limit.

* I have a hard time starting something that seems too big, or that I don't want to do. Recently I've begun to "trick myself". I'll set a 10-minute timer and tell myself that I'll only work for 10 minutes. I don't need to get to any particular benchmark in the work; only to work, however fast or slow, for 10 minutes. Usually this is enough to "divert the current" of my attention and comfort to keep me working effectively far past the 10 minutes.

* Jen noticed that sometimes when she's programming, she'll just start to surf the internet, and has a hard time stopping. We thought of having a hard rule never to have a browser open, but she realized she often needs to look things up, so that was out. Then she noticed that this tended to happen when she wasn't sure what to do next. Now she's able to recognize when she's getting to a sticking point, and call me over so we can discuss it. Then we can identify next steps together, and she's back on track.